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I. Death and BereavementJohn W. Riley, Jr.


II. The Social Organization of DeathRobert W. Habenstein



Death is a personal event that man cannot describe for himself. As far back as we can tell, man has been both intrigued by death and fearful of it; he has been motivated to seek answers to the mystery and to seek solutions to his anxiety. Every known culture has provided some answer to the meaning of death; for death, like birth or marriage, is universally regarded as a socially significant event, set off by ritual and supported by institutions. It is the final rite de passage.

The social and psychological aspects of death have been studied by anthropologists, sociologists, psychologists, and psychiatrists; and the main outlines of their understandings can be summarized on three levels—cultural, social, and individual. The meanings which have been attached to death in most cultures include beliefs in some kind of existence after death; most peoples—save the nonliterate—have entertained theories of personal salvation; and religion, philosophy, and political ideology have provided some answers to man’s quest for the meaning of death. The relationship between death and the social structure has received little systematic attention from social scientists, although there is much research on the social prescriptions for bereavement, especially as these relate to ritualistic mourning and individual grief. Scattered empirical studies suggest that, for the individual in the contemporary Western world, matters of death are less salient than those of living, although there are clear traces of a latent and underlying ambivalence.

Although between fifty and sixty million people die each year, growing proportions of people in the world live into the later years. Thus, many people have the opportunity to contemplate their death, and unknown but even greater numbers of persons are affected by bereavement. For a phenomenon of such wide and pervasive significance, it is curious that the most recent systematic bibliography on the subject of Western social science literature on death and bereavement (Kalish 1965) does not exceed four hundred entries—many of them recent. In our time death has been largely a taboo topic (e.g., see Feifel 1959; Fulton 1965). But attention is now being directed to various social problems involving man’s relationship to death: the problem of death and bereavement for the aged, dilemmas faced by the practitioners who deal with death, risk taking by both nations and individuals, and the social and moral implications of scientific advance in the control of death.

Death and culture

Death raises two kinds of problems that require cultural definitions and norms: those pertaining to one’s own death, and those pertaining to the obligations imposed upon others by the fact of a death. In no known culture is the individual left to face death completely uninitiated. He is provided with beliefs about “the dead” and about his own probable fate after death. Similarly, all these cultures include norms governing the imperatives imposed by death: a corpse must be looked after; the deceased must be placed in a new status; his vacated roles must be filled and his property disposed of; the solidarity of his group must be reaffirmed; and his bereaved must be re-established and comforted (Blauner 1966).

Death in nonliterate society

Systematic analysis of the records on nonliterate peoples shows various recurrent components in their belief systems (Simmons 1945). Belief in a spirit world inhabited by the dead is practically universal among them. There is no clear theory of “natural” death; they believe that death results from the intervention of an outside agent. The culture typically includes a conception, implicit or explicit, of a relationship between the living and the dead. Death is viewed as a crisis through which the deceased enters upon a new status. Symbols of power, either malevolent or benevolent, are attached to the dead. Among the Navajo, for example, actions of the spirits of the dead are generally perceived as being hostile toward the living; while among the Tikopia, where cohesion and continuity between the two worlds is a central theme, the relationship between quick and dead is believed to be benign. Belief in personal salvation appears rare; and, in contrast to the pervasive concerns of civilized man, primitive man seems to have developed no eschatology of rewards and punishments in the worlds populated by the dead (Bellah 1964).

In respect to bereavement practices, anthropologists report great diversity. The actual bereavement period may extend, as it does for the Cocopa, over a period of years; or, as among the Pueblo, it may be but brief and perfunctory. In some cultures, bereavement begins with illness (which may be tantamount to death); in others, it begins only after the disposal of the corpse. In some cultures, the bereaved are required to idolize and placate the deceased, who is certain “to return”; in others, the deceased is held in such great fear that elaborate rituals are required to prevent his taking up his former role in the community (Krupp & Kligfeld 1962). There is, however, no satisfactory general theory to account for these cultural variations.

Historical perspectives

Within recorded history, answers to problems raised by death are found in religion, philosophy, and, to some extent, in political ideology. The major world religions include varying beliefs in a relationship between man’s life on earth and his ultimate fate after death. Rabbinic Judaism developed a detailed theory of a day of judgment. According to the teachings of Zoroaster, the soul is directed at death to balance its good and evil deeds. In the Islamic scheme, Allah is ready to prepare a happy place for the true believer. Buddhism postulates that nirvana (a final beatitude, oblivion) is attainable through a long succession of reincarnations, each mystically related to the karma (deeds) of preceding lives. Similarly, Hinduism rests upon a complex and philosophical relationship between dharma (civic and religious piety) and moksa (the attainment of salvation). The teachings of both Confucius and Lao-tzu carry an implication of salvation in that man must adapt both to the expectations of his ancestors and to cosmic moral law. The religions of East and West differ fundamentally with regard to death and life after death on only two main points. First, for the East, the route to salvation tends to be either contemplative or mystical; for the West, it tends to be ascetic and active. Second, the East views the ultimate outcome as an undifferentiated and impersonal “oneness” with the universe, while the West sees it as the continuation of the integrity of the personal self.

In the history of Western religion, the emergent Christian conception of salvation gave emphasis to an afterlife in which the individual’s identity continues essentially intact. The Roman Catholic church institutionalized the problem of salvation in the relationship of the individual to the priest; anxiety about death is reduced as the individual experiences sin, repentance, atonement, and release. In contrast, the Calvinist concept of predestination intensified anxiety about death and the afterlife, since it regarded man as powerless to control his fate. Thus new forms of conduct and social organization evolved, as Max Weber (1904–1905, pp. 99–128, 155–183 in 1958 edition) points out, to help the early Protestant deal with this increased anxiety; and, to ensure his salvation, the individual turned to a life that emphasized methodical, rational conduct in work and a disciplined family life. In present-day religious thinking, however, the clear connection between death and salvation has become blurred. Schneider and Dornbusch’s (1958) study of popular religion in America (an analysis of the inspirational writings by Norman Vincent Peale, Joshua Loth Liebman, and others) shows a predominant stress on salvation in this life rather than in the next and small preoccupation—since man is assumed to be essentially good—with spiritual preparation for death.

The most active periods of philosophical concern with death tend to coincide with periods of relative inactivity in formal religious institutions (Choron 1963). In Greece during the fifth and fourth centuries b.c., for example, death was a central theme of philosophical speculation. Plato developed his theories of the interlocking relationship of knowledge and the immortality of the soul—a juxtaposition of ideas destined to play a dramatic role in the history of Christendom. During the second and first centuries b.c. in Rome, the problem of death again became a major focus for philosophy; to the Stoics, for example, preparation for death was considered the only proper end of philosophy.

Although the history of Christian belief in eternal life seems to have largely inhibited widespread philosophical treatments of the problem of death in the West, a notable development took shape toward the end of the nineteenth century in the form of existentialism. Contemporary existentialist theories, often obscure and contradictory, are of special interest because of their emphasis upon death. Jean-Paul Sartre, in one view, echoes several earlier philosophical traditions in his argument that the self is finite, that nonbeing follows death, and that the immortality of the soul is a fiction. Sartre thus ignores and despises “the stranger,” which is death. Martin Heidegger, in another view, wants to “disarm” death by taking it into the consciousness. Hence, the individual’s search for the meaning of existence (Dasein) points to death as the ultimate phenomenon of life (Choron 1963). In still another existentialist view, the question posed by death has been reinterpreted to ask: Can the individual cope with the threat of nothingness by replacing his belief in personal immortality with a belief in social immortality?

Various ideologies throughout history have involved such higher principles as patriotism or work in seeking answers to the meaning of death. The Homeric singers extolled death for warriors, promising that they would not be forgotten. The ideology of the Greek polis offered the individual a kind of immortality if his life was sacrificed for the common good—an element in political ideology that has changed little over the centuries. Man has always been willing to die for the state; in the extreme case, even by his own hand (for example, Durkheim’s conception of altruistic suicide). The stress on death for the state typically gains currency during wartime. War consecrates the meaning of death (Warner 1959), and the similarity between the soldier and the man who perishes “in his calling” foreshadows an important element in the ideology of the monolithic state. According to communist doctrine, the individual can reduce his anxiety about death through work and identification with the party. Thus the Russians, like the Puritans, have incorporated work into their ideology as one answer to the threat of death.

Death and society

Death and the changing patterns of mortality are reflected in the structure of society. With the exception of a number of highly significant and institutionalized practices—war, infanticide, cannibalism, ceremonial human sacrifice, capital punishment—social institutions have evolved to facilitate life and to prevent death. The demographic history of man bears out the generalization that he has been more interested in death control than in birth control. Thus, mortality rates have tended to fall faster than fertility rates. Yet, despite an impressive literature on the means for controlling demographic changes, relatively little attention has been paid to the larger problems inherent in the relationship between death and social structure. Two examples will illustrate the range of developing theoretical concern with such problems, although no general theory is yet at hand.

First, the recent work of Blauner (1966) points to the fact that mortality operates on society as a variable, not as a constant. According to this theory, the higher the mortality, the greater the threat to the social system, a threat which is reflected both in ritualistic mourning practices and in the social prescriptions that are activated when deaths occur. In high mortality societies, social relationships tend to be diffuse and widely dispersed throughout the group (everyone knows everyone else), and, when someone dies, the entire community mourns along with the next of kin and close associates. Similarly, in such societies there tend to be prescriptions that “solve” the social problems created by individual deaths. Thus, elaborate kinship rules provide new families for orphaned children, just as such customs as the levirate and sororate provide new spouses for widows and widowers.

In societies with low mortality rates, however, death poses a greater threat to the personality system. In the West today, for example, the small family tends to socialize its members for interpersonal competence, giving bereavement an especially personal significance. Furthermore, since a person’s significant others are concentrated among his close relatives and friends, bereavement reactions tend to be highly varied and individually therapeutic. The most striking exceptions to this tendency are the highly ritualistic occasions produced by the deaths of heads of state and other prominent figures, such as the funeral of President Kennedy.

Findings of recent studies in the United States and Great Britain support such an individualistic emphasis in bereavement practices. In the United States, the appropriate expressions of grief and the length of the bereavement period, rather than following a widely accepted pattern, are found to vary greatly with the circumstances of the death, the status of the deceased, the status of the bereaved, the nature of their former relationship, and the age and sex of both the bereaved and the deceased (although women are permitted a greater display of sorrow than men, the general prescription is “to be brave”). Bereavement, with few social limitations, is susceptible to individual definition to fit individual needs (Bowman 1959). Similarly, a study of bereavement in Britain concludes that “the majority of the population lack common patterns or ritual to deal with bereavement” (Gorer 1965).

A second theoretical approach, developed by Parsons (1963), calls attention to the changing context of death in American society; it notes that increasing proportions of any birth cohort live to the approximate completion of the life cycle and that death has been largely separated from its long and complex relationship to suffering. Thus, the twin threats of suffering and prematurity have been greatly reduced by medical advances. Death is now more often inevitable than adventitious; as early as the beginning of the twentieth century, Sir William Osier was able to report that few of his dying patients died in agony. Within this context, Parsons argues, new orientations toward death are developing that are less influenced by these traditional anxieties.

Parsons classifies the developing orientations into two types: a “normal” or active orientation (consistent with the high evaluation placed by contemporary society on science and activity) that stresses the moral significance of death as the termination of a completed life cycle of effort and achievement; and a deviant orientation that is essentially regressive and fatalistic. To the extent that this “normal” orientation prevails in American society, the individual is expected to “face up” to death in realistic terms, and his bereaved are expected to do their “grief work” quickly and privately—within the intimate circle of family and close associates. At the same time, the deviant orientation to death is also clearly in evidence, and to this Parsons relegates the denial of the reality of death, which some scholars have regarded as the modal American view (as indicated by such phenomena as the impermeability of caskets, the practice of cosmetic embalming, and the lifelike presentation of the corpse). How widespread each type of orientation actually is becomes an empirical question to which studies have only recently begun to be directed.

Apart from such special theories, the over-all relationships between human death and human society have recently been probed by a few writers (for example, Choron 1963; Hoffman 1964; Sulzberger 1961; Brown 1959) but have not yet received systematic theoretical attention from social scientists. Yet the fact of death raises problems on several levels of social structure (Blauner 1966). Mortality challenges social continuity—and societies are universally characterized by institutions for transmitting the heritage from one generation to the next. Mortality threatens the orderly functioning of society—and social structures are universally characterized by mechanisms for replacing deceased performers of social roles. Mortality weakens the group—and groups have traditionally established means, in the face of death, for reassembly and restoration.

Mannheim (1923–1929) pursues one theoretical approach that begins to deal with such broader issues by asking the disarmingly hypothetical question of what society would be like if there were no death. He points to connections between death and other basic processes: as participants in society die, there are roles to be filled by new participants; moreover, since the accumulated heritage can be only imperfectly transmitted, there is a continual process of transition from generation to generation. Consequently, as new participants are able to take a fresh look at society, social change is facilitated. New approaches and solutions are constantly being developed, and old solutions are discarded and forgotten when they are no longer necessary or effective.

While Mannheim’s provocative essay probes a wide range of social phenomena, a more complete theoretical formulation of the adaptive and selective mechanisms implicit in the relationship of death to society might well be possible. Such widely used social science concepts as those pertaining to political succession, property inheritance, kinship structure, socialization—to list but a few—might be transferable to a more general sociological theory of death.

Death and the individual

The historical shift in bereavement practices from a social to an individual emphasis holds important implications for the individual, who must face not only his own death but also the possible loss of close relatives and associates. Despite the importance of the topic, empirical studies of the individual’s relationship to death have been comparatively few and recent. Great obstacles to research are posed by people’s reluctance to discuss so private a matter, as well as by their underlying ambivalence toward death itself. Nevertheless, attempts are now being made to examine different aspects of the individual’s feelings and attitudes, using a variety of research techniques, from projective tests and physiological response measures to interviews of cross-section samples. Reactions have been obtained from several special segments of the population—children, the aged, the dying, the mentally and the physically ill. Certain characteristics of the individual (sex, age, religiosity, education, health, etc.) have been studied as possible factors affecting attitudes toward death. And, although some of the first findings appear inconclusive or confusing, efforts are underway to explain individual attitudes through their interrelationships with the norms of the culture (Volkart & Michael 1957) and to design new research within a broader conceptual framework.

The image of death

While the empirical studies cannot yet support any over-all formulation of individual attitudes toward death, a few examples will illustrate the many clues and suggestive findings now beginning to emerge. One set of studies focuses on children, indicating, for example, that the child’s conception of death develops in stages. Thus, among very young children, prior to the development of the sense of causality, death is seen as reversible, not final (Nagy 1948). Emotional involvement with death tends to vary with stages in the development of the ego structure and with changing cultural pressures and expectations, so that involvement is greater during early childhood and adolescence than during the preadolescent period (Alexander & Adlerstein 1958). Fear of death in children (as well as in adults) has been related in various studies to such disparate phenomena as separation anxiety, sex guilt, physical restraint, fear of the dark, sibling rivalry, and the castration complex.

Another set of studies emphasizes the importance, for the dying individual, of a secure environment and a return to primordial kinship ties. Most subjects who know they are to die say they prefer to die at home and to be surrounded by families and friends (Fulton 1965; Feifel 1959). Elderly subjects are less apprehensive about death if they live in familiar surroundings and with relatives (or even in homes for the aged) rather than alone. Such indications point to a need for social support that may be out of keeping with present tendencies toward hospitalizing and isolating the dying individual (Glaser & Strauss 1965). And the increasing majority of people do, in fact, die in hospitals (Fulton 1965).

A series of small studies attempting to connect a person’s religion with his attitudes toward death has thus far produced inconclusive findings—in part because of conceptual differences in the attitudes studied and the specialized populations examined. Thus, fear of death is variously reported to increase with religious orientation, or to decline with religious activity. Some studies report that more thought is given to death by the religiously inclined. Other studies show no association whatsoever between religious conviction and attitudes toward death. While there are no satisfactory empirical data at hand to link these apparently conflicting findings, greater consistency will undoubtedly be found as research takes into account the differing definitions of death emphasized by the several religions and the differing needs met by religion in the various sectors of society.

Two other types of research offer preliminary support for Parsons’ argument regarding the development of an active orientation toward death as contrasted with the denial of its reality. In one strand, a few small but cogent studies suggest that many persons fear their own death largely because death eliminates the opportunity to achieve goals important to self-esteem and that death may appear appropriate to the dying under conditions of dignity and personal fulfillment (e.g., Diggory & Rothman 1961). The second type of research deals with people’s concerns with death in comparison with their concerns about the problems of life and studies the modes of their adaptation to death. A cross-section study of the adult population of the United States by Rosalie Goldwater and John W. Riley, Jr. (the results of this study were being analyzed in 1966, but had not yet been published) shows that large majorities report frequent concern with such problems as health (76 per cent) and money matters (74 per cent), in contrast to a minority who say they think often about the uncertainty of their own lives or about the possible death of someone else (32 per cent). That this lack of concern does not reflect a general “denial” of death is indicated by the finding that 85 per cent, in response to a question concerning different ways of adjusting to the uncertainty of life, concur that people should “try to make some plans about death.” Although relatively few adult Americans have executed wills (24 per cent) or made funeral or cemetery arrangements (28 per cent), eight out of ten have purchased life insurance, and half have made a point of talking about death with those closest to them (for a preliminary account of some of these findings, see Riley 1964).

Further analysis shows connections in this study between these views of death and the respondents’ educational attainment and age (analyzed jointly). The higher the education, the less negative the respondent’s image of death, the less his expressed anxiety about death, and the more active his adaptation to death. This suggests that, as the general level of education in the Western world rises, a new orientation toward death may be in the making, however many defense mechanisms may be operative. Furthermore, older people are more likely than their younger counterparts (at any given educational level) to reveal an active orientation to death and to disavow the idea that one should ignore death or avoid making plans. Similarly, other studies note that, among the aged, approaching death seems to provoke less anxiety (Cumming & Henry 1961); whereas among the young (adolescents), there is little structuring of the future and low tolerance for the idea of death (Kastenbaum 1964). Thus, an active adaptation to death seems to become greater as individuals come nearer to completing the life cycle.


Death means to the individual not only his own demise but also the loss of other people who are significant to him. From a psychological standpoint, bereavement—generally held to signify the emotional state and behavior of the survivor following the death of a person who fulfilled dependency needs—is a temporary condition from which the individual is expected to recover. Studies of grief reactions to death have identified such syndromes of associated psychological and physiological symptoms as somatic distress, preoccupation with the image of the deceased, guilt, hostile reactions, and loss of established patterns of conduct (Lindemann 1944). Freud (1915), whose classic work has afforded the theoretical foundation for the psychiatric literature on melancholia, paranoid reactions, and other emotional concomitants of bereavement, argued that recovery from the grief syndrome requires a process of reality testing to demonstrate that the loved object no longer exists; only when this process is complete is the ego free again. Mourning, then, is a psychological task to be performed (Krupp & Kligfeld 1962).

From a sociological standpoint, the bereaved individual may be aided through rituals and the support of family and friends to resume his usual social obligations after the mourning period (Eliot 1932). In this perspective, the task is to re-establish the systems of relationships interrupted by death or to develop new ones. Durkheim originally specified the function of ritual in enabling bereaved persons to cope with death (1912, pp. 445, 448 in 1961 edition): “When someone dies, the family group to which he belongs feels itself lessened and, to react against this loss, it assembles. … The group feels its strength gradually returning to it; it begins to hope and to live again.” Various studies suggest, however, that such social supports often work imperfectly. A large-scale British survey, for example, shows that the help afforded by family gatherings and religious ceremonies is limited to the period of initial shock; for the subsequent period of intense mourning and physiological stress, the bereaved is typically left alone, bereft of attention or affect from the external world (Gorer 1965). Thus societal supports may be ill designed to meet the needs of those who must live through bereavement and come to terms with grief.

The psychological response of the survivor and his need for social support depend upon many factors, and especially upon who has been lost—a child, a parent, a distant friend; in particular, many studies have focused upon the loss of a spouse. The majority of the widowed are older people, for whom the death of a spouse can leave a void that may never be filled, and research has called attention to the associated problems of financial support, changes in housing and daily routine, and social isolation. To be sure, the most extreme sense of desolation occurs with recency of bereavement and tends to decrease over the subsequent years (Kutner et al. 1956). Yet, numerous studies comparing widowed with married persons have consistently shown that the widowed have reduced contacts with their children, intensified feelings of loneliness, higher suicide rates, and higher death rates.

Some current issues

Two specific problems related to the meaning of death are engaging the research efforts of social scientists: the problems of an aging population who are approaching death, and the role conflicts experienced by those who must deal with death (doctors, nurses, ministers, life insurance agents, undertakers). There is increasing concern with the morale and living conditions of the aged. For instance, with death imminent, is disengagement from social relations to be preferred over continued activity (Cumming & Henry 1961)? Should age-homogeneous retirement facilities for the elderly be gradually developed? What are the relative responsibilities of public and private pension plans? Of the family? The solutions to such problems (of which there are many) are being sought by a wide variety of social science researchers.

Role conflicts among those who deal professionally with death are also being increasingly identified and studied. The clergy ponder the distinction between faith and therapy; doctors debate the Hippocratic mandate that life must be preserved at all costs; and nurses are caught between the demands of recuperating and dying patients. Life insurance agents attempt both euphemistic and realistic approaches in their efforts to bring into salience the uncertainty of life; while undertakers, constant reminders of the certainty of death, are berated as “grief therapists” and commercializers of ritual (Mitford 1963; Fulton 1965).

The ambiguity of death is also to be seen in various other fields of scientific advance. Although the law generally holds that death occurs when auscultation can no longer detect a heartbeat, such a definition is frequently made obsolete in routine medical practice. Distinctions are drawn between clinical death (of the organism) and biological death (of the organs), so that the time of death is increasingly a matter for decision, and moral questions arise as to the individual’s “right to die with dignity.” An important issue in the ethics of birth control is also involved—does the intrauterine device cause an abortion and hence a death? Furthermore, while science can neither prove nor disprove the hypothesis of some form of communication between living and dead, recent research in the field of parapsychology, reactivating an old tradition of psychic research (Myers 1903), is demanding attention from reputable scientists. To be sure, the “findings” of such research have not yet earned a place in the framework of modern science, but such efforts cannot be completely ignored. Finally, with the discovery that cells can be kept alive (apparently indefinitely) in a nutrient medium and that such cells can perhaps be reconstituted through the process of genetic transformation, biological immortality itself can no longer be entirely ruled out. Thus science in various ways challenges the social definition of death.

John W. Riley, Jr.

[Directly related is the entryAging. Other relevant material may be found inKinship, article ondescent groups; Life cycle; Llfe tables; Mortality; Ritual.]


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The physical extinction of its members, not all at the same time but all eventually, is a contingency that every human group must face. Each death initiates significant responses from those survivors who in some way have personally or vicariously related to the deceased. Inevitably, the collectivities in which the dead person held membership also react. Despite the social (symbolic) ambiguity presented by the dead body, the survivors continue to relate to it for some time with predeath imagery. At the same time, they must attempt to cope with emotions no longer secured within the pre-existing balance of interpersonal relations.

The reciprocal problem for the social group or collectivity remains the reassigning and reassembling of social roles and statuses, optimally in such fashion that not only is the social order in some measure re-established but the survivors affected by the death are re-equipped with images and symbols appropriate for building and sustaining an altered yet viable self-conception. This group problem forms the basis for the treatment of mortuary behavior that follows. No categorical separation is attempted between the personal and organizational dimensions of the subject. The emphasis remains, however, on the latter.

Death as passage

No social group socializes and controls members with a cosmology that categorically holds out death as nothing more than the total eclipse of the person. To the primitive and preliterate, the opposite orientation is more likely. The belief that life is not the end underlies some of the ritual behavior of all peoples. It is perhaps a necessary premise to the development of human culture.

A corollary premise suggests that the death of a society is inconceivable by its members, inasmuch as their belief and symbol systems link man and society reciprocally. Total obliteration of the person would so challenge the grounds for society’s existence that the very idea constitutes, in effect, a sacrilege.

Possibly the most elementary and universal response is found in the conception of death as a transition or journey, as a series of happenings rather than an event complete in itself. The notion of transition implies qualitative changes in time and place. Consequent to death, secular time and location are replaced by sacred time and existence in another world, in which the spirit is either absorbed or exists with some measure of individuality. Recognition cannot help but be given to physical dissolution of the dead body, but the force or entity that gave the body life is held to be only transformed but never extinguished. All great religious systems seemingly build on this principle; its universality directs attention, then, to death as a passage or as stages in the career of some life force that for a time inhabits the body but neither begins nor ends with it.

Channeling of death responses

For the survivors the death of an intimate has its most immediate diate consequence in vaguely or distinctly felt ambiguity and confusion. The intensity of the individual response will be roughly proportionate to the intensity of the interpersonal interaction, vicarious as well as face-to-face, that the survivor enjoyed with the deceased. For these individuals, as well as for the group, the response will in great measure vary with the difficulty of replacing the departed member in an ongoing system of role and status relationships.

The channeling of basic human sentiments is never an automatic process, nor is it possible to guarantee that the collectivity suffering such rupture in its affairs will not react so violently as to threaten all operating institutions. Whatever the rationale or general belief about the nature of death, elaboration into a set of operative prescriptions for behavior proceeds expeditiously in the context of symbolically ritualized ceremonials. The social prescriptions surrounding death do not unequivocally control the responses of individuals and groups to the phenomenon of death. Personal reactions where these prescriptions are embracing, as in preliterate, tribal societies, may seem reflexive. But it would be incorrect to assume that the emotional responses of the survivors must and do coincide exactly with the demands of a socially prescribed mortuary etiquette. Death of an intimate always results in some loss of the bereaved ego— an impoverishment of self—and when the association has been close, whether characterized by positive or negative sentiments, the loss will trigger off emotional responses that can overflow the channels for appropriate mortuary behavior provided by the culture.

The effectiveness of death rituals stems from the fact that, through the medium of a sacred-symbol system, they assist man in defining his relations to himself, his fellow man, and the cosmos. Rites are for the most part performed or engaged in collectively; the representations thus evoked and expressed in ritual carry the authority and sanction of society itself. Mortuary rites characteristically operate to give meaning and sanction to the separation of the dead person from the living, to help effect the transition of the spirit, soul, or life force into an otherworldly realm, and to assist in the incorporation of the spirit of the dead into its new existence.

Ritualization and the drama of funerals

Ritualization of mortuary behavior evokes new or changed self-conceptions, insofar as it serves to move people from moments of personal confusion and ego impoverishment toward a restructuring of identity. Through such ritualization the “work of grief,” as postulated in dynamic psychology, is expedited by the meaningful social interaction of the bereaved survivors. Since this interaction involves role playing, such rearrangement as occurs through the emergence of new or different roles resolves the anomaly of the incumbentless role created by death.

The actual disposal of the dead body is generally handled in a number of ritual-bearing scenes or episodes. Once properly prepared for the funeral, the corpse will receive some form of attention from the survivors. Family and close kin, friends and neighbors, usually have the greatest emotional involvement, although where kin, sib, and clan bonds are strong, more extensive prescriptions for mortuary behavior channel and sanction the emotional and physical behavior of the most closely, as well as the most distantly, related.

Funerals for the dead are matters of dramatic and sacred moment. The manner of disposal of the body, the role of the corpse in the ritual, and the utilitarian care of the dead is highly variable from group to group. Despite preliminary magico-religious prophylactic and propitiatory acts of the survivors, bodies may still be considered so representative of virulence and danger that, as in the case of the Kaingang in South America, they may be abandoned in terror. In like manner, the Navajo and other Indian tribes in the southwestern United States quickly bury the body along with many, if not all, of its earthly effects; the deceased’s dwelling, if he died there, is abandoned and never reused. At another extreme, common among the Malayo-Polynesians, the corpse may for a long period of time be kept on display close at hand, seemingly benign or positive in its influence, or be temporarily sequestered until the remaining burial rites are performed.

Disposal of the dead emphasizes the separation of the physical dead from the society of the living. The role of the specialist, such as the priest, medicine man, shaman, or spiritual intercessor, is crucial at this juncture, since it is through ritualized actions, organized into episodes or scenes, that both the dead and the living are moved on to new points of orientation and to new status positions. The point to be emphasized is that mortuary ceremonials affect the individual’s sense of identity, or self, and provide entry into and departure from the system of roles and status relationships in the society. It is for this reason that funerals have the basic potential for the highest order of social significance. Within the framework of mortuary ceremonies, society-specific patterns of belief and action centering on death and burial arise to express or achieve other purposes, among which are the descent of property, authority, and sexual privilege and the enhancement of a popular aesthetic of beauty in death; or the projection of cults of personality, rationality, or pragmatism. Dramatization of all such purposes—even that of expressing indifference—may achieve a measure of functional autonomy.

Robert W. Habenstein


Feifel, Herman (editor) 1959 The Meaning of Death. New York: McGraw-Hill.

Freud, Sigmund (1917) 1959 Mourning and Melancholia. Volume 4, pages 152–170 in Sigmund Freud, Collected Papers. International Psycho-analytic Library, No. 10. New York: Basic Books; London: Hogarth.

Fulton, Robert L. (editor) 1965 Death and Identity. New York: Wiley.

Gennep, Arnold van (1908) 1960 The Rites of Passage. London: Routledge; Univ. of Chicago Press. → First published in French. A classic anthropological essay on birth, puberty, marriage, childbirth, and death.

Gluckman, Max (editor) 1962 Essays on the Ritual of Social Relations. Manchester (England) Univ. Press.

Goody, J. R. 1962 Death, Property and the Ancestors: A Study of the Mortuary Customs of the Lodagaa of West Africa. Stanford (Calif.) Univ. Press.

Gorer, Geoffrey 1965 Death, Grief, and Mourning. New York: Doubleday.

Habenstein, Robert W. 1954 The American Funeral Director: A Study in the Sociology of Work. Ph.D. dissertation, Univ. of Chicago.

Habenstein, Robert W.; and Lamers, William M. 1961 Funeral Customs the World Over. Milwaukee, Wis.: Bulfin.

Henry, Jules 1964 Jungle People: A Kaingang Tribe of the Highlands of Brazil. New York: Random House.

Hertz, Robert (1907–1909) 1960 Death and The Right Hand. Glencoe, III.: Free Press. → First published as “La représentation collective de la mort” in Volume 10 of L’année sociologique, and “La prééminence de la main droite” in Volume 34 of Revue philosophique.

Kephart, William M. 1950 Status After Death. American Sociological Review 15:635–643.

Lindemann, Erich 1944 Symptomatology and Management of Acute Grief. American Journal of Psychiatry 101:141–148.

Malinowski, Bronislaw (1916–1941)1948 Magic, Science and Religion, and Other Essays. Glencoe, III.: Free Press. → A paperback edition was published in 1954 by Doubleday.

Radcliffe-Brown, A. R. (1922) 1948 The Andaman Islanders. Glencoe, I11.: Free Press.

Simmons, Leo W. 1945 The Role of the Aged in Primitive Society. New Haven: Yale Univ. Press.

Volkart, Edmund H.; and MICHAEL, STANLEY T. 1957 Bereavement and Mental Health. Pages 281–304 in Alexander H. Leighton et al. (editors), Explorations in Social Psychiatry. New York: Basic Books.

Warner, W. Lloyd 1959 The Living and the Dead: A Study of the Symbolic Life of Americans. New Haven: Yale Univ. Press.

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Accounts of the moments before and after death abound with reports of paranormal phenomena, including apparitions of the dying in distant places and phantom forms seen by the dying and occasionally by others. Such near-death apparitions remain a topic of intense debate in both psychological and parapsychological circles. Those who accept a psychic explanation of near-death experiences assert that the individual's spirit, when near to being freed from its connection to the body, is immersed in two planes of existence and acts in both the material and spiritual worlds. Many reports also exist in which persons who were dead returned to life and remembered their experience of death. They verify an often-told story that in the last moments of earthly existence a panorama of the person's life flashes by.

Near-Death Experiences

A Professor Heiron of Zurich slipped in the Alps on a snow covered crag, slid head first about a mile, and then shot 60 feet through the air, landing on his head and shoulders. He was not killed. Returning to consciousness, he not only testified to having seen a panoramic view of his life but also said he had heard the most delightful music. He interviewed many people who had a similar experiences; the great rapidity of mental action and the absence of terror and pain was narrated by all of them.

Prof. A. Pastore of the Royal Lyceum at Genoa relates his experience in the Annals of Psychic Science of February 1906:

"I have been through a very severe illness. At the crisis, when I had entirely lost consciousness of physical pain, the power of my imagination was increased by an extraordinary degree, and I saw clearly in a most distinct confusion (two words which do not accord, but which, in this case, are the only ones which will express the idea). I saw myself as a little boy, a youth, a man, at various periods of my life; a dream, but a most powerful, intense living dream. In that immense, blue, luminous space my mother met memy mother who had died four years previously. It was an indescribable sensation. Rereading the Phaedo of Plato after that experience, I was better able to under-stand what Socrates meant."

Still more is told by Leslie Grant Scott in Psychic Research (March 1931):

"Dying is really not such a terrifying experience. I speak as one who has died and come back, and who found Death one of the easiest things in lifebut not the returning. That was difficult and full of fear. The will to live had left me and so I died. I had been ill for some time but not seriously so. I was in a rundown condition, aggravated by the tropical climate in which I was then living. I was in bed, a large old fashioned bed, in which I seemed lost. I lay there quietly thinking and feeling more at peace than I had felt for some time. Suddenly my whole life began to unroll before me and I saw the purpose of it. All bitterness was wiped out for I knew the meaning of every event and I saw its place in the pattern. I seemed to view it all impersonally, but yet with intense interest and, although much that was crystal clear to me then has again become somewhat veiled in shadow, I have never forgotten or lost the sense of essential justice and rightness of things."

After telling of the doctor's visit and his attempts at reviving him, Scott continues:

"My consciousness was growing more and more acute. It seemed to have expanded beyond the limits of my physical brain. I was aware of things I had never contacted. My vision was also extended so that I could see what was going on behind my back, in the next room, even in distant places. I wondered if I should close my eyes or leave them open. I thought that it would be less gruesome for those around me if they were closed, and so I tried to shut thembut found that I could not. I no longer had any control over my body. I was dead. Yet I could think, hear and see more widely than ever before. From the next room came great engulfing waves of emotion, the sadness of a childhood companion. My increased sensitiveness made me feel and understand these things with an intensity hitherto unknown to me. The effort to return to my body was accompanied by an almost unimaginable sensation of horror and terror. I had left without the slightest struggle. I returned by an almost superhuman effort of will."

Sometimes, it appears, the return is automatic and against the will of the dying. In the Proceedings of the Society for Psychical Research (SPR) (vol. 8, 1892), F. W. H. Myers published the narrative of a Dr. Wiltse (first printed in the St. Louis Medical and Surgical Journal, November 1889), who, in a state of apparent death, lost all power of thought or knowledge of existence. Half an hour later, his narrative continues,

"I came again into a state of conscious existence and discovered that I was still in the body and I had no longer any interests in common. I looked with astonishment and joy for the first time upon myselfthe me, the real Ego, while the not me closed upon all sides like a sepulchre of clay. With all the interest of a physician I beheld the wonders of my bodily anatomy, intimately interwoven with which even tissue for tissue, was I, the living soul of that dead body. I realised my condition and calmly reasoned thus, I have died, as man terms death, and yet I am as much a man as ever. I am about to get out of the body. I watched the interesting process of the separation of soul and body. By some power, apparently not my own, the Ego was rocked to and fro, laterally as the cradle is rocked, by which process its connection with the tissues of the body was broken up. After a little while the lateral motion ceased, and along the soles of the feet, beginning at the toes, passing rapidly to the heels, I felt and heard, as it seemed, the snapping of innumerable small cords. When this was accomplished I began slowly to retreat from the feet, towards the head, as a rubber cord shortens. I remember reaching the hips and saying to myself: 'Now there is no life below the hips.' I can recall no memory of passing through the abdomen and chest, but recollect distinctly when my whole self was collected in the head, when I reflected thus: 'I am all the head now, and I shall soon be free.' I passed around the brain as if I were hollow, compressing it and its membranes slightly on all sides towards the centre and peeped out between the sutures of the skull, emerging like the flattened edges of a bag of membranes. I recollect distinctly how I appeared to myself something like a jelly-fish as regards colour and form. As I emerged, I saw two ladies sitting at my head. I measured the distance between the head of my cot and the knees of the lady opposite the head and concluded there was room for me to stand, but felt considerable embarrassment as I reflected that I was about to emerge naked before her, but comforted myself with the thought that in all probability she could not see me with her bodily eyes, as I was a spirit. As I emerged from the head I floated up and down and laterally like a soap bubble attached to the bowl of a pipe, until I at last broke loose from the body and fell lightly to the floor, where I slowly rose and expanded to the full stature of a man. I seemed to be translucent, of a bluish cast and perfectly naked. With a painful sense of embarrassment, I fled towards the partially open door to escape the eyes of the two ladies whom I was facing, as well as others whom I knew were about me, but upon reaching the door I found myself clothed, and satisfied upon that point, I turned and faced the company. As I turned, my left elbow came in contact with the arm of one of two gentlemen who were standing in the door. To my surprise, his arm passed through mine without apparent resistance, the severed parts closing again without pain, as air reunites. I looked quickly up at his face to see if he had noticed the contact but he gave me no signonly stood and gazed toward the couch I had just left. I directed my gaze in the direction of his, and saw my own dead body.

"Suddenly I discovered that I was looking at the straight seam down the back of my coat. How is this, I thought, how do I see my back? and I looked again, to reassure myself, down the back of the coat or down the back of my legs to the very heels. I put my hand to my face and felt for my eyes. They are where they should be, I thought. Am I like an owl that I can turn my head half way round? I tried the experiment and failed.

"No! Then it must be that having been out of the body but a few moments I have yet the power to use the eyes of the body, and I turned about and looked back in at the open door where I could see the head of my body in a line with me. I discovered then a small cord, like a spider's web, running from my shoulders back to my body and attaching to it at the base of the neck, in front.

"I was satisfied with the conclusion that by means of that cord, I was using the eyes of my body and turning, walked down the street. a small, densely black cloud appeared in front of me and advanced toward my face. I knew that I was to be stopped. I felt the power to move or to think leaving me. My hands fell powerless at my side, my shoulders and my head dropped forward and I knew no more.

"Without previous thought and without great effort on my part, my eyes opened. I looked at my hands and then at the little white cot upon which I was lying and, realising that I was in the body, in astonishment and disappointment I exclaimed: What in the world has happened to me? Must I die again?"

The clairvoyant description by Spiritualist medium Andrew Jackson Davis of the process of dying in Death and the After Life (1865) is often quoted. He writes:

"Suppose the person is now dying. It is to be a rapid death. The feet first grow cold. The clairvoyant sees right over the head what may be called a magnetic halo, an ethereal emanation, in appearance golden, and throbbing as though conscious. The body is now cold up to the knees and elbows, and the emanation has ascended higher in the air. The legs are cold to the hips and the arms to the shoulders; and the emanation, though it has not risen higher in the room, is more expanded. The death-coldness steals over the breast and around on either side, and the emanation has attained a higher position near the ceiling. The person has ceased to breathe, the pulse is still, and the emanation is elongated and fashioned in the outline of the human form. Beneath it is connected with the brain. The head of the person is internally throbbinga slow, deep throbnot painful, like the beat of the sea. Hence, the thinking faculties are rational, while nearly every part of the person is dead. Owing to the brain's momentum, I have seen a dying person, even at the last feeble pulsebeat, rouse impulsively and rise up in bed to converse with a friend; but the next instant he was gonehis brain being the last to yield up the life principle. The golden emanation, which extends up midway to the ceiling, is connected with the brain by a very fine life-thread. Now the body of the emanation ascends. Then appears something white and shining, like a human head; next, in a very few moments, a faint outline of the face divine; then the fair neck and beautiful shoulders; then, in rapid succession, come all parts of the new body down to the feeta bright shining image, a little smaller than its physical body, but a perfect prototype, or reproduction in all except its disfigurements. The fine life-thread continues attached to the old brain. The next thing is the withdrawal of the electric principle. When this thread "snaps" the spiritual body is free and prepared to accompany its guardians to the Summer Land. Yes, there is a spiritual body; it is sown in dishonor and raised in brightness."

The description is paralleled by the curious case sent by a Dr. Burgers to Richard Hodgson in 1902 and published in the Journal of the SPR (vol. 13, 1908). In it a Mr. G. gives this account of the death of his wife:

"At half-past six I urged our friends, the physician and nurses to take dinner. All but two left the room in obedience to my request.

"Fifteen minutes later I happened to look towards the door, when I saw floating through the doorway three separate and distinct clouds in strata. Each cloud appeared to be about four feet in length, from six to eight inches in width, the lower one about two feet from the ground, the others at intervals of about six inches.

"My first thought was that some of our friends were standing outside the bedroom smoking, and that the smoke from their cigars was being wafted into the room. With this idea I started up to rebuke them, when lo! I discovered there was no one standing by the door, no one in the hall-way, no one in the adjoining rooms. Overcome with astonishment I watched the clouds; and slowly, but surely these clouds approached the bed until they completely enveloped it. Then, gazing through the mist, I beheld standing at the head of my dying wife a woman's figure about three feet in height, transparent, yet like a sheen of brightest gold; a figure so glorious in its appearance that no words can be used fitly to describe it. She was dressed in the Grecian costume, with long loose and flowing sleevesupon her head a brilliant crown. In all its splendour and beauty the figure remained motionless with hands uplifted over my wife, seeming to express a welcome with a quiet glad countenance, with a dignity of calmness and peace. Two figures in white knelt by my wife's bedside, apparently leaning towards her; other figures hovered above the bed, more or less distinct.

"Above my wife, and connected with a cord proceeding from her forehead, over the left eye, there floated in a horizontal position a nude, white figure, apparently her astral body. At times the suspended figure would lie perfectly quiet, at other times it would shrink in size until it was no longer than perhaps eighteen inches, but always was the figure perfect and distinct; a perfect head, a perfect body, perfect arms and perfect legs. When the astral body diminished in size it struggled violently, threw out its arms and legs in an apparent effort to escape. It would struggle until it seemed to exhaust itself, then become calm, increase in size, only to repeat the same performance again and again.

"This vision, or whatever it may be called, I saw continuously during the five hours preceding the death of my wife. Interruptions, as speaking to my friends, closing my eyes, turning away my head, failed to destroy the illusion, for whenever I looked towards that deathbed the spiritual vision was there. All through these five hours I felt a strange feeling of oppression and weight upon my head and limbs; my eyes were heavy as if with sleep, and during this period the sensations were so peculiar and the visions so continuous and vivid that I believed I was insane, and from time to time would say to the physician in charge: 'Doctor, I am going insane.'

"At last the fatal moment arrived; with a gasp, the astral figure struggling, my wife ceased to breathe, she apparently was dead: however, a few seconds later she breathed again, twice, and then all was still. With her last breath and last gasp, as the soul left the body, the cord was severed suddenly and the astral figure vanished. The clouds and the spirit forms disappeared instantly, and, strange to say, all the oppression that weighed upon me was gone; I was myself, cool, calm and deliberate, able to direct, from the moment of death, the disposition of the body, its preparation for a final resting place."

Mr. G. was known to be hostile to Spiritualism, and the physician in attendance appended a statement to the effect that he had known him long enough to affirm that he had no tendency to any form of mental delusion.

Phenomena at Death

Watchers by the deathbed have often claimed to hear rushing sounds and see some kind of curious luminosity. Hyppolite Baraduc attempted to secure a photographic record when his son and wife died. He found that in each case a luminous, cloud-like mass apparently hovered over the bodies and appeared on the photographic plate.

Telekinetic phenomena (see movement ) have been known to occur before death. A Mme. Martillet and a Mme. Claudet, who nursed Alfred de Musset in his last illness, said that as he lay in his armchair they saw by the light of the lamp that he was looking at the bell near the mantelpiece. But he was so feeble that he could not rise. "At the moment," says Martillet, "we were surprised and frightened; the bell-pull that the sick man had not reached, moved, as if by an invisible hand, and my sister and I took each other's hands, saying: 'Did you hear? Did you see? He did not leave his chair.' The servant came, having heard the bell" (Annales des Sciences Psychiques [1899]).

Charles Richet, in a report on the case, inquires,

"Should the singular phenomena mentioned in all ages as accompanying a death or serious event be considered as akin to hauntings? There are legends of clocks stopping, pictures falling, some object noisily breaking, etc., but it is difficult to determine the part played by chance coincidence."

George Micklebury reported in the Daily Graphic (October 4, 1905) a startling instance of clairaudient premonition of impending death that occurred as he was listening to the High Mass in London. He suddenly heard his daughter's distressful voice: "Pray for me, father, I am drowning." Two friends, between whom he was kneeling, heard nothing, but asked him whether he was ill, because he looked so startled. After the mass he took a train to the farm where his daughter was working and found her in bed, alarmed, but safe. She had fallen into the river from a capsized boat and become entangled in weeds. She had lost consciousness before she was rescued. During the moments of unconsciousness, she said, she saw her father at High Mass between two friends, whom she named, and also saw Father Pycke, the celebrant. Then she saw no more.

The vision of traditional family apparitions, death-coaches, banshees, and phantasmal animals often proves to be a true premonition of death. In the Proceedings of the Society for Psychical Research (vol. 10, 1894), Mrs. E. L. Kearney narrates:

"My step-grandfather was lying ill in my father's house. I was coming downstairs when I saw a strange cat coming towards me along the hall. When it saw me it ran behind a green baize door which separated one part of the hall from the other. This door was fastened open, and I went forward quickly to hunt the strange cat (as I thought) away, but to my utter astonishment there was no cat there, or anywhere else in the hall. I at once told my mother (and she told me the other day that she remembers the occurrence). My grandfather died the next day. Taken in connection with the above the following is interesting. My mother told me that the day before he died she saw a cat walk round her father's bed: she also went to hunt it out, but it was not there."

After Death

The question, what happens immediately after death? is more difficult to answer since it is beyond observation and researchers must rely on accounts of after-death communications. They do not even know for certain whether the apparitions of the dead are the result of a voluntary effort or a simple repercussion of strong thought and emotions on the material plane.

Death-compact cases and purposive apparitions, conveying in some form a definite message, suggest conscious action of which the living remain ignorant. Such cases imply that the thoughts and emotional reactions of the dead may greatly depend on the circumstances of their dying. For example, a Private Dowding, who died by shell explosion, said through a medium.

"Something struck, hard, hard, hard against my neck. Shall I ever lose the memory of that hardness? It is the only unpleasant incident that I can remember. I fell, and as I did so, without passing through any apparent interval of unconsciousness, I found myself outside myself. You see, I am telling my story simply; you will find it easier to understand. You will know what a small incident dying is."

"Pelham" (the control of Leonora Piper ), who claimed to have died in a horse-riding accident, described his death as follows: "All was dark to me. Then consciousness returned but in a dim, twilight way as when one wakens before dawn. When I comprehended that I was not dead at all I was very glad." Significance should be attached to the phrase "When I comprehended."

According to numerous communications, many of those who died did not realize that they were dead at all, and finding themselves fully conscious and in a body which, to their perception, was just as material as the earthly one, refused to believe they were in the Beyond. It is still said that these "ghosts" keep performing their former actions in an aimless, automatic way the physician continues to visit his patients, the minister continues preaching. It is usually not until they meet the spirit of someone who died before them that they realize what has happened and begin to learn the conditions of their new existence.

Of the nature of this life, in spite of scores of descriptive accounts, man has only vague notions. William T. Stead, in a message quoted by Estelle Stead in a magazine article "My Father," is reported to have said, "When I think of the ideas that I had of the life I am now living, when I was in the world in which you are, I marvel at the hopeless inadequacy of my dreams. The reality is so much, so very much greater than ever I imagined. It is a new life, the nature of which you cannot understand."

A deceased friend of Richard Hodgson's gave an incoherent communication through Leonora Piper's husband. The control Pelham insisted that they should not go on because the spirit would be confused for some time, having suffered from headaches and neurasthenia while on Earth. Sometimes even the clearest minds give the impression of mental debility if they communicate too soon after death. Pelham said on this, "The words of the wisest persons who have left the material world but a short time ago are incoherent and inexact owing to the severe shock of being disincarnated and their arrival in a new environment where everything is unintelligible."

Public interest in death and claimed after-death communications is regularly stimulated by the loss of so many by unnatural causes during and immediately after wars. The intense interest in communicating with loved ones who have died frequently overrides a more rational approach to death. Many of the learned through the early twentieth century saw the secular approach as leading to an abandonment of belief in the afterlife by the public. However, numerous contemporary studies, such as those of Robert Crookall, who collected and collated hundreds of accounts of out-of-the-body travel experiences, have given a sense of scientific support to belief in survival of death and have contributed some knowledge of after-death consciousness. Whereas astral projection or out-of-body travel can be regarded as a temporary release from the physical body, death is the final release. Through the 1960s Crookall drew attention to many accounts from individuals who nearly died, or who were briefly dead but revived. Their accounts of another sphere of existence may have been colored by their religious background or expectations, but still demand careful consideration. In particular Crookall drew attention to reports of paradise and hell-like conditions in the accounts.

Since World War II a number of specialists in studies of death and dying (thanatology ) have arisen. While most of these studies have been rather mundane, the work of pioneering thanatologist Elisabeth Kübler-Ross has caught the popular imagination. Kübler-Ross is a psychiatrist who has spent many years dealing with dying patients and studying related states of consciousness. Her work since the early 1970s has added a spiritual dimension to the purely physical and medical aspects of death in dealing with terminally ill patients.

Experiences of the clinically dead have been widely reported by Raymond A. Moody, Jr., in his books Life After Life (1975) and Reflections on Life After Life (1977). A similarly conducted study by Kenneth Ring in 1978-79 confirmed many of Moody's observations (see Theta, vol. 7, no. 2, 1979).

A more specialized area of research into death has been the study of claims of reincarnation by psychiatrist Ian Stevenson and several associates at the University of Virginia. In the face of a growing belief in reincarnation by Westerners, a wide variety of attempts to demonstrate its reality have been made including those of hypnotists, such as Arnall Bloxham, who have obtained accounts from hypnotized subjects claiming to remember former earthly lives.


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Simpson, M. A. Death and Grief: A Critically Annotated Bibliography & Source Book of Thanatology and Terminal Care. New York: Plenum, 1979.

[Stead, William T.] Letters from Julia; or Light from the Borderland: A Series of Messages as to the Life Beyond the Grave Received by Automatic Writing. London, 1897.

Stevenson, Ian. Twenty Cases Suggestive of Reincarnation. New York: American Society for Psychical Research, 1966.

Stokes, Doris. Voices in My Ear. London: Futura, 1980.

Tyrrell, G. N. M. Apparitions. London, 1943. Reprint, New York: Macmillan, 1962.

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The idea of deaththe irreversible end to lifehas preoccupied, fascinated, and struck fear into human beings through the millennia. In the early twenty-first century, artists continue to sing about death, write about death, and depict it in paintings and photographs. Religious leaders are still talking about how to live a meaningful life in the face of death's inevitability. Governments go to war in the name of peace and the defense of the living, causing death on a massive scale. Ethicists and activists argue over the right to die, the right to live, the right to kill. Medical personnel strive to prevent it, are often present at the bedside of the dying, and pronounce when death has occurred. Biologists and physiologists puzzle over when it occurs and how it can be measured. Counselors, therapists, relatives, and dear friends help those who are dying make peace with their death, and help those left behind to live on. Young children wonder what has happened to their loved ones, and families struggle with their grief.

Defining Death

Death is clearly a part of lifeevery day. And yet, the word defies simple definition, because there are so many aspects to death and so many perspectives. A 1913 edition of Webster's Dictionary defined death as "the cessation of all vital phenomena without capability of resuscitation, either in animals or plants." The current Concise Oxford Dictionary defines death both as "dying" (a process) and as "being dead" (a state). As intoned in the Old Testament of the Bible, "All flesh is as grass" (Isaiah 40:68). The body dies but in the religious and philosophical traditions of many observers, the soul or spirit lives on.

The Roman Catholic Church, for example, advances the thought that death is the "complete and final separation of the soul from the body." The church, however, concedes that diagnosing death is a subject for medicine, not the church. In the Zen Buddhist and Shintō religious traditions, mind and body are integrated, and followers have difficulty accepting the brain-death criteria that are now common in Western medical and legal circles. For some Orthodox Jews, Native Americans, Muslims, and fundamentalist Christians, as long as the heart is beatingeven artificiallya person is still alive.

Advances in life-supporting technologies in the 1960s spawned the growth of medical ethics as a distinct field, and a new definition for physiological death was needed. For centuries death was indicated by the absence of a pulse or signs of breathing, but new technologies, including the respirator and heartlung machine, made it possible for physicians to artificially maintain heart and lung function, blurring clear signs of an individual's death. In the United States many states have adopted legislation recognizing brain deaththe loss of brain function, which controls breathing and heartbeatas the certification of death. Canada, Australia, and most of the nations of Europe and Central and South America have broader definitions for death: either loss of all independent lung and heart function, or the permanent, irreversible loss of all brain function.

From a physiological standpoint, somatic deaththe death of the organism as a wholeusually precedes the death of individual organs, cells, and parts of cells. The precise time of somatic death is sometimes difficult to determine because transient states, such as coma, fainting, and trance, can closely resemble the signs of death. Several changes in the body that occur after somatic death are used to determine the time of death and circumstances surrounding it. The cooling of the body, called algor mortis, is mainly influenced by the air temperature of the surrounding environment of the body. The stiffening of the skeletal muscles, called rigor mortis, begins from five to ten hours after death and ends in three or four days. The reddish-blue discoloration that occurs on the underside of the body, called livor mortis, is the result of blood settling in the body cavity. Shortly after death, blood clotting begins, along with autolysis, which is the death of the cells. The decomposition of the body that follows, called putrefaction, is the result of the action of enzymes and bacteria.

Bereavement, Grief, and Mourning

The word bereavement comes from a root word meaning "shorn off" or "torn up." It suggests that one has been deprived or robbed, dispossessed, left in a sad and lonely state. Bereavement is the state of being in which a person has suffered the death of a relative or friend.

Grief refers to the total range of emotions humans feel in response to a loss. The word suggests negative responses, including heartbreak, anguish, distress, guilt, shame, and thoughts of suicide. Grief also encompasses feelings of relief, anger, disgust, and self-pity.

Mourning is the expression of grief over someone's death. It is the process by which people incorporate the experience of loss into their ongoing lives. In mourning, a person searches for answers: How do I carry on in life? How do I survive this? Approaches to mourning are culturally prescribed: Each world culture has certain cultural "rules" for mourning in an appropriate manner. Mourning today is less formal than it was in the past, and so-called modern cultures are less formal in their rituals for mourning than traditional cultures.

Why Must People Die?

A number of answers to this question have been proposed by philosophically oriented biologists such as Sherwin B. Nuland and Basiro Davey and colleagues. The results of tissue cultures indicate that cells are "preprogrammed" by their genetic code to cease the dividing processes after a certain number of divisions have occurred, and then die. A further argument proposes that death is adaptive at the population level, ensuring that individuals do not compete with their offspring for scarce resources and instead channel precious energy into reproduction. Research accounts of the biochemical changes that occur in cells as they age support both these theories and a more straightforward "wear and tear" argument, indicating that death on a biological level can be understood as a combination of a number of factors.

These biological explanations for the occurrence of death focus on the process of aging. The death of younger people, especially one's own child, opens up broader philosophical questions that may be even more difficult to answer: "Why did my baby die, God?" is one of the ways human beings ask this type of question. If God truly is in his heaven and all is right with the world, why do babies die? Human beings have struggled with this type of question through the millennia, and there do not appear to be any definitive, widely accepted answers. Individuals seem to come to grips with such questions in an extraordinarily varied range of ways.

Historical Perspectives

In 1900 the average life expectancy at birth in the United States was 47 years, and this figure increased to a record high of 77.2 years a century later. The gap between female and male life expectancy peaked in 1979 when women outlived men an average of 7.8 years. By 2001 the gap was down to 5.4 years. That year, women lived an average of 79.8 years and men an average of 74.4 years. White males averaged 75.0 years and black males 68.6 years; white females averaged 80.2 years and black females 75.5 years (Arias and Smith).

In 1900 more than half of the deaths involved young people, age fourteen and younger. By 2001, only 1.6 percent of the total reported deaths occur among young people. Heart disease and cancer are the leading causes of death in the early twenty-first century, together accounting for more than half of all deaths in the United States each year. In order, the top fifteen leading causes of death, comprising fully 83.4 percent of all U.S. deaths in 2001, were: heart disease, cancer, stroke, chronic lower respiratory diseases, accidents (unintentional injuries), diabetes, influenza and pneumonia, Alzheimer's disease, kidney disease, septicemia (infection from microorganisms), intentional self-harm (suicide), chronic liver disease and cirrhosis, assault (homicide), hypertension, and pneumonitis (inflammation of the lungs) due to solids and liquids.

In the past century the experience of death has changed from a time when the typical death was rapid and sudden, often caused by acute infectious diseases such as tuberculosis, typhoid fever, syphilis, diphtheria, streptococcal septicemia, and pneumonia, to a time when the typical death is a slow, progressive process. In 1900 microbial diseases, often striking rapidly, accounted for about 40 percent of all deaths; in the early 2000s accounted for only about 3 percent. In sum, in the past century U.S. society has evolved from one in which many children and young people died to a society in which death has become increasingly associated with older-aged people. The U.S. infant mortality rate reached a record low level in 2001: 6.8 deaths per 1,000 live births.

Observers of this phenomenon have proposed a theory of epidemiologic transition, a three-stage model that describes the decline in mortality levels and the accompanying changes in the causes of death that have been experienced in Western populations. The first stage, called the Age of Pestilence and Famine, is characterized by high death rates that vacillate in response to epidemics, famines, and war. Epidemics and famines often go hand in hand, because malnourished people are susceptible to infectious diseases. The second stage, the Age of Receding Pandemics, describes a time in which death rates decline as a result of the improved nutrition, sanitation, and medical advances that go along with socioeconomic development. The third stage, labeled the Age of Degenerative and (Hu)man-Made Diseases, describes the period in which death rates are low (life expectancy at birth exceeds seventy years) and the main causes of death are diseases related to the process of aging. The biggest challenge to this theory comes from the emergence of new diseases (such as AIDS/HIV, Legionnaires' disease, and Lyme disease) and reemergence of old infectious diseases (such as smallpox and malaria) in the latter part of the twentieth century. HIV/AIDS, for example, took the lives of between 1.9 million and 3.6 million people worldwide in 1999.

According to the Population Reference Bureau, life expectancy at birth for the world's population at the turn of the twenty-first century was 67 years69 years for females, 65 years for males. In more developed countries life expectancy averaged 76 years79 years for females, 72 years for males. In less-developed countries, life expectancy averaged 65 years66 years for females, and 63 years for males.

Death throughout Art History

Death, an emotionally wrenching idea, has been both a subject for artists and an incentive for artistic production throughout history. Perhaps as much as, perhaps more than, any other subject, artists have dealt with death, dying, the threat of death, escape from death, thoughts of death, and preparation for death through the centuries.

The importance of death as a concept in ancient Egyptian culture is clearly seen in the creation of the pyramids and other burial artifacts. Ancient art in Greece focused on materialistic representations of life in an ideal state, including the physical perfection of its mythological heroes. This can be interpreted as art affirming life as the Greeks experienced it or desired life to be, and the cultural rejection of the finality of death. Looking at art in the Christian tradition with its focus on the death of its central figure, some art historians have described Christianity as a highly developed death cult; the idea of death, mediated through works of Christian art over the centuries, is ultimately affirming of life. Many artists in the period of the Enlightenment of the eighteenth century were commissioned to work in service to the lay aristocracy and eventually the merchant class. The social hierarchy in this time was reinforced through highly developed techniques in portrait painting. Portraiture, seen as self-constructed identity through painting, constitutes a large segment of traditional Western art. Thus, art during the Enlightenment was closely linked to the idea of personal mortality. Major themes in modern art include the importance of self-expression in the face of the forces of mass conformity and antihumanist ideas. The universal theme of mortality is seen in many modern works, and death remains firmly established as a central theme in contemporary art, though the themes surrounding the concept of death are not as likely to reflect religious, romantic, or metaphysical concerns as they were in earlier historical periods.

No one can predict future directions in artists' responses to death, but it is most likely that humankind will continue to look to these visionaries to both document and inform our thinking. Mourners in Greece during the early fifth century were depicted striking their heads, tearing out their hair, beating their breasts, and scratching their cheeks until they bled. Today, many find solace from the largest ongoing community arts project in the world, the AIDS Memorial Quilt. In both instances, artists helped society commemorate the lives of deceased loved ones, and they supported the living in their efforts to find meaning and the strength to endure their tragic feelings of loss.

The Psychology of Dying

The American psychiatrist Elisabeth Kübler-Ross developed a five-stage model of the psychology of dying and grief. In her book titled On Death and Dying (1969), she proposed that in response to the awareness of their impending death, individuals move through stages of denial, anger, bargaining, depression, and acceptance. Other authorities note that these stages do not occur in any predictable order, and feelings of hope, anguish, and terror may also be included in the range of emotions experienced.

Bereaved families and friends also go through stages from denial to acceptance. Grief can begin before a loved one has died, and this anticipatory grief helps lessen later distress. During the next stage of grief, after the death of the loved one, mourners are likely to cry, have trouble sleeping, and lose their appetite. Some feel alarmed, angry, or wounded by being left behind. After formal services for the deceased are over and conventional forms of social support end, depression and loneliness often occur.

Feelings of guilt are quite common, and in some cases individuals think seriously about taking their own life for somehow failing the loved one. This is especially true in response to the loss of a child. Though people often talk about healthy and unhealthy grief, it is very difficult to measure emotional pain in any precise way or advise how long one's grief should last. Many clinicians believe that those who abandon their grief prematurely are living in denial and make healing more difficult; but, on the other hand, it is also possible to become mired in despair. The death of a loved one, thus, threatens to take all the life out of the person who feels left behind.

Research on attitudes toward death and anxiety about death has been conducted mostly by social scientists around the world. There are more than one thousand published studies in this area, and four broad themes emerge from the findings:

  1. Most people think about death to some extent and report some fear of death, but only a small percentage exhibit a strong preoccupation with death or fear of death.
  2. Women consistently report more fear of death than men, but the difference in levels of fear is typically minor to moderate from study to study.
  3. Fear of death does not increase with age among most people.
  4. When considering their own death, people are more concerned about potential pain, helplessness, dependency, and the well-being of loved ones than with their own demise.

Death Education

The death-related experiences of most Americans and people in other Western and industrialized societies in the early twenty-first century are markedly different from how people experienced death a century ago. At present, death is much more likely to take place in a medical facility under the control of well-trained strangers. In the past, death more commonly was an intimate family event and usually took place at home with family members caring for the dying person. Loved ones were most likely present when the individual passed, and young children witnessed the events surrounding the death. The loved one's body was washed by the family and prepared for burial. A local carpenter or perhaps even family members themselves constructed a coffin, and the body lay in state for viewing by family and friends in the parlor of the home. Children kept vigil with adults and sometimes slept in the room with the body. The body was later carried to the gravesite, which might be on the family's land or at a nearby cemetery. The local minister would be present to read Bible verses and say goodbye, and the coffin would be lowered and the grave covered, perhaps by relatives.

In the early 2000s, death has been sanitized and separated from everyday lives. It is likely to happen in a high-tech, multilayered bureaucratic hospital. The body is soon whisked away from view. It is carefully prepared for viewing and subsequent burial by professionals with an artistic flair, and placed in an elaborate and expensive casket. The body is then carried via a dazzling motor coach to the cemetery for internment in a carefully draped burial plot giving little hint that the loved one will actually end up in the earth.

The choreography of the modern death and burial process has become so elaborate that many people react in frustration and dismay and seek more simple, emotionally connected experiences of death. At the same time, the field of death education has grown as colleges and universities create courses on death and dying. These courses include both formal instruction dealing with dying, death, and grief, plus considerable time invested in talking about the participants' personal experiences with death. These developments can all be interpreted as parts of a movement toward bringing death back into people's lives, as a painful and puzzling event to be explored, experienced, and embraced rather than denied and avoided.

See also Death and Afterlife, Islamic Understanding of ; Heaven and Hell ; Heaven and Hell (Asian Focus) ; Immortality and the Afterlife ; Suicide .


Arias, Elizabeth, and Betty L. Smith. "Deaths: Preliminary Data for 2001." National Vital Statistics Reports 51, no. 5 (2003): 1.

Arias, Elizabeth, et al. "Deaths: Final Data for 2001." National Vital Statistics Reports 52, no. 3 (2003): 21.

Carroll, Nöel. Philosophy of Art. London: Routledge, 1999.

Davey, Basiro, Tim Halliday, and Mark Hirst, eds. Human Biology and Health: An Evolutionary Approach. 3rd ed. Buckingham, U.K.: Open University Press, 2001.

DeFrain, John, Linda Ernst, and Jan Nealer. "The Family Counselor and Loss." In Loss during Pregnancy or in the Newborn Period: Principles of Care with Clinical Cases and Analyses, edited by James R. Woods Jr. and Jenifer L. Esposito Woods, 499520. Pitman, N.J.: Jannetti Publications, 1997.

DeSpelder, Lynne Ann, and Albert Lee Strickland. The Last Dance: Encountering Death and Dying. 7th ed. Boston: McGraw-Hill, 2005.

Kastenbaum, Robert. The Psychology of Death. 3rd ed. New York: Springer, 2000.

Kastenbaum, Robert, ed. Macmillan Encyclopedia of Death and Dying. New York: Macmillan Reference, 2003. See especially the entries on "Art History," "Causes of Death," and "Psychology."

Kübler-Ross, Elisabeth. On Death and Dying. London: Macmillan, 1969.

Nuland, Sherwin B. How We Die. London: Chatto and Windus, 1994.

Olshansky, Stuart Jay, and A. B. Ault. "The Fourth Stage of Epidemiologic Transition: The Age of Delayed Degenerative Diseases." Milbank Memorial Fund Quarterly 64 (1986): 355391.

Omran, Abdel R. "The Theory of Epidemiological Transition." Milbank Memorial Fund Quarterly 49 (1971): 509538.

Population Reference Bureau. "Life Expectancy at Birth by World Region, 2001." In 2003 World Population Data Sheet. Washington, D.C.: Population Reference Bureau, 2003.

Seale, Clive. Constructing Death: The Sociology of Dying and Bereavement. Cambridge, U.K.: Cambridge University Press, 1998.

Wollheim, Richard. Painting as an Art. Princeton, N.J.: Princeton University Press, 1987.

Wyatt, R. "Art History." In Encyclopedia of Death and Dying, edited by Glennys Howarth and Oliver Leaman, 3436. London: Routledge, 2001.

John DeFrain

Alyssa DeFrain

Joanne Cacciatore-Garard

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Death and Dying


Death is the end of life. Dying is the process of approaching death, including the choices and actions involved in that process.

Death has always been a central concern of the law. The many legal issues related to death include laws that determine whether a death has actually occurred, as well as when and how it occurred, and whether or not another individual will be charged for having caused it. With the development of increasingly complex and powerful medical procedures and devices in the middle and late twentieth century, the U.S. legal system has had to establish rules and standards for the removal of life-sustaining medical care. This would include, for example, withdrawing an artificial respirator or a feeding tube from a comatose person, or withholding chemotherapy from a terminally ill cancer patient. Such laws and judicial decisions involve the right of individuals to refuse medical treatment—sometimes called the right to die—as well as the boundaries of that right, particularly in regard to the state's interest in protecting life and the medical profession's right to protect its standards. The issues involved in death and dying have often pitted patients' rights groups against physicians' professional organizations as each vies for control over the decision of how and when people die.

Defining Death in the Law

The law recognizes different forms of death, not all of them meaning the end of physical life. The term civil death is used in some states to describe the circumstance of an individual who has been convicted of a serious crime or sentenced to life imprisonment. Such an individual forfeits his or her civil rights, including the ability to marry, the capacity to own property, and the right to contract. Legal death is a presumption by law that a person has died. It arises following a prolonged absence, generally for a prescribed number of years, during which no one has seen or heard from the person and there is no known reason for the person's disappearance that would be incompatible with a finding that the individual is dead (e.g., the individual had not planned to move to another place). Natural death is death by action of natural causes without the aid or inducement of any intervening instrumentality. Violent death is death caused or accelerated by the application of extreme or excessive force. Brain death, a medical term first used in the late 1960s, is the cessation of all functions of the whole brain. Wrongful death is the end of life through a willful or negligent act.

In the eyes of the law, death is not a continuing event but something that takes place at a precise moment in time. The courts will not wield authority concerning a death. The determination of whether an individual has died, and the way in which this is proved by the person's vital signs, is not a legal decision but rather a medical judgment. The opinion of qualified medical personnel will be taken into consideration by judges when a controversy exists as to whether an individual is still alive or has died.

Legal Death and Missing Persons

There is a legal presumption that an individual is alive until proved dead. In attempting to determine whether a person has died after having been missing for a certain period of time, the law assumes that the person is alive until a reason exists to believe otherwise.

The common-law rule is that where evidence indicates that the absent person was subject to a particular peril, he or she will be legally presumed dead after seven years unless the dis-appearance can be otherwise explained. The seven-year interval may be shortened if the state decides to enact legislation to change it. Some states may permit the dissolution of a marriage or the administration of an estate based on a mysterious disappearance that endures for less than seven years. A majority of states will not make the assumption that a missing person is dead unless it is reasonable to assume that the person would return if still alive.

A special problem emerges in a situation where a person disappears following a threat made on his or her life. Such an individual would have a valid reason for voluntarily leaving and concealing his or her identity. Conversely, however, the person would in fact be dead if the plot succeeded. A court would have to examine carefully the facts of a particular case of this nature.

In some states, the court will not hold that an individual has died without proof that an earnest search was made for him or her. During such a search, public records must be consulted, wherever the person might have resided, for information regarding marriage, death, payment of taxes, or application for government benefits. The investigation must also include questioning of the missing person's friends or relatives as to his or her whereabouts.

Death Certificates

The laws of each state require that the manner in which an individual has died be determined and recorded on a death certificate. Coroners or medical examiners must deal with issues establishing whether someone can be legally blamed for causing the death. Such issues are subsequently determined by criminal law in the event that someone is charged with homicide, and by tort law in the event of a civil suit for wrongful death.

The Nature of Dying

Because of the many advances in modern medicine, the nature of death and dying has changed greatly in the past several centuries. A majority of people in industrial societies such as the United States no longer perish, as they once did, from infectious or parasitic diseases. Instead, life expectancies range above 70 years and the major causes of mortality are illnesses such as cancer and heart disease. Medicine is able to prolong life by many means, including artificial circulatory and respiratory systems, intravenous feeding and hydration, chemotherapy, and antibiotics.

The cultural circumstances of death have changed as well. A study published by the American Lung Association in the late 1990s, indicated that 90 percent of patients who are in intensive care units of hospitals die as a result of surrogates and physicians deciding together to withhold life-sustaining medical care. This rate doubled from earlier in the decade.

Brain Death

In traditional Western medical practice, death was defined as the cessation of the body's circulatory and respiratory (blood pumping and breathing) functions. With the invention of machines that provide artificial circulation and respiration that definition has ceased to be practical and has been modified to include another category of death called brain death. People can now be kept alive using such machines even when their brains have effectively died and are no longer able to control their bodily functions. Moreover, in certain medical procedures, such as open-heart surgery, individuals do not breathe or pump blood on their own. Since it would be wrong to declare as dead all persons whose circulatory or respiratory systems are temporarily maintained by artificial means (a category that includes many patients undergoing surgery), the medical community has determined that an individual may be declared dead if brain death has occurred—that is, if the whole brain has ceased to function, or has entered what is sometimes called a persistent vegetative state. An individual whose brain stem (lower brain) has died is not able to maintain the vegetative functions of life, including respiration, circulation, and swallowing. According to the Uniform Determination of Death Act (§ 1, U.L.A. [1980]), from which most states have developed their brain death statutes, "An individual who has sustained either (1) irreversible cessation of circulatory and respiratory function, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead."

Brain death becomes a crucial issue in part because of the importance of organ transplants. A brain-dead person may have organs—a heart, a liver, and lungs, for example—that could save other people's lives. And for an individual to be an acceptable organ donor, he or she must be dead but still breathing and circulating blood. If a brain-dead person is maintained on artificial respiration until his or her heart fails, then these usable organs would perish. Thus, the medical category of brain death makes it possible to accomplish another goal: saving lives with organ transplants.

The Right to Die: Individual Autonomy and State Interests

The first significant legal case to deal with the issue of termination of life-sustaining medical care was in re quinlan, 70 N.J. 10, 355 A. 2d 647. This 1976 case helped resolve the question of whether a person could be held liable for withdrawing a life-support system even if the patient's condition is irreversible. In 1975, Karen Ann Quinlan inexplainably became comatose and was put on a mechanical respirator. Her parents authorized physicians to use every possible means to revive her, but no treatment improved her condition. Although doctors agreed that the possibility of her recovering consciousness was remote, they would not pronounce her case hopeless. When her parents themselves lost all hope of Quinlan's recovery, they presented the hospital with an authorization for the removal of the respirator and an exemption of the hospital and doctors from responsibility for the result. However, the attending doctor refused to turn off the respirator on the grounds that doing so would violate his professional oath. Quinlan's parents then initiated a lawsuit asking the court to keep the doctors and the hospital from interfering with their decision to remove Quinlan's respirator.

In a unanimous decision, the New Jersey Supreme Court ruled that Quinlan had a constitutional right of privacy that could be safeguarded by her legal guardian; that the private decision of Quinlan's guardian and family should be honored; and that the hospital could be exempted from criminal liability for turning off a respirator if a hospital ethics committee agreed that the chance for recovery is remote. Quinlan was removed from the respirator, and she continued to live in a coma for ten years, nourished through a nasal feeding tube.

In cases following Quinlan, courts have ruled that life-sustaining procedures such as artificial feeding and hydration are the legal equivalent of mechanical respirators and may be removed using the same standards (Gray v. Romeo, 697 F. Supp. 580 [D.R.I. 1988]). Courts have also defined the right to die according to standards other than that of a constitutional right to privacy. The patient's legal right to refuse medical treatment has been grounded as well on the common-law right of bodily integrity, also called bodily self-determination, and on the liberty interest under the due process clause of the fourteenth amendment. These concepts are often collected under the term individual autonomy, or patient autonomy.

Subsequent cases have also defined the limits of the right to die, particularly the state's interest in those limits. The state's interests in

cases concerning the termination of medical care are the preservation of life (including the prevention of suicide), the protection of dependent third parties such as children, and the protection of the standards of the medical profession. The interests of the state may, in some cases, outweigh those of the patient.

In 1990, the U.S. Supreme Court issued its first decision on the right-to-die issue, Cruzan v. Director of Missouri Department of Health, 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224. Cruzan illustrates the way in which individual and state interests are construed on this issue, but leaves many of the legal questions on the issue still unresolved. Nancy Cruzan was in a persistent vegetative state as a result of severe brain injuries suffered in an automobile accident in 1983. She had no chance of recovery, although with artificial nutrition and hydration could have lived another 30 years. Her parents' attempts to authorize removal of Cruzan's medical support were first approved by a trial court and then denied by the Missouri Supreme Court. Her parents then appealed the case to the U.S. Supreme Court.

The Court held that the guarantee of liberty contained in the Fourteenth Amendment to the Constitution does not prohibit Missouri from insisting that "evidence of the incompetent [patient's] wishes as to the withdrawal of treatment be proved by clear and convincing evidence." The Court left other states free to adopt this "clear-and-convincing evidence" standard but did not compel them to do so. Thus, existing state laws remained the same after the Cruzan decision. Although the Court affirmed that a competent patient has a constitutionally protected freedom to refuse unwanted medical treatment, it emphasized that an incompetent person is unable to make an informed choice to exercise that freedom.

The Court explained that the state has an interest in the preservation of human life and in safeguarding against potential abuses by surrogates and is therefore not required to accept the "substituted judgment" of the patient's family. The Court agreed with the Missouri Supreme Court ruling that statements made by Cruzan to a housemate a year before her accident did not amount to clear-and-convincing proof that she desired to have hydration and nutrition withdrawn. Cruzan had allegedly made statements to the effect that she would not want to live should she face life as a "vegetable." There was no testi mony that she had actually discussed withdrawal of medical treatment, hydration, or nutrition.

After the Court's decision, Cruzan's parents went back to the Missouri probate court with new evidence regarding their daughter's wishes. On December 14, 1990, a Missouri judge ruled that clear evidence of Cruzan's wishes existed, and permitted her parents to authorize withdrawing artificial nutrition and hydration. Cruzan died on December 27, 12 days after feeding tubes were removed.

Advance Directives

A court must consider many factors and standards in right-to-die cases. It must determine, for example, whether a patient is competent or incompetent. A competent patient is deemed by the court to be able to give informed consent or refusal relative to the treatment under consideration, whereas an incompetent patient (e.g., a patient in a coma) lacks the decision-making capacity to do so. According to the principle of individual autonomy, the court must honor the informed consent of competent patients regarding their medical care.

For incompetent patients who cannot make informed decisions regarding their care, an advance directive may provide a means of decision making for the termination of life-supporting treatment. An advance directive is a document, prepared in advance of incompetence, which gives patients some control over their health care after they have lost the ability to make decisions owing to a medical condition. It may consist of detailed instructions about medical treatment, as in a living will; or the appointment of a proxy, or substitute, who will make the difficult choices regarding medical care with the patient's earlier directions in mind. The appointment of a proxy is sometimes called a proxy directive or durable power of attorney. The patient names a proxy decision maker when he or she is competent. In other cases, the physician may appoint a proxy, or the court may appoint a legal guardian who acts on behalf of an incompetent person. Usually, a relative such as a spouse, adult child, or sibling is chosen as a proxy. If an advance directive provides adequate evidence of a patient's wishes, a decision about the termination of life support can often be made without involving a court of law.

For an incompetent patient whose preferences regarding medical care are known from prior oral statements, the patient's proxy may make a substituted judgment—that is, a judgment consistent with what the patient would have chosen for himself. If no preference regarding medical treatment is known, the standard for the proxy's decision is the "best interests of the patient." According to that standard, the proxy's decision should approximate what most reasonable individuals in the same circumstances as the patient would choose. Individual states have statutes governing the requirements for living wills and advance directives.

further readings

Callahan, Daniel. 1990. "Current Trends in Biomedical Ethics in the United States." Bioethics: Issues and Perspectives. Washington, D.C.: Pan American Health Organization.

Cohen-Almagor, Raphael. 2001. The Right to Die With Dignity: An Argument in Ethics, Medicine, and Law. New Brunswick, N.J.: Rutgers Univ. Press.

Council on Ethical and Judicial Affairs, American Medical Association. 1994. Code of Medical Ethics. Chicago: American Medical Association.

Ditto, Peter H., Joseph H. Danks, William D. Smucker, et al. 2001." Advanced Directives as Acts of Communication." Archives of Internal Medicine 161.

Howarth, Glennys, and Oliver Leaman, eds. 2001. Encyclopedia of Death and Dying. New York: Routledge.

Humphry, Derek. 1993. Lawful Exit: The Limits of Freedom for Help in Dying. Junction City, Ore.: Norris Lane Press.

——. 1991. Final Exit. Eugene, Ore.: Hemlock Society.

Monagle, John F., and David C. Thomasma. 1994. Health Care Ethics: Critical Issues. Gaithersburg, Md.: Aspen.

Schneider, Carl E., ed. 2000. Law at the End of Life: The Supreme Court and Assisted Suicide. Ann Arbor: Univ. of Michigan Press.

Urofsky, Melvin. 1994. Letting Go: Death, Dying, and the Law. Norman: Univ. of Oklahoma Press.


Euthanasia; Physicians and Surgeons; Power of Attorney.

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Death and Dying


Dying and death are profound aspects of the human experience. Social science research documents the fact that defining someone as "dying" is a social process. Although critical medical conditions certainly have a physiological basis, disease states are given significance through interpretation (Muller and Koenig). Perceptions that dying has begun and the meanings associated with those perceptions are contingent on a range of such social and cultural factors as the state of biological knowledge, the value of prolonging life or accepting finitude, the relative roles of religion, science, and medicine in creating meaning in everyday life, and personal familiarity with the dying transition. Dying today is shaped by particular notions of therapeutic possibility as well as ideals about approaching the end of life. The distinguishing feature about the process of dying today is that, to some degree, it can be negotiated and controlled depending on the preferences of the dying person, the goals of particular medical specialties, the organizational features of technology-intensive medical settings, and the presence and wishes of family members. It is impossible to think about death today except in language informed by institutionalized medicine.

A century ago, the leading causes of death in the United States were communicable diseases, especially influenza, tuberculosis, and diphtheria, and more than half of deaths occurred among individuals age fourteen or younger. During the twentieth century average life expectancy increased and the chance of dying in childhood was greatly diminished (Quadagno). Since the Second World War, heart disease, cancer, and stroke have become the leading causes of death. In 1995 they accounted for 67 percent of deaths for persons age sixty-five and older. The fact that more people than ever before are dying in advanced age of chronic conditions creates unprecedented challenges for individuals as they confront the dying process of relatives and friends, for the health care delivery system, and for American society as its members struggle to define and implement the idea of a "good death."

Medicalization of dying

In 1900 most Americans died at home, often surrounded by multiple generations of family members. By 1950 approximately half of all deaths occurred in hospitals, nursing homes, or other institutions. By the mid-1990s, 80 percent of Americans died in medical institutions, attended by paid staff. Persons over age sixty-five comprised less than 13 percent of the population, yet they represented 73 percent of all deaths in the United States in the mid-1990s. At the beginning of the twenty-first century, 55 to 60 percent of persons over the age of sixty-five die in the acute-care hospital, though patterns vary considerably across the nation (Institute of Medicine). Those persons fall into two distinct groups. The first includes elderly who were functioning independently until they were struck by a serious illness such as heart attack, stroke, or fractured hip. Most of those patients receive relatively intensive care. The second group includes people who are older, frail and debilitated, have multiple degenerative and chronic conditions, but are not clearly dying. The second group is larger, comprising 70 percent to 80 percent of elderly patients in the hospital. Individuals in that group may require repeated hospitalizations for supportive or intensive care, to stabilize conditions and treat acute problems (Scitovsky and Capron ).

As the place of death has shifted from the home to the hospital, medicine, as a system of knowledge, has become the dominant cultural framework for understanding death, the process of dying, and how to act when death approaches. Health professionals have the assumed responsibility, once held by family and community, for the care of persons at the end of life, and they now widely influence how that care is understood and delivered. Physicians have become the gatekeepers of the dying transition in the United States. They, rather than the dying person or family, define when the dying process has begun. This is most obvious in the hospital intensive care unit (ICU), where the inevitability of death frequently is not acknowledged until the end is very near, and the discontinuation of life-sustaining treatments often signifies the beginning of the dying process. Moreover, in the ICU, medical staff members are able to orchestrate and control the timing of death (Slomka).

A growing elderly population, cultural ambivalence about the social worth of the frail and very old, medical uncertainty about whether or not to prolong frail lives, and rising health care costs contribute to controversy both among health professionals and the wider public about decision-making and responsibility at the end of life. The costs of medical care, and especially the costs of intensive care, are high in the last months of life. Those rising costs have been the source of debates about rationing health care to elderly persons in order to reduce health care costs. For many people both within and outside of medicine, the value of prolonging life by technological means competes with the value of allowing death to occur without medical intervention. That cultural tension has given rise to a vast array of seemingly insoluble dilemmas about the management of dying. A vast literature in bioethics illustrates dilemmas in treatment and care for the dying elderly for which there are competing claims and no distinct solutions. Common dilemmas about technologically prolonging life include the following: whether or not to artificially feed (through a feeding tube) a person who can no longer feed him or herself; whether or not to place a person who has difficulty breathing on a mechanical ventilator; and whether or not to admit a dying person to an intensive care unit.

As more technological and clinical innovations become available, there is more that can be done to postpone death. The technological imperative in medicine to order ever more diagnostic tests, to perform procedures, to intervene with ventilators, medications, and surgery in order to prolong life or stave off death whenever there is an opportunity to do so is the most important variable in contemporary medical practice, influencing much decision-making at the end of life. There are no formulas that health professionals, patients, or families can use to decide between life-extending treatments and care that is not aimed at prolonging life. It is very common for patients, family members, and health professionals to feel obligated to continue aggressive medical treatment even though they do not wish to prolong the dying process.

The largest study ever conducted on the process of dying in the hospital was carried out in five university hospitals across the United States over a four-year period beginning in 1989 (SUPPORT Principal Investigators). In the first two-year phase of the project, 4,300 patients with a median age of sixty-five who were diagnosed with life-threatening illnesses, were enrolled. The SUPPORT investigators concluded that the dying process in the hospital was not satisfactory. For example, only 47 percent of physicians knew when their patients wanted to avoid cardiopulmonary resuscitation (CPR); 38 percent of patients who died spent ten or more days in an ICU preceding death; 46 percent of Do Not Resuscitate (DNR) orders were written within two days of death even though 79 percent of the patients had a DNR order; and for 50 percent of the conscious patients, families reported moderate to severe pain at least half the time in the three days preceding death. Even when a focused effort was made to reduce pain and to respect patient wishes regarding end-of-life care, no overall improvement in care or outcomes was made.

The technological imperative shapes activities and choices in the hospital even though death without high-technology intervention is valued by many in principle. One survey of nurses and physicians revealed that health professionals would not want aggressive life prolonging treatments for themselves, and many would decline aggressive care on the basis of age alone (Gillick, Hesse and Mazzapica). Approximately half of physicians and nurses interviewed in another study stated they had acted contrary to their own values by providing overly aggressive treatment (Solomon et al.).

Philosopher Daniel Callahan has noted that American society, including the institution of medicine, has lost a sense of the normal or natural life span, including the inevitability of decline and death. Callahan and other critics challenge the medical imperative of considering death as an option, one of several available to practitioners and consumers of health care (Callahan). Medicine pays little credence to the biological certainty of death; the tendency instead is to believe that dying results from disease or injury that may yield to advances in technology (McCue). Yet there is a lack of clarity about what constitutes normal aging and decline and what distinguishes them from disease.

Family members are sometimes confronted with the choice of prolonging the life of a person who they consider to have died already as the result of a stroke, a coma, or other serious condition that destroys or masks the personality of the individual. Such social death, when the person can no longer express the same identity as before the health crisis, occurs days, weeks, months, or years before biological death, when the physical organism dies. The discrepancy between social and biological death is one of the most difficult features of contemporary medical decision-making.

The use of hospice programs, in which clinical, social, and spiritual support are given to dying persons and their families without the intention of prolonging life, began in the United States in 1974. Hospice embodies a philosophy, originating with Dr. Cicely Saunders in Great Britain, that pain control, dignity, and the reduction of spiritual and psychological suffering are the most important goals of patient care as death approaches. Hospice care, delivered both in the home and institutional setting, has been growing steadily since the 1980s. Yet in 1995 only about 17 percent of all deaths (all ages) took place in a hospice setting. The notion of palliative care, medical care that seeks to reduce and relieve symptoms of disease during the dying process without attempting to effect a cure or extend life, is gaining support and acceptance among health care practitioners and the public, but the desire to control and conquer end-stage disease still strongly influences most medical thought and action (Institute of Medicine 1997).

Cultural diversity

There is not just one attitude or approach toward dying and death among Americans. Studies in the social science and health literatures on how cultural diversity influences patient, family, and provider responses to end-of-life treatments and decision-making have been appearing slowly but steadily since the mid-1980s. Two themes emerge from this research. First, health workers are trained in particular professional cultures and bring their own experiences to bear on the dying process. Physicians, nurses, social workers, chaplains, and other health care professionals hold different assumptions from one another about how death should be approached as a result of their different types of training, and those sets of assumptions differ from the experiences of patients and families (Koenig). Second, the relationships among ethnic identification, religious practices, ways of dying, and beliefs and priorities about care, autonomy, and communication are complex and cannot be neatly organized along ethnic, class, or professional lines. In assessing cultural variation in patient populations, for example, cultural background is only meaningful when it is interpreted in the context of a particular patient's unique history, family constellation, and socioeconomic status. It cannot be assumed that patients' ethnic origins or religious background will lead them to approach decisions about their death in a culturally specified manner (Koenig and Gates-Williams).

In an increasingly pluralistic society, there is growing diversity among health care workers as well as among patient populations. Especially in urban areas, the cultural background of a health professional is often different from that of a dying patient to whom care is being given. It is impossible and inappropriate to use racial or ethnic background as straightforward predictors of behavior among health professionals or patients. In their study of ethnic difference, dying, and bereavement, Kalish and Reynolds found that although ethnic variation is an important factor in attitudes and expectations about death, "individual differences within ethnic groups are at least as great as, and often much greater than, differences between ethnic groups" (p. 49). The impact of cultural difference on attitudes and practices surrounding death in the United States cannot be denied. The challenge for society is to respect cultural pluralism in the context of an actively interventionist medical system.

Sharon R. Kaufman

See also Bereavement; Hospice; Medicalization of Aging; Mortality; Palliative Care; Refusing and Withdrawing Medical Treatment.


Callahan, D. The Troubled Dream of Life: Living with Mortality. New York: Simon and Schuster, 1993.

Gillick, M.; Hesse, K.; and Mazzapica, N. "Medical Technology at the End of Life: What Would Physicians and Nurses Want for Themselves?" Archives of Internal Medicine 153 (1993): 25422547.

Institute of Medicine. Approaching Death: Improving Care at the End of Life. Washington, D.C.: National Academy Press, 1997.

Kalish, R. A., and Reynolds, D. K. Death and Ethnicity: A Psychocultural Study. New York: Baywood, 1976.

Koenig, B. "Cultural Diversity in Decision Making about Care at the End of Life." In Approaching Death: Improving Care at the End of Life. Institute of Medicine. Edited by M. Field and C. K. Cassel. Washington, D.C.: National Academy Press, 1997. Appendix E. Pages 363382.

Koenig, B., and Gates-Williams, J. "Understanding Cultural Difference in Caring for Dying Patients." Western Journal of Medicine 163 (1995): 244249.

Mccue, J. D. "The Naturalness of Dying." Journal of the American Medical Association 273 (1995): 10391043.

Muller, J., and Koenig, B. "On the Boundary of Life and Death: The Definition of Dying by Medical Residents." In Biomedicine Examined. Edited by M. Lock and D. Gordon. Boston: Kluwer, 1988. Pages 351374.

Quadagno, J. Aging and the Life Course: An Introduction to Social Gerontology. Boston: McGraw-Hill, 1999.

Scitovsky, A. A., and Capron, A. "Medical Care at the End of Life." An American Review of Public Health 7 (1986): 5975.

Slomka, J. "The Negotiation of Death: Clinical Decision Making at the End of Life." Social Science & Medicine 35 (1992): 251259.

Solomon, M., et al. "Decisions Near the End of Life: Professional Views on Life-Sustaining Treatments." Journal of Public Health 83 (1993): 1423.

SUPPORT Principal Investigators. "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients." Journal of the American Medical Association 274 (1995): 15911634.

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Death and Dying


DEATH AND DYING. In the last 400 years, life expectancies in America have increased, the leading causes of death have changed, and twentieth-century technology has spawned the invention of antibiotics, vaccines, organ transplants, cloning, and genetic engineering. But in seventeenth-century America, death was a terrifying and uncontrollable reality. Half of the original Pilgrims who landed at Plymouth died in the first winter of 1620–1621. Puritan tradition taught that death was a release from the world but juxtaposed this comfort with a fear of God's punishment for earthly sin.

Life in the colonies was made more precarious by infectious diseases, fevers, intestinal worms, spoiled food, and tainted water supplies. One in ten children died before the age of one, and forty percent of children did not reach adulthood. Epidemics (such as diphtheria, influenza, pneumonia, and smallpox), diseases, and accidents were the primary causes of adult deaths, together with frontier Indian wars. Death was so common, and Puritan beliefs so encompassing, that early colonists had no elaborate rituals for the dying or the dead. Funerals were simple; sermons focused on sin and the judgment of God rather than the individual. Bodies were wrapped in cloth (known as winding sheets) or a shroud for burial, and vigils were limited. Wood markers were used to mark graves and listed little more than a person's name. Images on markers were forbidden, and the focus was on preparing the soul to be judged, not on remembrance.

Eighteenth-century America treated death with more elaborate ritual, even though death continued to be a constant, if not more controllable, companion. One in seven children died in childhood, and life expectancies were limited by sweeping epidemics. Urban areas along the coast developed primitive sanitation systems and attracted physicians wishing to set up practice. But the general lack of medical advances (bleeding patients and applying herbal remedies were the mainstays of medical care), limited sanitation practices, poor food preservation, and military casualties during the Revolutionary War limited natural life spans. After the spiritual revivals of the 1730s and 1740s (known as the Great Awakening), colonists viewed death as a spiritual transition rather than a fearful judgment of God. American society embraced European traditions such as tolling the bell to announce deaths and publishing invitations to funerals. Bodies were laid out for vigil, allowing friends and family time to gather. Trinkets such as gloves or rings were offered to funeral participants in memory of the dead. The act of dying and the treatment of death had evolved into a more individualized and elaborate event. Care for the dying and the dead attended to the physical process of death while showing concern for the soul. Bodies were washed and wrapped (using a cloth shroud similar to a nightgown) to preserve them for visitation and were sometimes placed in icehouses or cellars to keep preserved until the funeral could take place. Stonemasons began producing permanent gravestones; the vivid symbols of skulls, the face of Medusa, and urns were carved on stones, as were epitaphs. By the end of the eighteenth century, an aesthetic of simplicity engaged the newly independent United States, and elaborate mourning rituals and funerals fell out of fashion. Death again became a simpler process, now focused on reunion with God and family in heaven. The gentler symbols of cherubs and mourning angels became popular.

The nineteenth century brought a period of expansion and abundance, followed by the Industrial Revolution. Medical advances remained limited until late in the century, and death rates remained high compared with twentieth-century standards. The child death rate remained high, and by 1850, one in sixty-six children died in childhood. Less than ten percent of all adults living in 1860 arrived at adulthood with both parents living and all siblings surviving. At the beginning of the nineteenth century, the average woman gave birth to seven children during her lifetime—a phenomenon that reflected the expectation that children would die from childhood diseases. As medical care, housing, and food preservation improved, birth rates decreased to an average of 3.5 children in 1900. As westward expansion distributed the population throughout the Deep South and the Midwest, Americans experienced a variety of climates and harsh living conditions. Frontier towns such as Detroit and St. Louis had open sewage lanes running through their main streets, and professional medical care was limited in rural areas. Influenza and scarlet fever epidemics plagued the North, and malaria and yellow fever epidemics spread through the South throughout the century, killing thousands at a time. The Civil War (1861–1865) brought the greatest carnage, resulting in an estimated 618,000 deaths by combat, disease, and imprisonment by 1865. This did not include the 472,000 wounded or the numerous civilian deaths caused by disease, malnutrition, and natural causes. It was generally believed in the nineteenth century that diseases were caused by bad air, vapors, and stagnant marshes. Physicians recommended little more for patients than limited bathing, a light diet, and fresh air. Bloodletting and narcotics such as opium powders were used as well, and medicinal concoctions, often laced with lead or mercury, were given as tonics. As a result, the sick often died from the remedies or became invalids. Dying had become such a natural topic of discussion that manuals and books of consolation on preparing the sick for death or coping with loss became popular.

The American middle class emerged in the 1830s, bringing with it a desire to be accepted by the affluent, which required that it follow the appropriate fashions, rituals, and etiquette of genteel society. Many etiquette and household manuals included a section on caring for invalids, laying out the dead, dressing in mourning, preparing a funeral, and decorating the home for mourning. Americans were highly influenced by English and French customs and adapted them to suit American society. Mourning, rather than the dead themselves, became the focus. Once a death had occurred, the body was laid out, washed, and dressed in a shroud or in formal attire. The hair was dressed, and locks were sometimes cut and saved for later use in hair jewelry, hair wreaths, or other memorials. The body was laid out for vigil in a coffin or on a bed in the family home. Concern for the preservation of the body became much more important to Americans, and the process of embalming bodies (removing the bodily fluids and replacing them with preservative chemicals) became common by the time the Civil War began. Wood, metal, and iron coffins were common throughout the nineteenth century, and floral wreaths and arrangements were placed on graves. The funeral industry had begun: cabinetmakers built coffins, liveries arranged or provided hearses and carriages, and professions such as "layers out of the dead" could be found in city directories. (Undertakers were known in England in the 1840s, but the first undertakers in the United States did not establish themselves until the 1870s.) Death was considered a gentle deliverance and was not feared as it had been by the early colonists. Private graveyards gave way to commercially designed cemeteries, where the dead could rest and the living could visit in a pastoral setting. Gravestones evolved into monuments and works of art, rife with symbolism such as weeping willows and hands pointing toward heaven. Epitaphs included more personal information, poems, and phrases such as "at rest" or "going home." Mourning was a feminine responsibility. Women wore black garb trimmed with crape, and veils to hide their faces; they also removed themselves from social activities. Photography brought a peculiar innovation to nineteenth-century death rites. For the first time, Americans could have photos of family members to remember them by. A culture of postmortem photography began in the 1840s and continued through the 1930s. Photos of the dead, of the family in mourning, and of funeral flowers and mementos became an option for mourning memorials.

The twentieth century brought gradual and sweeping changes in the way Americans dealt with death and dying. World War I led to the demise of the visual mourning so important to the Victorians. The emerging garment industry could not keep up with deaths caused by extensive European battles and the mass mourning that ensued. Mourning rituals that demanded special clothing and the mourner's removal from society became archaic luxuries. World War II furthered this trend, as women stepped out of the home and into factories to support the war effort. By 1970, most Americans were not wearing black for funerals and were not using any sign of visual mourning, such as black wreaths, crape, and memorials, in their homes.

The twentieth century also brought great strides in medical care, hygiene, and the extension of life. Vaccines, antibiotics, antiviral drugs, improved water and sewage systems, better food preservation, and food enhancements have allowed Americans to live healthier and longer lives. In 1900 the average life span was 47.5 years; by the end of the century, the average life span had increased to 76.5—a thirty-year increase in 100 years. Cultural focus has shifted to the "cult of youth"; death has become secondary, and for many Americans, the approach to death emphasizes the physical rather than the spiritual. This shift toward a focus on life has taken death outside the home and into hospitals, nursing homes, hospices, assisted living facilities, and funeral homes. This trend began when nursing homes and assisted living facilities were created to provide better medical care for the sick and the elderly. Responsibility for medical care was transferred from the family to corporations and government. Removal of the elderly from the family caused the focus on youth to grow, and the discussion of death and mourning became almost taboo. In the last years of the twentieth century, however, a growing elderly population increased compassion for the dying. Patients' rights, living wills, euthanasia, and assisted suicide have all become important concerns for Americans.

In modern America, bodies are no longer laid out in the home but taken to a morgue and then transferred to a funeral home, which carries out arrangements requested by the family. Family members do not participate in the process of washing and laying out the body, although they may still keep vigil through visitation at a local house of worship or funeral parlor. The funeral industry provides comprehensive services that include transportation and preparation of the body, caskets or cremation, visitation of the body, printing of memorial cards, transportation for the family, and the actual burial and service at the cemetery. Preservation of the body continues to be important in U.S. culture, though cremation is becoming more accepted. Cremation (burning of the body at a high temperature to reduce it to ashes) has been practiced since the Stone Age (circa 3000 b.c.). Cremation was common in pagan societies, but the early Christians associated it with paganism and rejected it. In 1873, crematoriums were reintroduced in Europe and were gaining acceptance by the 1880s. Americans did not openly accept cremation until about 1980, as funeral and burial costs have risen, and cremation remains one of the cheapest methods of disposal. Ashes are disposed of by burial or scattering or are kept in the home. Most Americans still prefer traditional burial, and preparation of the body includes embalming and dressing the corpse in favorite clothing. Unique to this century is the desire to make the body look lifelike by using cosmetics on the face and hands and dressing the hair. The second half of the century has also brought experiments with mummification, cryonics (freezing), and even sending bodies into space to preserve them. Preparation of the body is followed by display and visitation in a funeral home or house of worship, a funeral service, and interment at a cemetery or memorial garden. Persons who have chosen cremation are given a traditional funeral or memorial service after the family has had time to mourn. Visual presentations of mourning are limited to flowers, a memorial card, a hearse, and a procession with cars. Services in the late twentieth century have become very individualized and include favorite music, the display of scrapbooks and pictures, the deceased's favorite objects, or participation by clubs to which the deceased belonged. The funeral has become a celebration and remembrance of life rather than a mourning of death.

Since the late twentieth century, Americans have had many new death-related issues to contend with and choices to make. In the 1990s the leading causes of deaths in America were heart disease, cancer, and stroke. Since 1981, Americans have also had to contend with Acquired Immune Deficiency Syndrome (AIDS), a deadly epidemic that has killed over thirty-six million people worldwide since its discovery. Technology in the twentieth century expanded the frontiers of science and pushed the ethics of medicine to the brink. Organ transplants, chemotherapy, and other medical advances have improved the length and quality of life, and stem cell research, cloning, and genetic engineering are taking Americans into un-known realms of medical options.


Ariès, Philippe. The Hour of Our Death. New York: Knopf, 1981.

Callahan, Maggie, and Patricia Kelley. Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. New York: Bantam Doubleday Dell, 1997.

Coffin, Margaret M. Death in Early America: The History and Folklore of Customs and Superstitions of Early Medicine, Funerals, Burial, and Mourning. Nashville, Tenn.: Nelson, 1976.

Curl, James Stevens. The Victorian Celebration of Death. Phoenix Mill, U.K.: Sutton, 2000.

Halttunen, Karen. Confidence Men and Painted Women: A Study of Middle-Class Culture in America, 1830–1870. New Haven, Conn.: Yale University Press, 1982.

Jones, Barbara. Design for Death. Indianapolis, Ind.: Bobbs-Merrill, 1967.

Kübler-Ross, Elisabeth. On Death and Dying. New York: Scribners, 1997.

Mitford, Jessica. The American Way of Death Revisited. New York: Vintage, 2000.

Prothero, Stephen R. Purified by Fire: A History of Cremation in America. Berkeley: University of California Press, 2001.

Reich, Warren T., ed. The Encyclopedia of Bioethics. New York: Macmillan, 1995.

Karen RaeMehaffey

See alsoBioethics ; Cemeteries ; Epidemics and Public Health ; Funerary Traditions .

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Death and Dying

Death and Dying

Death is something that all human beings can expect to experience. But just as there are variations in when life is seen to begin, so too are there variations in when death is seen to occur. In Western cultures, death is assumed to occur when a person irreversibly stops breathing, their heart stops, and there is no evidence of brain activity (Frederick 2001), but this definition is not necessarily held by other cultures.

Death is a social construction, which means that it is defined by using words, concepts, and ways of thinking available in the culture (Kastenbaum 1998). Because this meaning is socially constructed, death can mean different things to different people, and the meaning can change over time for each person. Marilyn Webb (1997) writes about the cultural mix that is the United States:

American families in fact have widely different views on such crucial issues as the nature of death, necessary rituals, expectations of an afterlife, whether folk medicines or faith healers need to be involved in the medical process, whether or not the patient should even be told of a poor prognosis whether the patient or the family should be the primary decision maker, and who in the family should make decisions. (p. 214–215)

When one looks around the world, one can see evidence of differences in interpretations of death and dying and appropriate behavior in their regard. Death may be seen differently in other cultures, with questions not just about when and how death occurs, but what death is. As an example, persons who would be considered unconscious by Western physicians, would be seen as dead by people living on Vanatinai, a small island near Papua New Guinea, leaving the possibility that they could die over and over (Lepowsky 1985). Clearly, there are social and cultural constraints that act upon beliefs, attitudes, standards, and behavior with regard to death and dying.

Death Systems

Death systems (Kastenbaum 1998) are "the interpersonal, sociophysical and symbolic network, through which an individual's relationship to mortality is mediated by his or her society" (p. 59, emphasis in original). In one sense, we face death as individuals; in another, we face it as a part of a society and a culture. As indicated above, there is no single, consistent, cross-cultural view of death and how we are to respond to it. Death systems help the members of a particular group to know what death is and how to respond. A death system includes cognitive, emotional, and behavioral components and teaches the members of a group how to think, feel, and behave regarding death. Even when social groups share basic beliefs, such as religious beliefs, death systems will differ among groups, as Kathryn Braun and Rhea Nichols (1997) described in their study of four Asian-American cultures, and with groups over time, as Patricia Swift (1989) saw in the evolving death system of Zimbabwe.

Although death systems are most clearly seen in large cultural groups, the family, with its unique shared past, present, and assumed future, also maintains a death system. Its assumptions about who can and should participate in such things as a death watch, who should attend a funeral, what they should wear, and how they should behave are all elements of a family's death system. The family, as an intimate system, acts as a filter for information from the broader culture. Beliefs about what death means, if there is an afterlife and what it is like, may come from the broader culture, but these beliefs are mediated by the family's death system.

Family Relationships and Death

"There is no more emotionally connected system than the family, if for no other reason than because no one can ever truly leave it" (Rosen 1998, p. 17). Families are a collection of individuals, with a unique shared history and unique responsibilities to each other. Indeed, the understanding of family in its most expansive sense, includes all generations: those living, those dead, and those yet to be born (Rosen 1998). We may choose to sever ties by ending contact, or terminating legal responsibilities, but in truth, can never truly sever relationship ties. Family ties may be voluntary or involuntary, wanted or unwanted, central to our thoughts or held to the side, and they often extend beyond death.

For any system to operate, it needs certain functions to take place and roles to be played (Rosen 1998). Each family has its own unique structure, functions, relationships, roles and role responsibilities, and interaction patterns (Rando 1984). Family members often carry out many roles in the family, and the more central these roles are to the family's ongoing operation, the more disruptive is the loss of the person who carried them out.

Families also maintain a certain balance and achieve a predictability in normal day-to-day life (Rosen 1998). This can be challenging without the loss of a family member, because families must deal with normative change that comes from such simple things as normal aging of family members and the evolving character of relationships within the family (Doka 1993). When a crisis like a death occurs, the family is thrown into disorder. The stability that has been established in the family is disrupted and, in order to continue to function, the family must somehow regain some sort of stability and shift the various responsibilities among the remaining family members. Death is what Reuben Hill (1949) referred to as a crisis of dismemberment, an apt term for the loss of a part of the family body. This form of crisis occurs when a family member is lost to the family and his or her various role responsibilities must be shifted to at least one other family member.

The family's ability to adapt to a terminal illness or a death is affected by a variety of factors (Murray 2000): the timing of the illness or the death in the life cycle, the nature of the death itself, and the degree to which the loss is acknowledged— that is, the degree to which it is disenfranchised (Doka 1989), stigmatized, or both. In addition, if families have concurrent stressors, if the person is central to the family's operations, or if there was conflict with the person who is dying or has died, the family will be more vulnerable at this time. Families with a variety of resources within and outside the family as well as openness, flexibility, and cohesiveness are better able to handle the various stressors related to the death (Murray 2000).

The Dying Process—Moving Toward a Death

There is disagreement as to when dying begins. In a sense, dying begins at birth. As Colin Murray Parkes, Pittu Laungani and Bill Young (1997) note, "Life [is] an incurable disease which always ends fatally" (p. 7). Typically, though, dying is considered as starting at a point close to the end of one's life when a life-threatening illness or condition develops. A variety of approaches can be taken: dying can be seen as beginning when the facts are recognized by the physician, when the facts are communicated to the patient, when the patient realizes or accepts the facts, or when nothing more can be done to preserve life (Kastenbaum 1998). Kenneth Doka (1995–96) broke the process of dying into three phases: the acute, the chronic, and the terminal phases of dying, in which the individual initially is given the diagnosis, then lives with the disease and then, finally, succumbs to death.

Like the dying person, the family goes through their own dying process. Families who are faced with the potentiality of the death of a family member generally will follow a pattern of changes, according to Elliott Rosen (1998):

Preparatory phase. In this phase, fear and denial are common. The family may be highly disorganized and the illness is highly disruptive to normal family operation. The family turns inward and is protective of itself and of its members. Anxiety may be higher at this time than at any other point in the dying process.

Living with the disease/condition. This phase can be quite long, and the family may settle into their new roles within the family. Supporters may become comfortable in their caregiving role and adjust to the idea of death. This is an important adjustment, because a great deal of the care for the terminally ill is provided by family members (Mezey, Miller, and Linton-Nelson 1999). Other roles may shift throughout this phase, including those of the terminally ill person. The family may close itself off from others. The family may be less disorganized during this phase, but the reorganization may not be healthy if, for example, the family isolates themselves and refuses offers of help. Anxiety is related to finances, resource availability, and caregiving. As Doka (1998) notes, this phase "is often a period of continued stress, punctuated by points of crisis" (p. 163).

Final acceptance. Usually the shortest phase, death is accepted and family members may say goodbye, although not all family members are equally willing to accept the death. The family is again disorganized and in shock, and roles no longer work as they did in the last phase. The family may become anxious of how others will think of them and view them, which can cause the family to move to extremes, becoming closer or moving further apart.

Throughout this process of moving toward the biological death of the family member, some or all family members may see the dying person to be socially dead (Sudnow 1967). In this, the dying person is seen to be "already dead" with the result that they may then become more and more isolated, as others move on with their lives and visit less and less frequently.

In a model similar to Rosen's, Doka (1993) includes a fourth phase, which he calls recovery, where the family resumes and reorders family roles and expectations. This may take place relatively smoothly, or may be complicated by the reluctance of some family members to give up the roles they held during the illness.

The Family After Death

Froma Walsh and Monica McGoldrick (1991) proposed that in order to successfully adapt to the loss of their family member, the family must do the following:

Recognize the loss as real. Family members must acknowledge the loss as real while each family member shares his or her grief. In order to do this, family members must share emotions and thoughts with each other. Grief is an isolating experience; a sense of acceptance among members would be promoted by displays of tolerance of differences in behavior by family members.

Reorganize and reinvest in the family system. As indicated above, the family system is destabilized by the loss; yet for it to continue to function, order and control must be reclaimed. Family members must reconstruct what family means to them and the roles and related tasks of the person who has died must be reassigned or given up. Family life may seem chaotic at this time and there may be battles over how the family will be reorganized. Differences in grieving may contribute to a feeling of being out-of-synch among family members. To get in-synch, families must reframe, that is, relabel their differences as strengths rather than weaknesses. The family must reinvest itself in normal developmental evolution. Tasks that are carried out as a matter of course in families must again be carried out in the family. This reclaiming of a normal life may be seen by some as abandonment of the deceased loved one. Trying to avoid mention of the deceased may inhibit communication, contributing to a sense of secretiveness in the family. Family members should let each other hold onto the memory until releasing them feels voluntary.

According to Walsh and McGoldrick, open communication is essential to completion of these tasks. This process may be slow, as each family member has strong needs and limited resources after a loss. Family members, who are already more emotional, may not recognize each other's different grief styles as legitimate. Rituals like funerals, religious rites, even family holiday rituals, can be used to facilitate the process of recognition, reorganization, and reinvestment in the family.

See also:Acquired Immunodeficiency Syndrome (AIDS); Chronic Illness; Disabilities; Elders; Euthanasia; Grief, Loss, and Bereavement; Later Life Families; Health and Families; Hospice; Infanticide; Stress; Sudden Infant Death Syndrome (SIDS); Suicide; War/Political Violence; Widowhood


braun, k. l., and nichols, r. (1997). "death and dying infour asian american cultures: a descriptive study." death studies 21:327–360.

doka, k. j., ed. (1989). disenfranchised grief. lexington,ma: lexington books.

doka, k. j. (1993). living with life-threatening illness: aguide for patients, their families and caregivers. new york: lexington books.

doka, k. j. (1995–96). "coping with life-threatening illness: a task model." omega: journal of death and dying 32:111–122.

hill, r. (1949). families under stress; adjustment to thecrises of war separation and reunion. new york: harper.

kastenbaum, r. j. (1998). death, society, and human experience, 6th edition. boston: allyn and bacon.

lepowsky, m. (1985). "gender, aging and dying in an egalitarian society." in aging and its transformations—moving toward death in pacific societies, ed. d. r. counts and d. a. counts. lanham, md: university press of america.

mezey, m.; miller, l. l.; and linton-nelson, l. (1999). "caring for caregivers of frail elders at the end of life." generations 23:44–51.

murray, c. i. (2000). "coping with death, dying, andgrief in families." in families and change: coping with stressful events and transitions, ed. p. c. mckenry and s. j. price. thousand oaks, ca: sage.

parkes, c. m.; laungani, p.; and young, b. (1997). introduction to death and bereavement across cultures, ed. c. m. parkes, p. laungani, and b. young. london: routledge.

rando, t. (1984). grief, dying and death: clinical interventions for caregivers. champaign, il: research press.

rosen, e. j. (1998). families facing death: a guide forhealthcare professionals and volunteers. san francisco: jossey-bass.

sudnow, d. (1967). passing on: the social organization of dying. englewood cliffs, nj: prentice hall.

swift, p. (1989). "support for the dying and bereaved inzimbabwe: traditional and new approaches." journal of social development in africa 4:25–45.

walsh, f., and mcgoldrick, m. (1991). "loss and the family: a systemic perspective." in living beyond loss: death in the family, ed. f. walsh and m. mcgoldrick. new york: norton.

webb, m. (1997). the good death: the new americansearch to reshape the end of life. new york: bantam books.

other resource

frederick, c. j. (2001). "death and dying." microsoft encarta online encyclopedia, 2001. available from

kathleen r. gilbert

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Death and Dying

Death and dying


Death is the end of life, a permanent cessation of all vital functions. Dying refers to the body's preparation for death, which may be very short in the case of accidental death, or can last weeks or months in some patients such as those with cancer.


Risks of surgery

Specific risks vary from surgery to surgery and should be discussed with a physician. All surgeries and every administration of anesthesia have some risks; they are dependent upon many factors including the type of surgery and the medical condition of the patient. The patient should ask the anesthesiologist about any risks that may be associated with the anesthesia. Specific standards are set by the American Society of Anesthesiologists to enhance the safety and quality of anesthesia before surgery, basic methods of monitoring patients during surgery, and the best patient care during recovery.

Overwhelming data compiled in 2001 has confirmed that albumin is an effective marker of general nutrition; low albumin levels can increase the likelihood of post-surgery complications such as pneumonia, infection, and the inability to wean from a ventilator, by as much as 50%. In a national study of 54,000 surgery patients (average age of 61 years old), it was found that only one in five surgical patients were tested for low albumin before their operations.

In a study of 2,989 hospitalized patients admitted for more than one day, risk factors such as cholesterol levels (primarily low levels of high-density lipoprotein, HDL) and low serum albumin were associated with inhospital death, infection, and length of stay. During the study follow-up, 62 (2%) of the patients died, 382 (13%) developed a nosocomial infection, and 257 (9%) developed a surgical site infection.

The National Veterans Affairs Surgical Risk Study was conducted in 44 Veterans Affairs Medical Centers and included 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia. Patient risk factors predictive of postoperative death included serum albumin level, American Society of Anesthesia class, emergency operation, and 31 additional preoperative variables.

Other factors related to death during surgery are: increasing age, emergency surgery , and general postoperative complications including cardiac, renal, and pulmonary complications. Age-related changes in the immune system play a significant role in the increased risk of infection, decreased ability to fight diseases, and slower wound healing after surgery. An aging body is more susceptible to subsequent infections because of previous illness or surgery and the subsequent weakening of the immune system. The anti-inflammatory medications (e.g., to control conditions such as arthritis) that many older people take are also known to slow wound healing.

One study found that risk of death during coronary artery bypass graft surgery is associated with hospital volume, i.e., the number of surgeries performed. High volume hospitals had a lower mortality rate during surgery. Mortality decreased with increasing volume of surgeries performed (3.6% in low [less than 500 cases], 3% in moderate [500-1,000 cases], and 2% in high [over 1,000 cases] volume hospitals). Thus, the volume of surgeries performed may be an important consideration when selecting a hospital.

Complications of surgery

The most common complications to surgery that can prove fatal are infection, bleeding, and complications of anesthesia.

The Joint Commission's Board of Commissioners reviewed 64 cases related to operative and post-operative complications since the late 1990s. Of the events reviewed, 84% of the complications resulted in patient deaths, while 16% resulted in a serious injury. All of the cases occurred in acute care hospitals; cases directly related to medication errors or to the administration of anesthesia were excluded. Of these complications, 58% occurred during the postoperative procedure period, 23% during intraoperative procedures, 13% during post-anesthesia recovery, and 6% during anesthesia induction.

The following types of procedures were most frequently associated with these reported complications:

  • endoscopy and/or interventional imaging
  • catheter or tube insertion
  • open abdominal surgery
  • head and neck surgery
  • thoracic surgery
  • orthopedic surgery

Of the 64 cases reviewed, 90% occurred in relation to non-emergent (elective or scheduled) procedures. The most frequent complications by type of procedure included the following:

  • Naso-gastric/feeding tube insertion into the trachea or a bronchus.
  • Massive fluid overload from absorption of irrigation fluids during genito-urinary/gynecological procedures.
  • Endoscopic procedures (including non-gastrointestinal procedures) with perforation of adjacent organs. Of all abdominal and thoracic endoscopic surgery, liver lacerations were among the most common complications.
  • Central venous catheter insertion into an artery.
  • Burns from electrocautery used with a flammable prep solution.
  • Open orthopedic procedures associated with acute respiratory failure, including cardiac arrest in the operating room.
  • Imaging-directed percutaneous biopsy or tube placement resulting in liver laceration, peritonitis, or respiratory arrest while temporarily off prescribed oxygen.

Complications associated with misplacement of tubes or catheters usually involved a failure to confirm the position of the tube or catheter, a failure to communicate the results of the confirmation procedure, or misinterpretation of the radiographic image by a non-radiologist.

Preparing for death or incapacitation legally

An advance directive is a way to allow caregivers to know a patient's wishes, should the patient become unable to make a medical decision. The hospital must be told about a patient's advance directive at the time of admission. Description of the type of care for different levels of illness should be in an advance directive. For instance, a patient may wish to have or not to have a certain type of care in the case of terminal or critical illness or unconsciousness. An advance directive will protect the patient's wishes in these matters.

A living will is one type of advance directive and may take effect when a patient has been deemed terminally ill. Terminal illness in general assumes a life span of six months or less. A living will allows a patient to outline treatment options without interference from an outside party.

A durable power of attorney for health care (DPA) is similar to a living will; however, it takes effect any time unconsciousness or inability to make informed medical decisions is present. A family member or friend is stipulated in the DPA to make medical decisions on behalf of the patient.

While both living wills and DPAs are legal in most states, there are some states that do not officially recognize these documents. However, they may still be used to guide families and doctors in treatment wishes.

Do-not-resuscitate (DNR ) orders can be incorporated into an advance directive or by informing hospital staff. Unless instructions for a DNR are in effect, hospital staff will make every effort to help patients whose hearts have stopped or who have stopped breathing. DNR orders are recognized in all states and will be incorporated into a patient's medical chart if requested. Patients who benefit from a DNR order are those who have terminal or other debilitating illnesses. It is recommended that a patient who has not already been considered unable to make sound medical decisions discuss this option with his or her physician.

None of the above documents are complicated. They may be simple statements of desires for medical care options. If they are not completed by an attorney, they should be notarized and a copy should be given to the doctor, as well as to a trusted family member.

Mourning and grieving among cultures

The death of a loved one is a severe trauma, and the grief that follows is a natural and important part of life. No two people grieve exactly the same way, and cultural differences play a significant part in the grieving process. For many, however, the most immediate response is shock, numbness, and disbelief. Physical reactions may include shortness of breath, heart palpitations, sweating, and dizziness. At other times, there may be reactions such as loss of energy, sleeplessness or increase in sleep, changes in appetite, or stomach aches. Susceptibility to common illnesses, nightmares, and dreams about the deceased are not unusual during the grieving period.

Emotional reactions are as individual as physical reactions. A preoccupation with the image of the deceased, feelings of fear, hostility, apathy, emptiness, and even fear of one's own death, may occur. Depression, diminished sex drive, sadness, and anger at the deceased may occur. Bereavement may cause short- or long-term changes in the family unit and other relationships of the bereaved.

It is important for the bereaved to work through their feelings and not avoid their emotions. If emotions and feelings are not discussed with family members, friends, or primary support groups, then a therapist should be consulted to assist with the process.

Various cultures and religions view death in different manners and conduct mourning rituals according to their own traditions. In most cultures, visitors often come to express their condolences to the family and to bid farewell to the deceased. At times, funeral services are private. Various ethnic groups host a gathering after the funeral for those who attended. It is common for these events to become a celebration of the life of the deceased, which also helps the bereaved to begin the mourning process positively. Memories are often exchanged and toasts made in memory of the deceased. Knowing how much a loved one is cherished and remembered by friends and family is a comfort to those who experience the loss. Other methods of condolences include sending flowers to the home or the funeral parlor; sending a mass card, sending a donation to a charity that the family has chosen; or bringing a meal to the family during the weeks after the death.



Beauchamp, Daniel R., Mark B. Evers, Kenneth L. Mattox, Courtney M. Townsend, and David C. Sabiston, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. London: W. B. Saunders Co., 2001.

Coberly, Margaret. Sacred Passage: How to Provide Fearless, Compassionate Care for the Dying. Boston: Shambhala Publications, 2002.

Heffner, John E., Ira R. Byock, and Lra Byock, eds. Palliative and End-of-Life Pearls. Philadelphia: Hanley and Belfus, Inc., 2002.

Kubler-Ross, Elisabeth, and David Kessler. Life Lessons: Two Experts on Death and Dying Teach Us About the Mysteries of Life and Living. New York: Scribner, 2000.

Soto, Gary. The Afterlife. Orlando, FL: Harcourt Children's Books, 2003.

Staton, Jana, Roger Shuy, and Ira Byock. A Few Months to Live: Different Paths to Life's End Baltimore, MD: Georgetown University Press, 2001.

Sweitzer, Bobbie Jean, ed. Handbook of Preoperative Assessment and Management. Philadelphia: Lippincott Williams & Wilkins, 2000.


Byock, Ira, and Steven H. Miles. "Hospice Benefits and Phase I Cancer Trials." Annals of Internal Medicine 138, no. 4 (February 2003): 335337.

Smykowski, L., and W. Rodriguez. "The Post Anesthesia Care Unit Experience: A Family-centered Approach." Journal of Nursing Care Quality 18, no. 1 (January-March 2003): 515.


American College of PhysiciansAmerican Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106-1572. Washington Office: 2011 Pennsylvania Avenue NW, Suite 800, Washington, DC 20006-1837. (202) 261-4500 or (800) 338-2746. <>.

Hospice Foundation of America, 2001 S Street, NW, Suite 300, Washington, DC 20009. (800) 854-3402 or (202) 638-5419. Fax: (202) 638-5312. E-mail: <>.

Inter-Institutional Collaborating Network On End-of-life Care (IICN). (415) 863-3045. <>.

National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-4000. E-mail: NIHInfo@od. <>.

Promoting Excellence in End of Life Care, RWJ Foundation National Program Office, c/o The Practical Ethics Center, The University of Montana, 1000 East Beckwith Avenue, Missoula, MT 59812. (406) 243-6601. Fax: (406) 243-6633. E-mail: <>.

Washington Home Center for Palliative Care Studies (CPCS), 4200 Wisconsin Avenue, NW, 4th Floor, Washington, DC 20016. (202) 895-2625. Fax: (202) 966-5410. E-mail: <>.


American College of Physicians. "How to Help During the Final Weeks of Life." ACP Home Care Guide for Advanced Cancer. [cited March 2, 2003]. <>.

American College of Physicians. "What to Do Before and After the Moment of Death." ACP Home Care Guide. [cited March 2, 2003]. <>.

Byock, Ira, M.D. [cited March 2, 2003]. <>.

Kubler-Ross, Elisabeth, and Carol Bilger. On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Family. (Audio Cassette, Abridged edition.) New York: Audio Renaissance, 2000.

Jacqueline N. Martin, M.S. Crystal H. Kaczkowski, M.Sc.

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death Reports of the first human heart transplants in 1967 made controversy over the definition of death seem as unprecedented as heart transplantation itself — a radically new issue produced by a radically new technology. But disagreements over the meaning of death long predated the 1960s, and such debates never were simply products of new technical knowledge. From the intense fear in the eighteenth and nineteenth centuries that people were being mistakenly buried alive, to current controversies over brain death, death has long been a contested and changing construct, shaped by scientific discoveries in resuscitation and vivisection, the changing social powers of the medical profession, and changing cultural values. If death means the end of life, defining death implies defining life — a long-contentious issue indeed.


For much of the eighteenth and nineteenth centuries, an intense fear of ‘premature burial’ haunted Western culture, from the tales of Edgar Allen Poe to European laws that imposed long waiting periods before interment. This concern was neither an isolated curiosity nor an outbreak of mass hysteria. Rather, it reflected major changes in the concept of death itself, prompted in large part by new scientific discoveries in resuscitation and experimental vivisection. For example, beginning in the 1740s a series of widely-publicized cases demonstrated that breathing and heartbeats could be restarted after they had stopped. To make sense of such resuscitations, London physician John Fothergill proposed that suspended animation was a curable form of death. Like a machine, life could be turned off and on; reanimation was a form of resurrection. However Fothergill's view was rejected by such vitalists as Scottish medical theorist William Cullen (1710–90). Cullen redefined death, not as the actual cessation of heart and lung functions, but as the loss of the potential for muscle and nerve activity (‘irritability’ and ‘sensibility’). His approach reconciled resuscitation with the belief that death was by definition irreversible. However, it offered no way of diagnosing when this vital potential had been lost, and thus no way of knowing for certain when resuscitation efforts should be ended. Others rejected both these new definitions of death, denying that ‘suspended animation’ was real. They postulated that undetectable levels of heart and lung activity must by definitions have been continuously present in all cases of successful resuscitation.

The mid seventeenth-century discovery that the heart and lungs could be maintained alive in an animal that had been decapitated also challenged concepts of death, by dramatizing the distinction between the death of an organism and the death of its component parts. The guillotine, invented by a doctor to make execution swifter and more humane, also seemed to demonstrate that human heads and bodies could show signs of separate life. Based on such observations, many eighteenth-century medical writers concluded that death was not a single event but a long process taking place at a succession of physiological levels, and that death could not be diagnosed with certainty until the process had concluded with decomposition of body tissues. Such doctors' doubts about their own ability to diagnose or define death played a key role in triggering the cultural concern that people were being buried alive.

However, the specific fear of premature burial was not simply a product of medical uncertainty. To make sure that their bodies would be dead before burial, some people requested that they be cremated or embalmed. Their terror of being buried alive was more than simply a fear of being mistaken for dead. Romantic fascination with the claustrophobia of isolated helpless confinement, anti-Semitic opposition to traditional Jewish rapid interments, and post-Enlightenment doubts about the afterlife helped shape medical uncertainty about death into the specific horror of being buried too soon.


While the fear of premature burial was triggered by the discoveries of eighteenth-century scientists and physicians, late nineteenth-century doctors generally concluded that new technologies, from the stethoscope to X-rays had solved the problem of diagnosing death. These new instruments did not resolve any of the underlying conceptual controversies over the meaning of death, but an unprecedented faith in technology, from the 1880s through the first half of the twentieth century, led both the medical profession and much of the lay public to stop expressing concern over the persisting philosophical uncertainties. The fear of premature burial never disappeared, but it was largely relegated to such marginal organizations as the Association for the Prevention of Premature Burial, an international group of vitalists, anti-vivisectionists, and anti-bacteriologists, united by their opposition to the growing philosophical materialism and social power of twentieth-century medicine. Women also were disproportionately active in this movement. Some opposed the new technological medicine for undermining nineteenth-century women's efforts to integrate moral and physical healing. Others worried that women were particularly at risk of premature burial, because women were believed to be especially susceptible to fainting spells, catatonic fits, and spiritual trances that mimicked death.

Dramatic new discoveries, including recoveries from prolonged hypothermia and successful animal head transplants, continued to complicate the era's concepts of death. The resulting uncertainties were widely debated by scientists and the public. Many physiologists agreed with Boston embryologist Charles Minot that organisms were illusory, and that life and death could be defined only at the cellular level. Alternatively, neurologists like Charles Sherrington redefined the life of an organism as the nerve-mediated capacity to integrate organ and tissue functions. Mass culture, from journalism to science fiction, avidly reported these discoveries and disputes. However, unlike in prior centuries, when such scientific developments sparked public panic, in the first half of the twentieth century they were represented as wonderful marvels of modern science, possibly leading to resurrection or immortality. Also, while physiologists, philosophers, and the public continued to ponder the meaning of death, few of this era's practitioners of clinical medicine joined the discussion.

Since 1960

The brain death debates that began in the late 1960s thus did not constitute an unprecedented change in the meaning of death. But the 1960s did mark two new developments: a revival of interest in the issue on the part of clinicians, and a change from optimism to renewed concern on the part of the public. In the late 1960s, several medical leaders such as Harvard University anesthesiologist Henry K. Beecher proposed that patients be declared dead if their brains had irreversibly lost all functioning, even if their other vital functions were being maintained by mechanical ventilators. At first, ‘brain death’ was explained primarily as a means of defending organ transplantation, and of protecting medicine against the era's renewed social criticism of professional authority. But in the early 1980s, this representation of the issue was dramatically reversed. Brain death now was promoted, not as a defence of medical technology against public criticism, but as a defence of the public against that technology's invasive indignities. Redefining death was understood as logically distinct from euthanasia, but each provided a different way to answer the same clinical question: when should a physician stop treating a patient? Growing public support for a ‘right to die’ and ‘death with dignity’ proved crucial to the rapid adoption in the US of the brain death legislation advocated in the 1981 report of the President's Commission on bioethics. To diagnose brain death, the commission specified that the patient must have suffered permanent loss of all brain functions, both ‘higher-brain’ based activities, such as consciousness, and basic brain stem reflexes, such as gagging and pupil constriction. Great Britain adopted slightly different criteria, promoted by Christopher Pallis, under which the permanent loss of brain stem functions was considered sufficient to diagnose brain death.

Despite the success of brain death legislation, the fear of being treated too long was added to, not substituted for, the fear of being abandoned too soon. Mass culture continued to link brain death with organ-stealing doctors, as in the 1977 book and subsequent motion picture Coma. Orthodox Jews, traditionalist Japanese, and ‘right to life’ supporters are all deeply divided over whether to accept any brain-based definition of death. Some African Americans expressed concern that brain death was being used to take organs prematurely from blacks for transplantation to whites.

On the other hand, many philosophers, such as pioneer bioethicist Robert Veatch, attacked ‘whole brain’ legislation as failing to resolve crucial conceptual ambiguities. They promoted various ‘higher-brain’ alternatives that define human death as the permanent loss of consciousness and personal identity — as in the persistent vegetative state.

Thus, while the whole-brain definition of death has won wide acceptance, death remains a controversial and contingent concept, as it has been for centuries, at the intersection of changes in physiological research, medical practice, social structure, and cultural values.

Martin Pernick


Pernick, M. S. (1988). Back from the grave: recurring controversies over defining and diagnosing death in history. In Death: beyond whole-brain criteria, (ed. R. M. Zaner), pp. 17–74. Kluwer Academic Publishers, Dordrecht and Boston.
Pernick, M. S. (1999). Brain death in a cultural context: the reconstruction of death 1967–1981. pp 3–33 In The definition of death, (ed. S. Younger, R. Arnold, and R. Schapiro). Johns Hopkins University Press, Baltimore.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1981). Defining Death. US Government Printing Office, Washington, DC.

See also brain death; coma; corpse; euthanasia; funeral practices; life support; organ donation; resurrection; resuscitation; transplantation; vegetative state; zombie.

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Death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem), and breathing.


Death comes in many forms, whether it be expected after a diagnosis of terminal illness or an unexpected accident or medical condition.

Terminal illness

When a terminal illness is diagnosed, a person, family, friends, and physicians are all able to prepare for the impending death. A terminally ill individual goes through several levels of emotional acceptance while in the process of dying. First, there is denial and isolation. This is followed by anger and resentment. Thirdly, a person tries to escape the inevitable. With the realization that death is eminent, most people suffer from depression. Lastly, the reality of death is realized and accepted.

Causes and symptoms

The two leading causes of death for both men and women in the United States are heart disease and cancer. Accidental death was a distant third followed by such problems as stroke, chronic lung disorders, pneumonia, suicide, cirrhosis, diabetes mellitus, and murder. The order of these causes of death varies among persons of different age, ethnicity, and gender.


In an age of organ transplantation, identifying the moment of death may now involve another life. It thereby takes on supreme legal importance. It is largely due to the need for transplant organs that death has been so precisely defined.

The official signs of death include the following:

  • no pupil reaction to light
  • no response of the eyes to caloric (warm or cold) stimulation
  • no jaw reflex (the jaw will react like the knee if hit with a reflex hammer)
  • no gag reflex (touching the back of the throat induces vomiting )
  • no response to pain
  • no breathing
  • a body temperature above 86 °F (30 °C), which eliminates the possibility of resuscitation following cold-water drowning
  • no other cause for the above, such as a head injury
  • no drugs present in the body that could cause apparent death
  • all of the above for 12 hours
  • all of the above for six hours and a flat-line electroencephalogram (brain wave study)
  • no blood circulating to the brain, as demonstrated by angiography

Current ability to resuscitate people who have "died" has produced some remarkable stories. Drowning in cold water (under 50 °F/10 °C) so effectively slows metabolism that some persons have been revived after a half hour under water.


Only recently has there been concerted public effort to address the care of the dying in an effort to improve their comfort and lessen their alienation from those still living. Hospice care represents one of the greatest advances made in this direction. There has also been a liberalization of the use of narcotics and other drugs for symptomatic relief and improvement in the quality of life for the dying.


A contemporary physician who was a world authority on the subject of death and after-death states. Born in Switzerland on July 8, 1926, she worked as a country doctor before moving to the United States. During World War II she spent weekends at the Kantonspital (Cantonai Hospital) in Zürich, where she volunteered to assist escaped refugees. After the war she visited Majdanek concentration camp, where the horrors of the death chambers stimulated in her a desire to help people facing death and to understand the human impulses of love and destruction. She extended her medical background by becoming a practicing psychiatrist. Her formal work with dying patients began in 1965 when she was a faculty member at the University of Chicago. She also conducted research on basic questions concerning life after death at the Manhattan State Hospital, New York. Her studies of death and dying involved accounts by patients who reported out-of-the-body travel. Her research tends to show that while dying can be painful, death itself is a peaceful condition. Her 1969 text, On Death and Dying, was hailed by her colleagues and also became a popular best-seller.

In 1978 Kübler-Ross helped to found Shanti Nilaya (Final Home of Peace), a healing and growth center in Escondido, California. This was an extension of her well-known "Life-Death and Transition" workshops conducted in various parts of the United States and Canada, involving physicians, nurses, social workers, laypeople, and terminally ill patients. Much of Kübler-Ross's later research was directed toward proving the existence of life after death. Her publication To Live Until We Say Good-bye (1979) was both praised as a "celebration of life" and criticized as "prettifying" the real situation. She also dealt with issues such as AIDS and "near death" experiences. In the mid-1980s, Shanti Nilaya moved from San Diego County, California, to Head Waters, Virginia, where it continues to offer courses and short- and long-term therapeutic sessions.

Living will

One of the most difficult issues surrounding death in the era of technology is that there is now a choice, not of the event itself, but of its timing. When to die, and more often, when to let a loved one die, is coming within people's power to determine. This is both a blessing and a dilemma. Insofar as the decision can be made ahead of time, a living will is an attempt to address this dilemma. By outlining the conditions under which one would rather be allowed to die, a person can contribute significantly to that final decision, even if not competent to do so at the time of actual death. The problem is that there are uncertainties surrounding every severely ill person. Each instance presents a greater or lesser chance of survival. The chance is often greater than zero. The best living will follows an intimate discussion with decision makers covering the many possible scenarios surrounding the end of life. This discussion is difficult, for few people like to contemplate their own demise. However, the benefits of a living will are substantial, both to physicians and to loved ones who are faced with making final decisions. Most states have passed living will laws, honoring instructions on artificial life support that were made while a person was still mentally competent.


Another issue that has received much attention is assisted suicide (euthanasia). In 1997, the State of Oregon placed the issue on the ballot, amid much consternation and dispute. Perhaps the main reason euthanasia has become front page news is because Dr. Jack Kevorkian, a pathologist from Michigan, is one of its most vocal advocates. The issue highlights the many new problems generated by increasing ability to intervene effectively in the final moments of life and unnaturally prolong the process of dying. The public appearance of euthanasia has also stimulated discussion about more compassionate care of the dying.


Autopsy after death is a way to precisely determine a cause of death. The word autopsy is derived from Greek meaning to see with one's own eyes. A pathologist extensively examines a body and submits a detailed report to an attending physician. Although an autopsy can do nothing for an individual after death, it can benefit the family and, in some cases, medical science. Hereditary disorders and disease may be found. This knowledge could be used to prevent illness in other family members. Information culled from an autopsy can be used to further medical research. The link between smoking and lung cancer was confirmed from data gathered through autopsy. Early information about AIDS was also compiled through autopsy reports.



Finkbeiner, J. Autopsy: A Manual & Atlas. Philadelphia: Saunders, 2001.

Iserson, Kenneth B. Death to Dust: What Happens to DeadBodies? Tucson: Galen Press Ltd, 2001.

Mount, Balfour M. "Care of Dying Patients and Their Families." In Cecil Textbook of Medicine, edited by Lee Goldman, et al., 21st ed. Philadelphia: W.B. Saunders, 2000.

Sheaff, Michael T., and Deborah J. Hopster. Post Mortem Technique Handbook. New York: Springer Verlag, 2001.


Roger, V. L., et al. "Time Trends in the Prevalence of Atherosclerosis: A Population-based Autopsy Study." American Journal of Medicine 110, no. 4 (2001): 267-273.

Targonski, P., et al. "Referral to Autopsy: Effect of AtemortemCardiovascular Disease. A Populationbased Study in Olmsted County, Minnesota." Annals of Epidemiology 11, no. 4 (2001): 264-270.


American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (913) 906-6000.

American Medical Association. 515 N. State Street, Chicago, IL 60610. (312) 464-5000.

American Society of Clinical Pathologists. 2100 West Harrison Street, Chicago, IL 60612. (312) 738-1336.

College of American Pathologists. 325 Waukegan Road, Northfield, IL 60093. (800) 323-4040.

Hospice Foundation of America. 2001 S St. NW Suite 300, Washington, DC 20009. (800) 854-3402.


American Association of Retired Persons.

Association for Death Education and Counseling.

Death and Dying Grief Support.

National Center for Health Statistics.


Angiography X rays of blood vessels filled with a contrast agent.

Caloric testing Flushing warm and cold water into the ear stimulates the labyrinth and causes vertigo and nystagmus if all the nerve pathways are intact.

Electroencephalogram Recording of electrical activity in the brain.

Hospice Systematized care of dying persons.

Living will A legal document detailing a person's wishes during the end of life, to be carried out by designated decision makers.

Stroke Interruption of blood flow to a part of the brain with consequent brain damage, also known as a cerebrovascular accident (CVA).

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Within the popular Western Judeo-Christian tradition, death has usually been understood to be a consequence of original sin. This has, of course, not been a scientifically informed belief. And where theology has been in conversation with science on this point, or when theology is indirectly informed by a growing ecological consciousness, natural death in and of itself is increasingly seen as a natural piece of the creation that God called good.

Western religious perspectives

The growing perspective that death according to natural processes is not necessarily a consequence of sin would cohere with the early Christian tradition, as well as with Eastern Orthodox theology. The second-century Christian theologian Irenaeus, for example, emphasized how the first parents, as described in one of the Genesis accounts, were driven out of paradise so that they would not eat of the tree of life after they had sinned. Their being secured from that temptation by expulsion into a hard life was thus a giftfor who would want to live eternally estranged from God?and presupposes that they were mortal beings. Indeed, death was already part of the natural order designed by God. Eastern Orthodoxy reiterates this anthropology with its emphasis on the incarnation as more a leading of humanity into the next aspect of God's creative work than of rescue from sin and evil; the need for Christ to redeem the creation from the new exigency of sin was, as it were, added to the original agenda of leading the creation into the new age.

Western theology is beginning to adapt this perspective. Christian theologians like Karl Rahner (19041984) and Karl Barth (18861968) at the beginning of the twentieth century already recognized this impulse, and such thought is more advanced in this ecumenical age. Death is not so readily understood as an "evil." It is, rather, a "problem" in Christianity because sin became attached to it. Sin constitutes alienation from God, and thus the experience of death most often is attended by fear, loneliness, and loss. Though biblical scholars still debate the meaning of the apostle Paul's assertions that the wages of sin are death (Rom. 5:12) and that the travails of the creation are attributable to human sin, more and more exegetes are less willing to claim biblical warrant for the dominant Augustinian idea that physical death, along with physical suffering and corruptibility, are consequences of the Fall. Further, an ever more scientifically informed consciousness, one that ever more understands how consciousness itself has evolved from simple matter, is also less inclined to fix material processes, including natural physical death, in dualistic terms of good and evil. Concurrently, such consciousness may recognize that its own knowledge of finitudeand so, an intuited transcendenceis precisely the "problem" that is occasioned by fear of death.

Other religious perspectives are less ambivalent in asserting a spiritual origin to death, and will ascribe death more to God's direct agency than to natural processes. Islamic thought, like some Christian perspectives, links natural death more specifically to the will of God. The Qur'an teaches of death that God determines the span of a person's life: "He creates man and also causes him to die" (Qur'an, XLV:26). How this might cohere with Western religious notions of divine agency, design of creative processes, and so forth, are a ripe field for exploration as the science-theology dialogue begins more to engage Islamic scholars.

Eastern religious perspectives

Hindu tradition, with all its variety, is distinguished by the doctrine of the transmigration of the soul, that is, the passing at death of the soul from one body or being to another. Life and death are aspects of an eternal cycle, as over and against the linear understanding of time embedded in Western science and theology. This process of samsara refers to journeying or passing through a series of incarnational experiences. One's karma accompanies one through these stages, and can be roughly defined as the moral law of cause and effect. Some popular reflection attempts to correlate karmic doctrine with Newtonian physics. The thoughts and actions of the past determine the present state of being, and in turn present choices influence future states. This karmic process characterizes the ever-changing flow of everyday experience, as well as the successive rounds of deaths and rebirths. Each moment conditions the next, and karma impacts the reincarnational flow of being.

An interesting new trajectory might yet be explored with respect to the linking of the spirituality of Hindu self-abnegation and new science. According to Hinduism, underlying the apparent separateness of individual beings is a unitary reality. Just as the ocean is composed of innumerable drops of water, so undifferentiated being manifests itself in human experience as apparently separate selves. The goal of lifelivesis, in the end, to realize the eternal self, or Atman, which by nature defies description. This assuredly difficult task (of the realization of something beyond description) aspires to deliverance from a potentially endless cycle of birth, death, and rebirth. To achieve deliverance, one must act with pure insouciance and detachment, with no attentiveness to cause or effect or reward; "one must act without desire or purpose, independently of the results of the action (Kramer, p. 33)." Thereby the detached self dies to self and into Krishna, becoming a "True Self." The goal of Hindu religion, in other words, is to transcend or leave karma and its cause and effect activity behind, which is perhaps not unlike new science's movement away from Newtonian physics.

The general understanding of death in Buddhism in all its varieties (Zen, Tantric, etc.) is not greatly different from Hindu thought. Generally (there are notable variations in Buddhist thinking) Buddhism understands death as a transition toward either phenomenal rebirth or release from the phenomenal realm into pure nibbana (nirvana). Practicing a life that would ensure the latter, or at least ensure a return to a desirable station after rebirth, requires total moderation of self-will and desire. Death itself involves grieved losses; thus, a certain kind of pastoral care obtains at Buddhist funerals. Even so, death is a phenomenon to be transcended, and so a reality that is not as real or as significant as the transcendent. A Buddhist, in other words, might well question the relevance of an entry about death. Likewise with other Asian religions. Confucianism, the philosophy of Lao Tze, and Daoism, for example, significantly moderate the Buddhist perspective of death, and locate the meaning of life more in practiced simplicity and propitious behavior than in preparing for a hereafter. There are ritually correct ways to conduct life and death, and so human consciousness is at its best simply when it is attentive to the fullness of the present.

Death and ultimate destiny

Finally, the question of whether death is an end is, to be sure, energetically discussed. This, of course, is where religious faiths diverge from final entropy as the last word. Christians believe in a resurrection of the deadthough not necessarily in physicalist termswhich is subject to a coming judgment by God and the possibility of eternal joy (heaven) or despair (hell). Within Judaism, only the most mystical and apocalyptic fundamentalists share any similar concept. In the main, Judaism understands the legacy of a person's life as the moral example left to the next generations. Biophysically there is nothing more. Islamic thought, on another hand, is more detailed with respect to an afterlife and the Qur'an vividly describes the spiritual cum physical states of bliss or torment that await after death. Some of the above, though certainly not all, could cohere with contemporary scientific perspectives. Natural science understands death as the final expenditure of energy, as dissipation into stasis. Yet, that which has decomposed may well be fodder for the recycling of life. Stars turn to dust, stardust has come to mind in human being, human being may become again stuff for stars, and untold other phenomena. Nevertheless, death as a modus unto new, organized, and sentient life is not a theme that natural science readily explores or articulates.

See also Eschatology; Fall; Eternity; Karma; Life After Death; Transmigration


hefner, philip. the human factor: evolution, culture, and religion. minneapolis, minn.: fortress press, 1999.

kramer, kenneth, the sacred art of dying: how world religions understand death. new york: paulist press, 1988.

pannenberg, wolfhart. anthropology in theological perspective, trans. matthew j. o'connell. philadelphia: westminster, 1985.

reynolds, frank e. "death as threat, death as achievement." in death and afterlife: perspectives of world religions, ed. hiroshi obayashi. new york: greenwood press, 1992.

reynolds, frank e., and waugh, earle h., eds. religious encounters with death: insights from the history and anthropology of religions. university park: pennsylvania state university press, 1977.

duane h. larson

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Death and Dying


DEATH AND DYING. The certainty of death is something we share with our early modern ancestors, but they were more likely than we to die young and to experience throughout their lives a sequence of bereavements. Average life expectancy was shockingly low by modern (Western) standards: barely thirty in the seventeenth century. The averages are brought down by high infant mortality: around a quarter of children died in their first year, and barely half made it to their tenth birthday. For adults, remarriage after the death of a partner was commonplace. Nonetheless, suggestions that early modern people were somehow inured to death, making little emotional investment in young children, have been largely rejected by modern scholarship: there is plenty of evidence for deeply felt grief.

Throughout the period, epidemic disease was a major killer. Early modern Europe witnessed no pandemic on the scale of the "Black Death" of 13481349, but plague was a recurrent visitor, wiping out a quarter of London's population in 1563 and nearly half of Marseilles's in 1720. Plague disappeared from Western Europe in the early eighteenth century, but there was little protection against other virulent diseasestyphoid, dysentery, smallpox, influenza. In urban centers the death rate invariably exceeded the birth rate, and towns relied on immigration to sustain their populations. Periodic harvest failure and famine exacerbated the impact of disease. The 1590s were years of hunger across Europe, as were the 1660s and 1690s (when a third of Finland's population died). The "mortality regime" was punitive and changed little over the course of the early modern period.


If death was frequent and unpredictable, it was also highly ritualized. The late medieval church stressed the importance of a good death; pious texts taught the ars moriendi, the "art of dying." On the deathbed Christians felt particularly vulnerable to the wiles of the Devil, who might tempt them to despair and damnation. An elaborate sequence of "last rites"confession, communion, and anointing by a priestoffered some protection, though the moment of death remained fraught with danger, and "sudden death," with no opportunity to make amends for sin, was widely feared. Successful navigation of the deathbed was only the first stage toward eternal life with God in heaven. It was believed that since the ordinary good person could perform only a fraction of the penance due for their sins, the remainder would have to be paid off after their death, in purgatory. Images of fire and torment filled descriptions of purgatory, though it is unclear whether people typically lived in fear of the prospect or stoically accepted it as their lot. In any case, it was possible to ease the pains of souls there and hasten their passage to heaven by performing good works on their behalf, particularly by having masses said for them. A great deal of pre-Reformation religion was driven by a "commemorative impulse": the bequeathing of lands and goods in order to be remembered, and thus prayed for. For some reason, purgatory and intercessory prayer appear to have been a more marked feature of north European than of Mediterranean lands in the century before the Reformation.

The Protestant revolt against medieval Catholicism was from the outset deeply concerned with issues of death. Martin Luther's Ninety-Five Theses of 1517 questioned the pope's authority to issue indulgences (certificates remitting "time" spent in purgatory), and by 1530 Luther, with other reformers, had denounced the doctrine of purgatory itself. Purgatory offended Protestants because they could not find it in Scripture and because it seemed to undermine Christ's sacrifice upon the cross, making human beings active participants in the business of salvation. The doctrine of predestination held that God had from time eternal assigned all people to one of two destinations: heaven or hell. There was no room for a "middle place" and no possibility for the living to change the dead's preordained fate. In territories where the Reformation took hold, institutions (chantries and monasteries) whose purpose had been to intercede for the dead were dissolved, and requiem masses were abolished. Deathbed rituals were radically simplified, and the presence of a clergyman became less necessary. Most Protestant theologians taught, contrary to the medieval theory, that infants dying before baptism could still be admitted to heaven. In Catholic Europe, by contrast, the cult of the "holy souls" in purgatory was emphasized in the Counter-Reformation period.

Yet the dramatic changes of the Reformation were accompanied by underlying continuities. Protestants continued to display a concern with the "good death," and ars moriendi literature remained popular in both Catholic and Protestant societies. (To believers in predestination, appropriate deathbed demeanor might be an indication of "election.") Though Protestants were barred from praying for the dead, the impulse to commemorate them remained strong, finding expression in monuments and epitaphs and in a profusion of printed funeral sermons. The Reformation undoubtedly changed the relationship between the living and the dead, but it did not end it. Most evidence concerns the social elite, but it is at the level of popular belief that continuities were most marked. Though Protestant theologians taught that the souls of the dead could never return (and Catholic theologians imposed strict limitations on it), belief in ghosts was widespread. Indeed, some burial practices may have been concerned not so much with commemorating the dead as with providing protection against them. This was the case with the bodies of those committing suicidethe ultimate "bad death"which were often staked and interred at crossroads.


Moralists, Catholic and Protestant, presented death as a levelerthe artistic motif of the "Dance of Death" depicted popes, princes, and beggars linked by their common fate. Both before and after the Reformation, however, the delineation of rank was a major concern of funerary rites. This was particularly apparent in the case of royal funerals: the ritual was most elaborate in France, where it involved an eerily lifelike effigy of the deceased monarcha symbolic assertion of the survival of the king's "social body." Extravagant aristocratic funerals, involving vast amounts of black cloth, hundreds of mourners, and lavish distributions of charity sent out messages about the location of power in local communities. The poor were typically carried to the grave with little ceremony. Burial practices, too, reflected social status. In London, Paris, and some other urban centers, pressure on space led to the repositioning of cemeteries in suburban locations away from churchesa process under way throughout the period. But across much of Europe traditional patterns persisted: the elites could expect burial within the church building; the masses had to be content with the churchyard outside, where graves rarely received permanent markers and bones were periodically dug up to be stored in charnel houses. Those who had died "dishonorable" deaths (e.g., by execution) were refused burial in the churchyard and were often interred under the gallows or in other dishonored places. In Calvinist Scotland the authorities forbade church burial as "superstitious," but landowners got around the ban by erecting elaborate "burial aisles" on the side of churches. Early modern Europeans were unequal in death, as in so much else.

See also Medicine ; Plague ; Reformation, Protestant .


Ariès, Philippe. The Hour of Our Death. Translated by Helen Weaver. London, 1981. Translation of L'homme devant la mort (1977).

Gordon, Bruce, and Peter Marshall, eds. The Place of the Dead: Death and Remembrance in Late Medieval and Early Modern Europe. Cambridge, U.K., 2000.

Koslofsky, Craig M. The Reformation of the Dead: Death and Ritual in Early Modern Germany, 14501700. New York, 2000.

Marshall, Peter. Beliefs and the Dead in Reformation England. Oxford, 2002.

Peter Marshall

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Death and Dying

Death and Dying


Death is as much a cultural reality as it is a biological one. The only creature known to be aware of its inevitable demise, humans have dealt with their unique insight with considerable creative ritual and belief. Many have argued that religion, philosophy, consumerism, and even civilization itself were all created as antidotes to this terrifying insight (Becker 1973). Mythologist Joseph Campbell (1904-1987) hypothesized that mythmaking began with the first awareness of mortality, forcing early humans to seek purpose, to rationalize the irrational, and to deny deaths finality. Perhaps it should thus be of no surprise that much of what we know of past cultures is based on funerary artifactstheir attempts at death transcendence.

A cultures death system, or death ethos, determines such widely ranging phenomena as a peoples militancy and suicide rate; their preferences for bullfights, gladiator battles, or horror movies; their fears of or hopes for reincarnation and resurrection; their willingness to perform organ transplants or purchase life insurance; their decisions to bury, cremate, or eat their dead; and their attitudes toward capital punishment, abortion, and what constitutes a good death.

Cultures have been classified in terms of their death systems, shedding light on the meanings they give to life. Historian Arnold Toynbee (1889-1975), for example, categorized cultures by whether they are death-accepting or death-denying, hold a hedonistic or pessimistic view toward life, perceive death to be the end of existence or a transition to some personal or collective form of immortality, view corpses as sacred or profane objects, and whether or not the dead are believed to play an active role in the affairs of the living (and whether in a positive or negative way). In the death-defying West, for instance, strategies for salvation have historically featured activism and asceticism, whereas in the East they have often been more contemplative and mystical. In the West, postdeath conceptions typically involve the integrity and continuity of ones personal self; in the East, the ultimate goal is often an undifferentiated and impersonal oneness with the universe.

Changes in social solidarities (i.e., urbanization, religious pluralism), in selfhood (i.e., the shift from collectivist to individualistic identities), and in who dies and why, have historically produced several recognized epochs in the West, each featuring distinctive conceptions of death and funerary ritual. For most of human history, when life was short and death in the midst of life was a literal and not a figurative notion, cultural rituals and social systems were oriented to this fact. People were constantly reminded about times invariable passage and their inevitable mortal fate. Ancient Egyptians would have skeletons brought to their feasts; colonial Americans would daily walk past their church cemeteries, whose tombstones were adorned with skulls and crossbones. Death was tame, according to social historian Philippe Ariès (1914-1984). Deathbeds were community gathering places; public meeting spaces were often adjacent to mass graves whose contents were often partially visible. In early colonial America, realizing that two or three of their children would not survive until age ten, Puritan parents would send their offspring to family and friends as apprentices to avoid excessive attachments with them and the grief their deaths would cause (Stannard 1977).

According to Ariès, the contemporary era in the West features death denials and invisible death, fueling the illusion of immortality with institutions that conceal the dying (over 70 percent of Americans currently die within institutionalized settings) and that make the dead appear lifelike for funerary services. Those most likely to die are the old (nearly eight in ten deaths in the United States are those sixty and older), who are largely disengaged from many of their roles and physically segregated from other age groups in retirement communities and long-term care facilities. Gerontophobia, or fear of aging, has become interwoven with cultural thanatophobia, the fear of death.

So great is the power of an ethos, this construction of meaning thrown up against the terror of death, that social agencies invariably seek to harness its energy as a means of social controland to enhance the social status of their members. For instance, consider religions traditional threats of agonizing hells or bad reincarnations as a means for keeping the living in line. The power and status of the medical establishment increased dramatically during the last century with its growing ability to postpone death. Because of scientific breakthroughs, modern medicine has largely eliminated many traditional causes of premature death, especially infectious disease, and the medical establishment competes with religions traditional control over the dying process. Accordingly, death is shifting from being a moral rite of passage to a technological one. Traditional fears of postmortem judgment are morphing into fears of dying; those most likely to die, the old, fear being institutionalized within nursing homes more than they fear death.

With most premature death now the result of man-made and hence theoretically avoidable causes (e.g., accidents, homicides, and suicides), its occurrence has become increasingly tragic and highly politicized. Political rulers have long enforced their control through death squads, pogroms, war, capital punishment, and campaigns of fear. Disdaining such strategies, modern regimes instead establish legitimacy and citizen loyalty by thwarting (or at least predicting) the death threats of enemies with the countrys military forces, of lethal microbes with health care systems, of violent storms with weather satellites, of possible earthquakes or volcanic eruptions with seismic monitoring stations, and of potential asteroid or meteor collisions with telescope arrays.

Some of the most contentious moral debates in the contemporary United States center on the right to end life (e.g., capital punishment, physician-assisted suicide, and civilian casualties in military campaigns) and precisely where the line between life and death occurs, as in the controversies over abortion and euthanasia.

Materialism, individualism, secularism, and the distractions of consumer and popular cultures have not eliminated individuals fears of death nor their desires to transcend it. The proportion of Americans believing in an afterlife has generally increased over recent decades, with more than seven in ten confident that their existence does not conclude with death. At a minimum, cultural death systems promise at least symbolic immortality (Lifton 1979), such as being remembered through ones progeny or works of art, or surviving through the preservation of political or natural orders. Thus we witness the proliferation of such projects as halls of fame, the Social Security Administrations online database of deceased Americans, and Forbes magazines annual ranking of top-earning deceased celebrities.

SEE ALSO Euthanasia and Assisted Suicide; Funerals; Suicide


Ariès, Philippe. 1981. The Hour of Our Death. Trans. Helen Weaver. New York: Knopf.

Becker, Ernest. 1973. The Denial of Death. New York: Free Press.

Campbell, Joseph. 1974. The Mythic Image. Princeton, NJ: Princeton University Press.

Lifton, Robert. 1979. The Broken Connection: On Death and the Continuity of Life. New York: Simon and Schuster.

Stannard, David. 1977. The Puritan Way of Death: A Study in Religion, Culture, and Social Change. New York: Oxford University Press.

Toynbee, Arnold. 1980. Various Ways in Which Human Beings Have Sought to Reconcile Themselves to the Fact of Death. In Death: Current Perspectives, ed. Edwin Shneidman, 11-34. 2nd ed. Palo Alto, CA: Mayfield.

Michael C. Kearl

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157. Death

  1. Ah Puch deity of doom; represented as bloated corpse or skeleton. [Maya Myth.: Leach, 30]
  2. Ankou gaunt driver of spectral cart; collects the dead. [Brittany Folklore: Leach, 62]
  3. Anubis god and guardian of the dead. [Ancient Egyptian Rel.: Parrinder, 10]
  4. Arrow of Azrael angel of deaths way of summoning dead. [Islamic Myth.: Jobes, 129]
  5. As I Lay Dying Bundren family ordeal after Addies death. [Am. Lit.: Faulkner As I Lay Dying ]
  6. asphodel flower bloom growing in Hades. [Gk. Myth.: Kravitz, 37]
  7. Atropos Fate who cuts thread of life. [Gk. and Rom. Myth.: Hall, 302]
  8. Azrael angel of death; separates the soul from the body. [Islamic Myth.: Walsh Classical, 41]
  9. banshee female specter, harbinger of death. [Irish and Welsh Myth.: Walsh Classical, 45]
  10. bell passing bell; rung to indicate demise. [Christian Tradition: Jobes, 198]
  11. black Western color for mourning. [Christian Color Symbolism: Leach, 242; Jobes, 357]
  12. Bodach Glas gray specter; equivalent to Irish banshee. [Scot. Myth.: Walsh Classical, 45]
  13. Bran god whose cauldron restored dead to life. [Welsh Myth.: Jobes, 241]
  14. Bury the Dead six dead soldiers cause a rebellion when they refuse to be buried. [Am. Drama: Haydn & Fuller, 768]
  15. Calvary (Golgotha ) where Christ was crucified. [N.T.: Luke 23:33]
  16. Cer goddess of violent death. [Gk. Myth.: Kravitz, 75]
  17. Charun god of death. [Etruscan Myth.: Jobes, 315]
  18. Conqueror Worm the worm ultimately vanquishes man in grave. [Am. Lit.: Ligeia in Tales of Terror ]
  19. Dance of Death Holbein woodcut, one of many medieval examples of the death motif. [Eur. Culture: Bishop, 363-367]
  20. danse macabre Dance of Death; procession of all on their way to the grave. [Art: Osborne, 299300, 677]
  21. dust and ashes I am become like dust and ashes. [O.T.: Job 30:19]
  22. Endgame blind and chair-bound, Hamm learns that nearly everybody has died; his own parents are dying in separate trash cans. [Anglo-Fr. Drama: Beckett Endgame in Weiss, 143]
  23. Ereshkigal goddess of death; consort of Nergal. [Sumerian and Akkadian Myth.: Parrinder, 93]
  24. extreme unction Roman Catholic sacrament given to a person in danger of dying. [Christianity: RHD, 506]
  25. Gibbs, Emily dying in childbirth, welcomed by the other spirits in the graveyard, she tries to relive her twelfth birthday. [Am. Drama: Thornton Wilder Our Town in Benét, 747]
  26. Grim Reaper name given to personification of death. [Pop. Culture: Misc.]
  27. handful of earth symbol of mortality. [Folklore: Jobes, 486]
  28. horse symbol of agents of destruction. [Christian Tradition: N.T.: Revelation 6; Mercatante, 65]
  29. Ilyitch, Ivan afflicted with cancer, he becomes irritable, visits many doctors, gradually disintegrates, and dies almost friendless. [Russ. Lit.: Tolstoy The Death of Ivan Ilyitch in Magill III, 256]
  30. Kali Hindu goddess to whom Thug sacrificed victims. [Hinduism: Brewer Dictionary, 600]
  31. Krook rag dealer dies spectacularly and horribly of spontaneous combustion. [Br. Lit.: Dickens Bleak House ]
  32. Lenore saintly soul floats on the Stygian river. [Am. Lit.: Lenore in Hart, 468]
  33. Lord of the Flies showing mans consciousness and fear of dying. [Br. Lit.: Lord of the Flies ]
  34. manes spirits of the dead. [Rom. Rel.: Leach, 672]
  35. Mania ancient Roman goddess of the dead. [Rom. Myth.: Zimmerman, 159]
  36. Niflheim dark, cold region to which were sent those who died of disease or old age. [Scand. Myth.: Brewer Dictionary 642]
  37. nightingale identified with mortality. [Animal Symbolism: Mercatante, 163]
  38. On Borrowed Time an old man chases Death up a tree and keeps him there until the old man is ready to die. [Am. Drama: Sobel, 517]
  39. pale horse fourth horse of Apocolypse, ridden by Death personified. [N.T.: Revelation 7:78]
  40. Pardoners Tale, The seeking to slay death, three rioters are told he is under a certain tree; there they find gold and kill each other over it. [Br. Lit.: Chaucer The Pardoners Tale in Canterbury Tales ]
  41. Requiem religious mass (music or spoken) for the dead. [Christianity: Payton, 568]
  42. Rime of the Ancient Mariner, The when Death wins the toss of the dice, the two hundred crew members drop dead. [Br. Poetry: Coleridge The Rime of the Ancient Mariner]
  43. Sacco Benedetto yellow robe worn going to the stake during Inquisition. [Span. Hist.: Brewer Dictionary, 948]
  44. scythe carried by the personification of death, used to cut life short. [Art.: Hall, 276]
  45. skeleton visual representation of death. [Western Folklore: Cirlot, 298]
  46. skull representation of bodys dissolution. [Christian Symbolism: Appleton, 92]
  47. skull and crossbones symbolizing mortality; sign on poison bottles. [World Culture: Brewer Dictionary, 1009]
  48. Styx river which must be crossed to enter Hades. [Gk. Myth.: Howe, 259]
  49. Thanatos (Mors ) god of death; brother of Somnos (sleep). [Gk. Myth.: Gayley, 54]
  50. Thoth record-keeper of the dead. [Egyptian Myth.: Leach, 1109]
  51. Valdemar, M. in hypnotic trance, recounts impressions from other side of death. [Am. Lit.: The Facts in the Case of M. Valdemar in Portable Poe, 268280]
  52. viaticum Eucharist given to one who is dying. [Christianity: Brewer Dictionary, 1128]

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death, cessation of all life (metabolic) processes. Death may involve the organism as a whole (somatic death) or may be confined to cells and tissues within the organism. Causes of death in human beings include injury, acute or chronic disease, and neoplasia (cancer). The physiological death of cells that are normally replaced throughout life is called necrobiosis; the death of cells caused by external changes, such as an abnormal lack of blood supply, is called necrosis.

Somatic death is characterized by the discontinuance of cardiac activity and respiration, and eventually leads to the death of all body cells from lack of oxygen, although for approximately six minutes after somatic death—a period referred to as clinical death—a person whose vital organs have not been damaged may be revived. However, achievements of modern biomedical technology have enabled the physician to artificially maintain critical functions for indefinite periods.

Somatic death is followed by a number of irreversible changes that are of legal importance, especially in estimating the time of death. These include rigor mortis, livor mortis (discoloration of the body due to settling of blood), algor mortis (cooling of the body), autolysis (breakdown of tissue by enzymes liberated by that tissue after death), and putrefaction (invasion of the body by organisms from the gastrointestinal tract).

Brain death, which is now a legal condition in most states for declared death, requires that the following be absent for at least 12 hours: behavioral or reflex motor functions above the neck, including pupillary reflexes to testing jaw reflex, gag reflex, response to noxious stimuli, and any spontaneous respiratory movement. Purely spinal reflexes can remain. If the patient has agreed to be an organ donor, the observation period can be shortened to 6 hours.

As a result of recent refinements in organ transplantation (see transplantation, medical) techniques, the need has arisen to more precisely define medical death. The current definition is that of a 1981 U.S. presidential commission, which recommended that death be defined as "irreversible cessation of all functions of the entire brain, including the brain stem," the brain stem being that part of the brain that controls breathing and other basic body functions. Some feel, however, that people in persistent vegetative states, i.e., people who have brain-stem function but have lost higher brain functions (vision, abstract thought, personality), should be considered dead and allowed, through living wills or relatives, to donate organs.

See euthanasia; funeral customs; vital statistics.

See E. Kübler-Ross, On Death and Dying (1969); S. B. Nuland, How We Die (1994).

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112. Death

See also 63. BURIAL ; 99. CORPSES ; 232. KILLING

an obsession with suicide.
cerement, cerements
the cloth or clothing in which the dead are wrapped for burial or other form of funeral.
a place where the cremated remains of the dead are stored. cinerary , adj.
a vault where the remains of cremated bodies are kept, usually in one of a number of recesses in a wall.
crematorium, crematory
a place where cremations are done.
1. an inscription on a monument, as on a gravestone.
2. a short piece of prose or verse written in honor of a dead person. epitaphial, epitaphian, epitaphic, adj.
the deliberate killing of painfully ill or terminally ill people to put them out of their misery. Also called mercy killing .
the science of putting people to death.
1. the state or quality of being on the verge of death.
2. close to extinction or stagnant. moribund , adj.
an improvised funeral song, composed for the dead and sung by women in modern Greece. myriologist , n. myriologic , myriological, adj.
the worship of the dead.
1. an announcement of death; obituary.
2. a list of persons who have died within a certain time. Also necrologue . necrologist , n.
1. the magie practiced by a witch or sorcerer.
2. a form of divination through communication with the dead; the black art. Also nigromancy . necromancer , necromant, nigromancien, n. necromantie , adj.
an obsession with death or the dead.
an abnormal condition in which a person believes himself dead.
necrophilia, necrophilism
an abnormal, often sexual attraction toward the dead or a dead body. necrophile , n.
an abnormal fear of death. Also called thanatophobia .
the death or decay of body tissue, the result of loss of blood supply or trauma. necrotic , adj.
Rare. any learning that pertains to the dead.
a place or receptacle for the bones of the dead. Also called ossuary .
taphophilia, taphephilia
an excessive interest in graves and cemeteries.
resembling death; deathly.
the study of death or the dead. Also thanatism. thanatological, adj.
an obsession with death. See also necromania .
a survey of or meditation upon death.
the Eucharist given to one about to die; last rites or extreme unction. viatic, viatical, adj.

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Death. The human and religious imagination of the nature and meaning of death has been prolific: virtually everything that can be imagined about death has been imagined. Yet almost universally the major religious traditions did not in origin have any belief that there will be some worthwhile continuing life after death. This is in strong contrast to the popular impression that religions came into being to offer ‘pie in the sky’—i.e. some compensation for the miseries and inequalities of this life. This erroneous view was elevated to a formal theory by such anti-religious theorists as Marx and Freud.

In fact, the early human imagination of death was entirely realistic: since the breath returns to the air and the body to the dust, there is nothing that can survive. Thus in both E. and W., the emphasis originally was on the positive worth of this life, not on some imagined heaven or hell.

The development of beliefs that there may be life beyond death (see AFTERLIFE) came about historically in different ways and with different anthropologies (accounts of human nature) in different religious traditions. In the Judaeo-Christian tradition, the belief developed in the 3rd or 2nd cent. BCE that the ‘friendship with God’ (as Abraham's relationship with God was described) might perhaps be continued by God through death. The imagination of how God might bring that about then varied.

In the E., the sense that death can be contested and, in favourable circumstances (especially with the help of sacrifices), be postponed, led to the belief in Hinduism that a self or soul is reborn many millions of times as it moves toward mokṣa (release). In early Buddhism, it was accepted that there is continuing reappearance, but no self or soul being reborn. In China, the caution of Confucius was widely prevalent: ‘Confucius said, “If we are not yet able to serve humans, how can we serve spiritual beings?” Tzu-lu then said, “Then let me ask you about death.” Confucius said, “If we do not yet know about life, how can we know about death?” ’ But in the Immortality Cult, and even more in the development of Taoism, the quest for immortality was undertaken in the schools of alchemy, sometimes literally, more often in spiritual terms.

On the basis of these understandings of death, different religions have expressed different preferences in the treatment of dead bodies: see CREMATION; FUNERAL RITES. They have also been in agreement to a large extent that excessive grief or mourning is inappropriate. See also AFTERLIFE.

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death often (as Death) represented in art and literature as a skeleton or an old man holding a scythe, the personification of the power that destroys life.
death in the pot a biblical phrase, from the story of a famine during which a pottage containing poisonous herbs was made by Elisha's servant for the sons of the prophets; when they cried out, ‘O thou man of God, there is death in the pot’ (2 Kings 5:40), Elisha added meal to the dish, and they were able to eat it safely.
death is the great leveller all people will be equal in death, whatever their material prosperity. The saying is recorded in English from the early 18th century, but the Alexandrian-born Latin poet Claudian (370–c.404) has, ‘omnia mors aequat [death levels all things].’
death knell the tolling of a bell to mark someone's death; in figurative usage, referring to the imminent destruction or failure of something.
death-or-glory brave to the point of foolhardiness (in the British Army, the Death or Glory Boys was a nickname for the 17th Regiment of Lancers, from the regimental badge of a death's head with the words ‘or glory’).
death pays all debts the death of a person cancels out their obligations. The first recorded use is in Shakespeare's Tempest (1611); earlier in 2 Henry IV (1597), Shakespeare has, ‘The end of life cancels all bands [bonds].’
death row especially with reference to the US, a prison block or section for prisoners sentenced to death.
death's head a human skull as an emblem of mortality.
death wish an unconscious desire for one's own death.
till death us do part for as long as each of a couple live, from the marriage service in the Book of Common Prayer.

See also Black Death at black, dance of death, dice with death, a fate worse than death, the kiss of death, nothing is certain but death and taxes.

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death / de[unvoicedth]/ • n. the action or fact of dying or being killed; the end of the life of a person or organism. ∎  an instance of a person or an animal dying. ∎  the state of being dead. ∎  the permanent ending of vital processes in a cell or tissue. ∎  (Death) [in sing.] the personification of the power that destroys life, often represented in art and literature as a skeleton or an old man holding a scythe. ∎  [in sing.] fig. the destruction or permanent end of something: the death of hopes. ∎ fig., inf. a damaging or destructive state of affairs. social death. PHRASES: at death's door (esp. in hyperbolic use) so ill that one might die. be the death of (often used hyperbolically or humorously) cause someone's death: you'll be the death of me with your questions. be in at the death be present when a hunted animal is caught and killed. ∎  be present when something fails or comes to an end. catch one's death (of cold) inf. catch a severe cold or chill. do something to death perform or repeat something so frequently that it becomes tediously familiar. a fate worse than death a terrible experience. like death warmed over inf. extremely tired or ill. a matter of life and death see life. put someone to death kill someone, esp. with official sanction. to death used of a particular action or process that results in someone's death: stabbed to death. ∎  used to emphasize the extreme nature of a specific feeling or state of mind: I'm sick to death of you. to the death until dead: a fight to the death.DERIVATIVES: death·like / -ˌlīk/ adj.

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Death and Dying

Death and Dying

How Do We Understand Death?

What Is Grief?

How Do Children Cope with the Death of a Parent or Sibling?

How Do Adults Cope with the Death of a Child?

How Do Rituals Help People Cope with Death?

What Happens After Death?


A person is dead when he or she stops breathing and the heart and brain permanently stop functioning. A dead person cannot see, hear, taste, touch, or smell and has no awareness or feelings.


for searching the Internet and other reference sources



Terminal illness

Everyone on this earth shares two experiences: we are born and we die. Someone dies about every 20 seconds. Most of us know someone who has died. But we do not generally like to think about death or talk about death or even acknowledge that we all die. Around the world throughout the ages, death always has been a source of mystery and fear.

How Do We Understand Death?

Our reactions to death often depend on how someone has died and how old they were. The most easily understood are deaths at an old age, when a persons body simply wears out. But others die before their bodies wear out, and sometimes people die with no advance warning. Illness, injuries, natural catastrophes, and violence all can cause early death.

Sometimes people, including children, have to face their own deaths. They may have a terminal illness, a disease or condition that eventually will cause death. Psychologists and physicians who have worked with families in this situation believe that honesty and love from others are very important at this time. People with terminal illness and their families need to understand the effects of the illness and find ways to express their feelings about it. It helps to talk about it, enjoy time together, and help with caregiving.

What Is Grief?

Grief is the wide range of feelings that accompany a death, such as shock, sadness, anger, and confusion. Even when we know ahead of time that someone is going to die, it does not necessarily soften the impact. It still may be difficult to believe that the death has occurred and hard to imagine life without this special person. When the death is sudden and unexpected, the shock of the news may make it hard to come to grips with the reality. Such shock can take a while to fade. Most people need comfort and support while they grieve, either from their personal circle of family and friends or from clergy, therapists, or support groups.

How Do Children Cope with the Death of a Parent or Sibling?

When a sibling or parent dies, everyone in the family suffers. Very young children may not fully understand what has happened and that the death is permanent. Children feel many of the same feelings that adults do when someone dies: shock, sadness, or confusion. Children often personalize a death, asking, Will it happen to me? or Did I cause this to happen to someone else? A death can stir up fears: Will I get cancer too? or Is it safe to drive? A child may wonder how the death will alter his or her life: Will Mom remarry now that Dad has died? or My brother died. Will we have to move?

Adjusting to the terminal illness or death of a loved one is a gradual process, according to Elisabeth Kübler-Ross, author of the landmark On Death and Dying (1969). When normal life (1) is disrupted, people first go through a stage of denial (2), acting as if nothing in their lives has changed. Denial may be followed by anger (3) at the unwanted changes, and by praying or bargaining (4) such as If I never fight with my sister again, Mom wont die. Sadness and depression occur when the loss sinks in (5). Acceptance comes when a loss has been mourned. Acceptance is not a happy feeling, but it does give people the strength to go on with their own lives (6).

Sometimes it is hard for young people to understand their own feelings and reactions to death. Grief can cause people to lose interest in things that they normally enjoy, or they might avoid situations that used to involve the person who died. Reactions like these are normal. Finding someone to talk with (a family member, friend, or trusted adult) usually helps young people understand their feelings and eventually accept the death.

How Do Adults Cope with the Death of a Child?

As with the death of a parent or sibling, the death of a child causes extreme sadness and distress in a family. Whether the death came suddenly or gradually, parents often struggle with guilt that they could not prevent their childs death or even that they outlived their child. Sometimes, after a death, parents might feel the urge to move or change their lives to avoid situations that remind them of their dead child. Most experts say that this is not the best course. As the psychiatrist Elisabeth Kübler-Ross notes, it is usually healthier to face and acknowledge the pain, rather than avoid it.

How Do Rituals Help People Cope with Death?

Funerals, memorial services, and burials are generally held a short time after a death and sometimes on the anniversary of a death. These ceremonies

Mummies Of Ancient Egypt

In ancient Egypt, there were elaborate rituals performed to preserve the body after death. This was done to make sure that the dead person would be connected to gods and spirits in the afterlife.

The first step was embalming, which involved removal of major body organs, drying the body, and wrapping it in linens and spices. The higher the individuals status in society, the more elaborate the ritual. The coffin was painted with a portrait of the person and filled with valuables, such as gems and prized possessions of the deceased, to be used in the afterlife. Cats, which were thought to be sacred, were sometimes mummified and buried with their owners.

An Egyptian mummy dating from about 1000 B.C., that shows the outer decoration of the coffin and wrapped body inside. The Bridgeman Art Library

are often sad and difficult to attend. But they help people to express their feelings, take comfort with others who are grieving, and pay tribute to a persons life. Funerals or other ritualssuch as planting a memorial garden, writing, enjoying the persons interestshelp people stay connected to the person even after the death.

What Happens After Death?

No one knows what happens after death, and people have many different beliefs about it. They might believe that people go to heaven when they die. Some people believe that a persons soul lives on and that the spirit goes somewhere else after death. Still others believe in rebirth or reincarnation, with the soul continuing its life in another person. Some people do not believe in a soul. Even in the face of these unknowns, most people take comfort in the natural cycle of life and death and find meaningful ways to enjoy the memories of people who have died.

See also





Brown, Laurie Krasny, and Marc Tolon Brown. When Dinosaurs Die: A Guide to Understanding Death. Boston: Little, Brown, 1998. A picture book written for younger children, but thorough and thoughtful enough to appeal to adolescents.

Dower, Laura. I Will Remember You: What To Do When Someone You Love Dies: A Guidebook Through Grief for Teens. New York: Scholastic, 2000. Personal stories from teens who have experienced loss, and handson creative exercises in coping.

Fitzgerald, Helen. The Grieving Teen: A Guide for Teenagers and Their Friends. New York: Simon and Schuster, 2000. A practical guide that answers questions and helps a teenager understand a range of situations involving dying and death.

Gootman, Marilyn. When A Friend Dies: A Book for Teens About Grieving and Healing. Minneapolis: Free Spirit Publishing, 1994. A sensitive guide to help teens cope with the death of a friend. For ages 11 and up.

Kübler-Ross, Elisabeth. On Children and Death: How Children and Their Parents Can and Do Cope with Death. New York: Simon and Schuster, 1997. A compassionate guide for families of dead or dying children.

Kübler-Ross, Elisabeth. On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Families. New York: Simon and Schuster, 1997.

Trozzi, Maria, with Kathy Massimini. Talking with Children About Loss: Words, Strategies, and Wisdom to Help Children Cope with Death, Divorce, and Other Difficult Times. New York: Perigree, 1999. For adults, and suitable for older teen readers.


Nemours Center for Childrens Health Media, A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803. This organization is dedicated to issues of childrens health. Their website has articles on coping with death, with valuable links to support organizations.

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death Cessation of life. In medicine, death has traditionally been pronounced on cessation of the heartbeat. However, modern resuscitation and life-support techniques have enabled the revival of patients whose hearts have stopped. In a tiny minority of cases, while breathing and heartbeat can be maintained artificially, the potential for life is extinct. In this context, death may be pronounced when it is clear that the brain no longer controls vital functions. The issue is highly controversial.

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death (deth) n. absence of vital functions. brain d. permanent functional death of the centres in the brainstem that control breathing, heart rate, and other vital reflexes (including pupillary responses). Many decisions in medicine depend on death being clearly defined and objectively observed. Particular problems arise when a potential organ donor is being kept artificially alive. Legally, two independent medical opinions are required before brain death is agreed and organs can be removed.

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death The point at which the processes that maintain an organism alive no longer function. In humans it is diagnosed by permanent cessation of the heartbeat; however, the heart can continue beating after a large part of the brain ceases to function (see brain death). The death of a cell due to external damage or the action of toxic substances is known as necrosis. This must be distinguished from programmed cell death (see apoptosis), which is a normal part of the developmental process.

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death OE. dēað = OS. dōð, OHG. tōd (G. tod), ON. dauðr, Goth. dauþus :- Gmc. *dauþuz, f. *dau- (cf. ON. deyja DIE 1) + -TH 1.

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death The permanent cessation of living functions within an organ or organism.

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deathBeth, breath, death, Jerez, Macbeth, Seth •megadeath • Japheth • shibboleth

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