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INTRODUCTION
The terms "death" and "dying" are not
synonymous and have no unequivocal definitions. Death may be considered
the absolute cessation of vital functions, while dying is the process of
losing these functions. Dying may also be seen as a developmental
concomitant of living, a part of the birth-to-death continuum.
What Is Death?
Death
is defined as the cessation of all vital functions of the body including
the heartbeat, brain activity (including the brain stem), and breathing.
It can arrive unannounced at any time and is not the special province of
the very aged.
Meanings of Death
Weissman (2000)
distills meanings of death into four categories: (1) Death is an illusion
and an extension of life, a prologue to another form of life; death means
transition, not extinction. (2) Death is an inevitable and inexorable fact
of life, a confrontation with finitude; it is an endpoint in the
"contract" between the living and life's parameters. (3) Death is an
explanation and expiation of life, a final judgment on the life process;
it offers retribution or reward, a release from mortality's constraints.
(4) Death is an exigency and a defeat of life, a tragedy, negating life's
values, signifying failure and futility. Each of these theories about
death is in fact a belief about life (Zisook & Downs, 2000).
From biological point of
view, death is the permanent cessation of all vital functions. From
broader psychological, societal and cultural perspectives, death is much
more than the end stage of a biological process. Concepts of death are
highly subjective, are exceedingly complex, and change over time.
Furthermore the meanings of death are highly coloured by the attitudes of
the individuals who hold them as well as the situational context in which
these individuals find themselves.
Dimensions of Death
Death has three
dimensions. Impersonal dimension of death considers it as an impersonal
event, stripped of human element and the dead are simply dead bodies
classified or discarded according to various categories. We stand in an
impersonal and unilateral I-It relation to specimens whose unique
existence does not matter. It is death of an object that entails no
personal grief or loss. Obituaries of strangers have impersonal
significance because emotional loss is missing (Weisman, 1985).
Interpersonal dimension
of death is concerned with the objective fact of the death of the other
one. Our subjective death is not involved; it is the loss of a significant
person that affects us. It is represented by I-You; the typical response
is grief and bereavement. While impersonal death refers to “it is dead”,
Interpersonal death means “someone else is dead”. Interpersonal death
changes the psychosocial field and, in turn, alters the interpersonal
experience of those affected.
Intrapersonal death
refers to the inner experience of personal mortality, which most people
dread but find difficult to anticipate. It is the only dimension that
really matters. The impact of the dead body or death of the other one is
important only because of their importance for subjective death (Weisman
and Haekett, 1961).
ATTITUDE TOWARDS DEATH:
LIFE CYCLE CONSIDERATIONS
How could we understand
why people sometimes withdraw from friends who are terminally ill? How can
we comprehend intimate relationships without insight into the fear of
loss? Even the youngest children are aware of separation and its threat to
their survival.
Children
Young children do
occasionally express spontaneous insight into the finality of death, as
when encountered a dead animal or withered plant (Encyclopedia of
Psychology, 2000). Nagy (1948) reported three stages of development of
death related cognitions in children. Stage one present until age five,
lacks appreciation of death as final and complete cessation. Separation is
the theme most clearly comprehended by the youngest children. Stage two
children think of death as final but not inevitable. A strong tendency to
personify is noted in this stage. Stage three beginning at age nine or ten
is marked by comprehension of death as both final and inevitable. The
prospect of personal mortality seems to be accepted. Anecdotal reports
suggest that the child’s discovery of death begins much earlier than the
most cognitive theorists seem prepared to accept.
The affective and
cognitive development of children colors their understanding of death and
their subsequent fears about dying. At the preschool, preoperational stage
of cognitive development, death is seen as a temporary absence, incomplete
and reversible, like departure or sleep. Separation from the primary
caretakers is the main fear of a preschooler. This fear surfaces as an
increase in nightmares, more aggressive play, or concern about the deaths
of others rather than in direct discourse. Regression to more infantile
behaviors signals increasing dependence on parents. Dying preschoolers
need reassurance from their parents that they are loved, that they have
done nothing wrong, that they are not responsible for their illness, and
that they will not be abandoned.
School-aged children
manifest concrete-operational thinking and recognize death as a final
reality. However, they view death as something that happens to old people,
not to them. Between the ages of 6 and 12 years children have active
fantasy lives of violence and aggression, often dominated by themes of
death and killing. Death may be personified as a skeleton or bogeyman that
takes people away. Dying school-aged children ask questions about their
illness if encouraged to do so; however, if they receive cues that the
subject is taboo, they may withdraw and participate less fully in their
own care.
Many of us hesitate to
talk about death, particularly with youngsters. But death is an
inescapable fact of life which we must deal with, and so must our
children. By talking to them about death, we may discover what they know
and do not know; if they have misconceptions, fears, or worries. We can
then help them by providing information, comfort, and understanding.
Long before we realize
it, children become aware of death. They see dead birds, insects, and
animals lying by the road. They may see death at least once a day on
television. They hear about it in fairy tales and act it out in their
play. Death is a part of everyday life, and children, at some level, are
aware of it.
Mixed messages are
confusing, and may deepen apprehensions and misunderstandings and may
leave children confused. Children look to adults for cues about how to
behave in certain situations. It is usually easier to talk about death
when we are less emotionally involved. Taking opportunities to talk to
children about dead flowers, trees, insects, or birds may be helpful. Some
young children show intense curiosity about dead insects and animals. They
may wish to examine them closely, or ask detailed questions about what
happens physically to dead things. Although this interest may seem
repulsive or morbid to us, it is a way of learning about death. Children
should not be made to feel guilty or embarrassed about their curiosity.
Their interest may provide an opportunity to explain, for the first time,
that all living things die and make room for new living things. If the
death is violent, a murder or an assassination, it is probably a good idea
to say something to reassure children about their safety.
Be open to their
questions. Answer them truthfully and as completely as possible, given the
age of the child. If you don’t know the answer, just say so. If they want
to attend the funeral, let them. If they want to view the body with the
rest of the family, don’t prevent them if they are mature enough to
understand inevitability and irreversibility of death. Avoid euphemisms.
Watch your terminology. Do not equate death with a journey or sleep or the
child may be afraid to go to bed. Do not say the person is "with Jesus"
without further explanation. The child may hate Jesus for taking his/ her
loved ones away from them. Make sure the child understands the difference
between minor illness and fatal illness. The child may think they will die
the next time they get a cold (NIH, 1995).
Adolescents
Capable of formal cognitive operations, adolescents understand that death
is inevitable and final. Their major fears parallel those of all
teenagers: loss of control, being imperfect, and being different. Concerns
about body image, hair loss, or loss of bodily control may generate great
resistance to continuing treatment. Alternating emotions of despair, rage,
grief, bitterness, numbness, terror, and joy are common. An adolescent's
cognitive capacity to understand death may not translate into an
understanding that their own personal death is possible. The potential for
withdrawal or isolation is great because teenagers may equate parental
support with loss of independence or may deny their fear of abandonment by
actually repulsing friendly gestures. Teenagers must be part of the
decision-making process surrounding their death. Many are capable of great
courage, grace, and dignity in facing death.
Adults
Unlike children
and teenagers, older adults often readily accept that their time has come.
Although they may not be happy to die, they can be reconciled to it.
According to Erikson,
the eighth and final stage in the life cycle brings either a sense of
integrity or despair. As elderly adults enter the last phase of their
lives, they reflect on their time and how it has been lived. Integrity of
the self allows an individual to accept inevitable disease and death
without fear of succumbing helplessly. However, if a person looks back on
life as a series of missed opportunities or as filled with personal
misfortunes, the sense is of bitter despair, a preoccupation with what
might have been if only this or that had happened; then death is viewed
with fear because it symbolizes emptiness and failure
(Zisook, & Downs, 2000).
DEATH ANXIETY AND ITS
CORRELATES
Fear and anxiety are
among the most frequently used words to characterize orientations toward death
throughout the life span. Investigations typically assume that death
universally elicits anxiety. Where manifest fear is not present, defensive
denial is inferred (Goldings et al., 1966; Jeffres et al., 1961).
Conscious fear of death is thought to occur only when there is a serious
breakdown of the individual’s defenses, as in extreme psychopathology (Kastenbaum
and Costa, 1977).
Janet Belsky (1999)
defines "death anxiety" as "the thoughts, fears, and emotions about that
final event of living that we experience under more normal conditions of
life". In other words, as people live their lives day to day, they suffer
different degrees of anxiety about death.
The various factors
psychologists have studied in attempting to measure death anxiety include:
age, environment, religious faith and ego integrity, or a personal sense
of fulfillment and/or self-worth. A complicating aspect of studying death
anxiety is that actually "measuring" anxiety as it relates to these
variables has been difficult. The studies used in examining death anxiety
do not experimentally manipulate the variables, thus limiting conclusions
to correlations (Forner & Neimeyer, 1999). An additional confounding
factor is the distinction between "death" and "dying." In other words, is
the greater source of anxiety associated with death, itself, or the
process of dying. In spite of these challenges, a number of researchers
have reported conclusive findings relating to the impact of the variables
noted above on death anxiety.
Fortner & Neimeyer
(1999) summarized 49 published and unpublished research studies concerning
the relationship between death anxiety and age, ego integrity, gender,
institutionalization, physical and psychological problems, and religiosity
in older adults and reported that lower ego integrity, more physical
problems, and more psychological problems are predictive of higher levels
of death anxiety in elderly people. Tang et al (2002) investigated death
anxiety among Chinese college students and reported that younger as
compared with older students and women as compared with men tended to be
more death anxious. Those with low levels of self-efficacy and external
health control orientations were more likely to report a high level of
death anxiety. Wu et al, (2002), who studied emotional
reactions of Chinese elderly people toward death, have also reported high
level of negative correlation between death anxiety and age. On the other
hand, Rasmussen & Brems (1996) advocate role of psychosocial maturity as
better predictor of death anxiety than age and that as psychosocial
maturity and age increase, death anxiety decreases. Suhail & Akram (2002)
also have concluded that Women and less religious people reported to
experience greater anxiety.
Gender and Death Anxiety
Women report higher
levels of death anxiety and they are more responsive and sensitive to the
needs of the people with life threatening conditions. This could be due to
the fact that, expression of feelings, especially those of vulnerability,
are encouraged in girls but discouraged in boys.
Age and Death
Anxiety
Available data do not
support the hypothesis that we become more anxious about death with
advanced age, because of the decreased distance from death. Two main
reasons have been proposed: first, gradual acceptance of death with
advancing age and maturity, second, for some elders fear of life can be
greater than fear of death. Many older people experience social isolation,
financial concern, and age related physical problems which increase their
dissatisfaction with life.
Role of Religious Belief
In general, no clear
pattern of association has been discovered between religious belief and
death anxiety. It interacts with various factors: the particular religion,
cultural history, individual history and situational context. Religious
belief, faith and belief in after life seem to help many people face the
prospect of death, but they are still vulnerable to concern about the
terminal experience and the effect of their death on others. Many people
feel secure when they are certain that the proper religious rituals will
be performed after their death.
Denial of Death
We can find many
examples of Death Denial and taboo in our society. On direct self-report
measures, most adults report low levels of death anxiety, but on indirect
measures, physical signs of stress have been found, when exposed to
death-related massages. Some authors have questioned about its specificity
for death related stimuli.
Arndt et al. (2001) have
shown that exposure to subliminal death, but not subliminal pain priming
was associated with facial electromyographic changes.
Studies have revealed
that fear of death is either due to the process or consequences of death (Abdel-Khalek
and Ahmed, 2002). Logically, no one can imagine about one’s own
extinction, and fantasies of death are projected fantasies of life. Thus,
problem in accepting death comes not from death per se, but the way one
has lived his life.
THEORIES OF DEATH
ANXIETY
As mentioned above,
study of death and death related phenomena has always fascinated
researchers which has resulted in the burgeoning of popular scientific
interest in thanatology. In their attempt to explain death anxiety and
related phenomena, various researchers have propounded several theories.
Some of the important theories and models are being discussed.
Freud’s Concept of Death
Instinct
Freud has
juxtaposed life instincts with death instincts, and the two were referred
to as Eros and Thanatos in Beyond the Pleasure Principle. Although Freud
could not provide clinical data that directly verified the death instinct,
he thought it could be inferred by observing the repetition compulsion,
the tendency of persons to repeat past traumatic behavior. Freud felt that
the dominant force in biological organisms had to be the death instinct.
He viewed it as a tendency of all organisms and their component selves to
return to an inanimate state. Freud's notion of the death instinct was
clearly linked to the constancy principle and was also associated with
what he termed the Nirvana principle, which postulates that an organism
strives to discharge internal tension and to seek a state of rest (Gabbard,
2000).
Terror Management Theory
Terror
management theory (TMT) is a theory based on existentialism which explains
how fear of death underlies much of what we do. It focuses on the
psychological mechanisms that we use to buffer the anxiety aroused by
death awareness. It was proposed by Jeff Greenberg et al (Greenberg et
al., 1986; Solomon et al., 1991). TMT assumes that death-related anxiety is our most fundamental
source of anxiety. Like other species, human beings have a basic
self-preservation drive. Combining this drive with the realization that we
will die creates in us a paralyzing terror of death. In order to ward off
this anxiety, according to terror management theorists, we create and
participate in culture. By participating in culture, we are able to
provide our lives with order, structure, meaning, and even permanence.
Greenberg et al (2000)
showed that people use two types of defense strategies against thoughts of
death: proximal defenses and distal defenses. They make use of these two
defense strategies under different circumstances, and in a different
temporal order. When their mortality was made salient and these
death-relevant thoughts remained in their immediate conscious awareness,
people attempted to deny their vulnerability to death, thus suppressing or
blocking out death-related thoughts. This denial of vulnerability operated
as a proximal defense. People whose mortality had been made salient but
for whom death-relevant thoughts were not in immediate conscious awareness
used distal defenses. The distal defense consisted of affirming a cultural
worldview. Because of the death denying function of the cultural world
view, the encounter with a different world view may pose a threat to the
validity of our beliefs and the defense from death awareness that they
provide. As a result, one may be motivated to reject the threatening
worldview and defend one’s beliefs (Florian et al., 2001).
The defensive management
of terror of death seems to be achieved by two psychological mechanisms.
The first mechanism consists of cognitive and behavioural efforts aimed at
validating one’s cultural world view. The second mechanism consists of
cognitive and behavioural efforts aimed at increasing self-esteem by
living up to hose standards of value prescribed by the culture (Taubman-Ben-Ari
et al., 2002).
Recently, Mikulincer and
Florian (2000) and Florian et al. (2002) claimed
that close relationships may also buffer the terror of death. Here it
becomes relevant to mention that Bowlby’s (1969) attachment theory also
claims that proximity maintenance to others is a psychoevolutionary device
that helps individuals deal with distress elicited by stressful events (Taubman-Ben-Ari
et al., 2002).
Meaning Management Model
How we view death
and how we cope with death anxiety can profoundly affect every aspect of
their lives - either positively or negatively. This model (Wong,
2002) proposes that meaning
management is more adaptive than terror management in dealing with death
anxiety. Death is the only certainty in life. All living organisms die;
there is no exception. However, human beings alone are burdened with the
cognitive capacity to be aware of their own inevitable mortality and to
fear what may come afterwards. Furthermore, their capacity to reflect on
the meaning of life and death creates additional existential anxiety.
According to Goodman
(1981), "The existential fear of death, the fear of not existing, is the
hardest to conquer. Most defensive structures, such as the denial of
reality, rationalization, insulation erected to ward off religiously
conditioned separation-abandonment fears, do not lend themselves readily
as protective barriers against the existential fear of death".
To cope with fear of
non-being, people resort to various kinds of symbolic immortality by
assuming that one can live forever through progeny (Biological), believing
in afterlife and that soul never dies (Religious and spiritual), living
through one's works (Creative), through the survival of nature itself
(Natural) and through identification with an institution or tradition
(Cultural).
Acceptance of death
involves a willingness to let go and detach oneself from events and things
which one used to value. The meaning management model emphasizes that
human beings are born with the innate need for meaning, but it may lie
dormant because of our preoccupation with the business of living and death
and suffering awaken in us the urgent need to search for meaning and
purpose for life and death. We can discover and create meaning in every
situation, even in the face of death.
Meaning management helps
deepen one’s faith and spirituality and also enables to achieve a better
understanding of the meaning and purpose of life. It helps construct a
useful psychological and spiritual model that offers the best protection
against the fear of death and dying. It motivates us to embrace life - to
engage in the business of living, regardless of our physical condition and
present circumstances;
It is not just
rationalization or cognitive reframing, but a reconstruction and
transformation of values, beliefs and meaning systems. It emphasizes that
the way we live foreshadows the way we die. By accepting death and
understanding its full meaning, we acquire wisdom. By accepting death
through faith, we find courage and an undying hope.
Evaluation of Theories
of Death Anxiety
Psychoanalytic theory
has served a useful guide to observation and reflection. The basic flaw of
this theory is unverifiability.
Existential theory
proposes that acceptance of death is a mark of maturity, but this is an
attractive philosophical proposition, rather than an established fact.
The proposition of
terror management and meaning management theories seems attractive, having
a secure interpersonal relationship and a sense of purpose in our life
protects us from death anxiety, but before acceptance, adequate empirical
validation is necessary to support these new theories.
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