Clifton D Bryant, Charles Edgley, Michael R Leming, Dennis L Peck, Kent L Sandstrom. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 2: The Response to Death. Thousand Oaks, CA: Sage Reference, 2003.
The chapters included in this two-volume Handbook of Death and Dying represent some of the most unique aspects of the human imagination. At the very least, these chapters illustrate how human perceptions and social meanings, as these refer to the phenomenon of death, are highly variable and almost limitless. Yet as noted throughout these essays, the meanings and perceptions of death and dying are embedded in and influenced by cultural beliefs, moral codification, social processes, and structural realities. Thus they are subject to controversy and change.
In addressing the content of this final chapter, the editors acknowledge that as public perceptions of death change and cultural practices increasingly serve the needs of the body politic, the more one can observe that a return to past orientations may be taking place. The fact that professionals and laypeople alike have become more sensitive to the issues discussed in this Handbook suggests a curious contradiction. Despite numerous scientific and technological advances, enhanced record-keeping practices, an increase in the amount of research on death-related issues, the professionalism of service providers, heightened ethical awareness, and the creation of critical care facilities for the aged, we may be witnessing a return to at least some past social practices. Examples include the decisions people make regarding euthanasia, physician-assisted suicide, end-of-life care, dying at home, cremation, and memorial services.
Advances in scientific knowledge are also cause for us to recognize that the inevitable end of the life cycle, death, can be postponed almost indefinitely. And medical science, with its vast knowledge of disease, an almost unlimited array of medicine and machines, and the willingness among medical practitioners to prolong life, particularly in a litigious environment, presents a unique set of issues related to the human condition. These issues include the notions of longevity and quality of life, especially among those who experience chronic illness; the aches, pains, and infirmity attendant to old(er) age; and the increasingly impersonal and legalistic nature of human relationships in the workplace and public spaces. Although fulfillment of personal needs is apparently the normative aspect of contemporary life, such an orientation places at risk a previous normality; that is, it creates an imbalance that causes people to reevaluate age-old philosophical questions pertaining to time, place, the collective order, and the individual in an overall scheme of nature.
Advances in thanatological understanding are predicated on the enhancement of both the humanistic and the scientific approaches to death, dying, and bereavement. Thanatology is, as Kutscher, Carr, and Kutscher (1987:316) note, an art and a science, and it is within this general context that the future of death must be evaluated. We submit that this future holds unlimited opportunities to capture the unbridled spirit and imagination of entrepreneurial activities. Already we witness the public and scientific debate over cryonics, the cloning of animals, and the sale of human organs. Advances in genetic research have led to the creation of human stem cells; ultimately, the cloning of human embryos will occur, leading, in turn, to an array of new ideas and even more innovative alternatives to those that presently dominate. Each of these is intended in some way to extend the limits of nature and to socially construct a new reality for those privileged few who possess the requisite resources to challenge the normative structure of a present reality.
Ideological orientations will affect religious positions; the result will undoubtedly be new movements of a religious nature. In turn, secular positions will be affected as well, leading to new cycles of social change. Although the basic concept of death will remain intact, the inevitable consequence of this process will not remain unchallenged in some sectors of Western societies. During this age of spiritual quest, unfulfilled by traditional religious institutions, we can anticipate a pull toward unconventional religious orientations. The continuing controversy over science (evolution) and religious fundamentalism (creationism) is not likely to be resolved. Some effort to merge these diverse belief systems, however, such as is currently the case with the reincarnation movement, should gain additional attention. The human imagination, apparently without limit, will add intriguing characterization to such efforts and to new death and dying practices among the living.
The future holds the prospect of improving the quality of mortality statistics, especially cause-of-death statistics. Electronic registration should enhance the accuracy of the recorded cause of death. As a result of this improved documentation system, vital statistics relied on by members of the scientific and public health communities will be more effectively employed. The technology that will allow us to record so quickly and extensively will also become an integral part of patient care as well as informing medical educators, state legislators, and the general public.
Death and human behavior are a multifaceted interface, and change in many of its myriad linkages is inevitable. Some of these changes will have significant social impact and are worthy of further examination and prognostication.
The Changing Demographics of Death
The United States, similar to countries such as Japan, has an aging population. At the turn of the 20th century (1900) only about 4.1% of our population was aged 65 or older—about 1 person of every 20. By 1940, the percentage rose to 6.8%, and by 1960, 9.2% of the population was 65 or older. That figure increased to 12.3% by 2000 (World Almanac 2002:385). The percentage of elderly in the population will continue to rise in the decades ahead. By 2010, 13.2% of the population will be 65 or older and, by 2025, the percentage will be 18.5%. The percentage of elderly will further rise to 20.3% in 2050, or approximately 1 person of every 5. Demographers project that by 2100, the elderly will make up 23% of the population, or almost 1 of every 4 persons (World Almanac 2002:385). This trend will reshape our culture during the 21st century and will have enormous implications for death-related activities.
Although the elderly are living to an older age, at some point, they will die, and the much larger proportion of elderly in the population means that death rates and numbers of deaths will rise significantly in the future. As shown in Table 1, the data indicate the U.S. death rate has remained relatively stable for the past 20 years, with only minor fluctuations from year to year. This trend will change around the year 2010. From that year on and for the next 70 years, the death rate in the United States will rise significantly. From a death rate of 8.8 per 1,000 in 2010, deaths will rise steadily over the following decades to a rate of 13.17 per 1,000 in the year 2060. The death rate declines only slightly over the subsequent 20 years but still remains quite high at above 13 per 1,000. A change in the death rate from 8.7 in 2001 to an estimated 13.17 in the year 2060 represents a 51.4% increase over a 50-year period.
Beyond the matter of a rising death rate, there is the attendant fact of death numbers. The death rate by way of derivation takes into account the number of deaths in the population increase. The absolute number of deaths is another matter. Population increase, even with a stable death rate, results in a larger actual number of deaths annually. In the instance of rising death rate projections for the United States, along with the projected increase in population, the result is a disproportionate absolute number of deaths by the year 2060. As reflected in Table 1, in 1960, there were 1,711,982 deaths. But even with a relatively stable death rate in the United States since then, by 2030, the actual number of deaths annually will be approximately twice that high. By 2080, the actual number of deaths occurring each year is projected to be 6,500,000, almost 4 times higher than in the year 1960.
Six and a half million deaths annually is an extraordinarily high number and will certainly affect culture and social behavior, contributing to the visibility of death with the creation of more funeral homes and cemeteries and enhanced levels of death-related economic activities. In effect, death will be a growth industry in the United States for much of the 21st century.
The Dying as Social Collectivity
Over time, the nature of dying changes. The salient distinction of dying in the late 20th century as opposed to the 19th century is prolonged dying. In the 19th century, individuals tended to die of acute infectious and parasitic diseases. People became infected, they developed symptoms, the disease reached a crisis stage, and people either survived or died; many of these individuals died. From the time of the appearance of the symptoms until their death was often a matter of days, if not hours. Thus dying was such an ephemeral process that there was no time for a social identity (as discussed below), much less social status, to crystallize.
| Table 1 U.S. Death Rates (per year): 1960 to 2080 | |||
| Year | U.S. Population | Number of U.S. Deaths | Death Rate per 1,000 Population |
| SOURCE: Data obtained from the National Center for Health Statistics and the Population Division, U.S. Bureau of the Census. | |||
| NOTE: For additional data on death rates you can contact www.cdc.gov or www.census.gov. National Funeral Directors Association, 13625 Bishop’s Drive, Brookfield, WI 53005, 800-228-6332, www.nfda.org. | |||
| a. Final data for 2000. | |||
| b. Provisional data for 2001. | |||
| c. Projected data. | |||
| 1960 | 179,323,000 | 1,711,982 | 9.55 |
| 1970 | 203,302,000 | 1,921,031 | 9.45 |
| 1980 | 229,637,000 | 1,989,841 | 8.78 |
| 1981 | 231,996,000 | 1,977,981 | 8.62 |
| 1982 | 231,966,000 | 1,974,797 | 8.52 |
| 1983 | 234,284,000 | 2,019,201 | 8.63 |
| 1984 | 236,477,000 | 2,039,369 | 8.65 |
| 1985 | 238,736,000 | 2,086,440 | 8.74 |
| 1986 | 241,107,000 | 2,105,361 | 8.73 |
| 1987 | 243,419,000 | 2,123,323 | 8.72 |
| 1988 | 245,807,000 | 2,167,999 | 8.83 |
| 1989 | 248,251,000 | 2,150,466 | 8.68 |
| 1990 | 248,709,873 | 2,162,000 | 8.6 |
| 1991 | 252,160,000 | 2,165,000 | 8.5 |
| 1992 | 255,082,000 | 2,177,000 | 8.5 |
| 1993 | 261,000,000 | 2,268,000 | 8.8 |
| 1994 | 262,693,000 | 2,286,000 | 8.8 |
| 1995 | 264,396,000 | 2,309,000 | 8.8 |
| 1996 | 265,200,000 | 2,322,265 | 8.7 |
| 1997 | 266,788,000 | 2,314,245 | 8.67 |
| 1998 | 270,298,524 | 2,337,256 | 8.65 |
| 1999 | 272,690,813 | 2,396,000 | 8.8 |
| 2000a | 275,360,000 | 2,408,000 | 8.8 |
| 2001b | 277,803,000 | 2,419,000 | 8.7 |
| 2010c | 299,861,000 | 2,638,000 | 8.8 |
| 2020c | 324,926,000 | 3,015,000 | 9.3 |
| 2030c | 351,070,000 | 3,472,000 | 9.9 |
| 2040c | 377,349,000 | 4,100,000 | 10.9 |
| 2050c | 403,687,000 | 4,550,000 | 11.2 |
| 2060c | 432,010,000 | 5,695,000 | 13.17 |
| 2070c | 463,639,000 | 6,035,000 | 13.01 |
| 2080c | 497,830,000 | 6,500,000 | 13.05 |
In contrast, during the late 20th century, most individuals died of chronic diseases, particularly cardiac and circulatory afflictions and cancer. With the advent of surgical procedures, such as heart bypass operations, angioplasty, heart transplants, artificial hearts, and highly effective cardiac and circulatory drugs, patients with cardiac impairment or a degenerative condition can now be sustained for years. Similarly, cancer patients benefit from a wide variety of chemotherapy treatments, radiation therapy, and surgical intervention that may extend their lives for many years. During this time, patients may be active, pain free, and able to live a relatively conventional life. Likewise, persons with end-stage renal disease may live for extended periods with the aid of dialysis, and diseases such as HIV/AIDS may be controlled for decades with drug therapy.
All these medical interventions will surely be enhanced and augmented in the future to the point that a terminal condition may routinely be extended by several years, even with the prognosis of ultimate death from the condition. With such an extended period of dying, there will be an opportunity for identity formation that will, in time, be formalized into a definable social status. To some degree, this is already the case with HIV/AIDS and cancer patients, and those on dialysis. In effect, the terminal condition will become a master status. When this occurs, persons with the dying status may well find commonality with other individuals sharing a similar identity, leading, in turn, to the formation of social networks that will seek to mediate their condition through group interaction and even interventions. The former already exists in the form of support groups for various afflictions, and the latter operate as social, legal, and political advocacy organizations for a variety of conditions and diseases such as HIV/AIDS and multiple sclerosis. These advocacy groups effectively lobby Congress and testify before various congressional committees in their efforts to generate benefits and concessions.
The terminally ill may well begin to see themselves as individuals who could benefit from group affiliation and structure. They may seek common cause and organize themselves; they may assume an activist posture in seeking political concessions from state and national governments. There is a strong precedent for this in the form of the American Association of Retired Persons (AARP) as well as various organizations representing the interests of the handicapped segment of the population. Examples include the National Rehabilitation Association, Rehab ACTION, and the National Federation of the Blind. It is evident that such organizations have enjoyed considerable political success in bringing about social and political changes that benefit their members.
The AARP is a formidable activist organization that has lobbied with great intensity to promote the causes and goals of its members. Perhaps even more striking is the success enjoyed by various advocacy groups representing the handicapped. Foremost in achievements here might be legislation passed on behalf of the handicapped, such as Section 504 of the Rehabilitation Act of 1973, requiring all public and private organizations receiving federal funding to make their programs accessible to the handicapped. An even broader and more powerful piece of legislation is the American with Disabilities Act (ADA) of 1990 (an act that is periodically renewed and scheduled to undergo a similar renewal in the year 2003) that was added to the civil rights legislation of the 1960s. The ADA now requires that those with disabilities be provided with equal opportunity, access, and accommodations in a number of areas, including employment, transportation, shopping centers, and restaurants.
The dying likely will become a powerful political group with a compelling agenda and goals relevant to their condition. Given their enormous numbers, they will speak with a strong voice in pushing for a variety of concessions, including the legalization of narcotic drugs such as marijuana and heroin for medical purposes, provision of additional funds for hospice programs, and assistance to ease the financial burdens experienced by terminal patients and their families.
The Changing Classification of Death
In the compilation of data for national mortality statistics, every death is attributed to one underlying condition. This condition is based on information recorded on the certificate of death and using the International Classification of Diseases (ICD) code for selecting the underlying cause. The underlying cause of death is defined as (a) the disease or injury that initiated the events leading directly to death or (b) the circumstances that produced the fatal injury.
Since year 1900, 10 revisions of the ICD have produced discontinuities in cause-of-death trends. Despite this analytical problem, the ICD has been revised periodically to incorporate changes in the medical field. Thus the ICD-9, in effect from 1979 to 1998, was revised in 1992 and adopted in 1999. To demonstrate the important effect this change has, the ICD-10 lists almost twice as many cause-of death categories as the ICD-9. In addition to minor changes in coding rules, the ICD-10 lists 113 selected causes of death, replacing the previous list of 72 selected causes, HIV infection, and Alzheimer’s disease. The ICD-10 also lists 130 selected causes of infant death, again replacing the 60 selected causes of infant death and HIV infection listed in the ICD-9. Thus, for the reasons cited, any future comparisons in the cause-of-death trends over time must be measured using comparability ratios.
Effective with deaths recorded in 1999, the United States began using the 10th revision of the ICD. Thus, as shown in Table 2, the leading causes of death for the years 1999 and 2000 are the same. Even the categorical numbers for each of the 10 causes are similar, and most of these deaths relate to long-term chronic illness. The consequence of this classification schema has long-range implications in the areas of public health and social policy.
Life expectancy has improved dramatically, even for the current aging generation. Along with curative medication and the procedures currently in place to prolong life and those that will be created in the future, we envision that with only modest alterations, as described below, the classification of cause of death observed at the end of the 20th century will continue well into the new millennium.
For the period 1975 through 1999, the American suicide rate ranked among the 10 leading causes of mortality. The effect of changes in the international system for death classification was demonstrated during the late 1950s when the 7th revision of the ICD (ICD-7) took effect; in 1958, the ranking of suicide increased dramatically. Although among males, suicide was the 8th-ranked cause of death during the year 2000 (Anderson 2002:8), when the ICD-10 became effective in 1999, suicide fell from the top 10 causes of death (McIntosh 2002). In the following section, the potential for suicide’s again ranking among the most frequent direct causes of death is cast within the context of a large and rapidly aging segment of the American population. This group is destined to address an old question, as described in the following section.
| Table 2 Deaths and Percentages of Total Deaths for the Ten Leading Causes of Death, 1999 to 2000 | |||||||
| Cause of Death | 2000 | 1999 | |||||
| Rank | Deaths | % of Total | Rank | Deaths | % of Total | ||
| SOURCE: “Deaths: Leading Causes for 2000” (Anderson 2002). | |||||||
| All Causes | 2,403,351 | 100.0 | 2,391,399 | 100.0 | |||
| Diseases of the heart | 1 | 710,760 | 29.6 | 1 | 725,192 | 30.0 | |
| Malignant neoplasms (cancer) | 2 | 553,091 | 23.0 | 2 | 549,838 | 23.0 | |
| Cerebrovascular (stroke) | 3 | 167,661 | 7.0 | 3 | 167,366 | 7.0 | |
| Chronic lower respiratory diseases | 4 | 122,009 | 5.1 | 4 | 124,181 | 5.2 | |
| Accidents (unintentional injuries) | 5 | 97,900 | 4.1 | 5 | 97,860 | 4.1 | |
| Diabetes mellitus | 6 | 69,301 | 2.9 | 6 | 68,399 | 2.9 | |
| Influenza and pneumonia | 7 | 65,313 | 2.7 | 7 | 63,730 | 2.7 | |
| Alzheimer’s disease | 8 | 49,558 | 2.1 | 8 | 44,536 | 1.9 | |
| Nephritis, nephritic syndrome and nephrosis (kidney disease) | 9 | 37,251 | 1.5 | 9 | 35,525 | 1.5 | |
| Septicemia | 10 | 31,224 | 1.3 | 10 | 30,6801.3 | ||
Suicide and Euthanasia: New Postures and Old Perspectives
During the last three decades, a heightened interest in rational suicide and euthanasia has generated a vast interest in these areas, and groups such as the Hemlock Society have organized to support legal reform. However, the conflict between the state and its citizens over the issues of suicide and euthanasia—so thoroughly documented by Fedden ([1938] 1972), Hoffman and Webb (1981), Battin (1982), and Minois (1999)—continues, and this conflict will undoubtedly gain momentum in the future as a growing elderly population exercises its political power, especially where the expected right to suicide or the desire for a good, merciful, or easy death is concerned. At issue is the general appraisal of the range of state authority over the individual.
With an increasing proportion of the U.S. population moving toward their so-called golden years, many individuals may be confronted with a dilemma, as will family members and those associated with the professions. That dilemma is essentially the same as that which has served as a point of social, moral, and legal controversy for more than 2,000 years; it is a point of contention that places human dignity and individual constitutional rights to privacy squarely in conflict with a political and moral conception of what constitutes the collective good and government authority. In the current early stage of both a new century and the new millennium, the suicide question remains unresolved, and the alternative concept, euthanasia, does little more than appear as a disguise, masquerading as but a different aspect of the same issue. Clearly, U.S. society has yet to establish a measured set of moral rules, laws, and customs pertaining to suicide and any other induced or assisted forms of merciful, easy death. This situation is most telling in that the issue of human suffering and euthanasia has become a focal point of debate and conflict. On this matter, Minois (1999) declares,
In spite of everything that the moral and political authorities can do, the problem of suicide is recurring today through the extreme case of euthanasia. Moral leaders continue to assert that suffering, even excruciating, incurable suffering, has a positive value; political leaders fear backsliding. This is why thousands of human beings who are dehumanized by intolerable suffering are condemned to live [italics added]. (P. 328)
The question germane to citizens of a free, democratic society is this: Should not such matters be addressed from the perspective of those directly affected?
In 1982, Margaret Pabst Battin stated, “Recent developments in the patients-rights advocacy tend to suggest the reawakening of a Stoic or eighteenth-century liberal view of suicide” (p. 3), inferring that contemporary Western culture was entering a period of renewed interest in the issues that surround suicide. These issues, according to Battin, include the moral attitude toward self-destructive behavior, prevention strategies, and legal determinations. More than two decades later, these issues clearly lie at the center of public attention. If we assume, as do many contemporary analysts, that rationality is an important component of understanding suicide and that rational suicide is a matter of right, then those who use moral, preventive, and sociolegal strategies to interfere with the exercise of this right condemn those who experience intolerable suffering to live when they may not wish to do so. Claims that suicide violates the intrinsic value of life, that it harms others, or that permissiveness toward and tolerance of suicide holds the potential for abuse, usurp this right, a right that should, according to Battin (1982:178), override such objections.
Such views indicate the scope of this lingering controversy. It is safe to state, however, that despite the plethora of scientific insights and the recent identification of suicide as rational, the vested interests of certain professional groups will undoubtedly continue to be at odds with and argue against the expressed will of an increasingly larger segment of the population. Perhaps it is not surprising that some professional groups uphold a traditional if not archaic paradigm, denying the importance of a rational component to suicide. But as stated in other chapters of this Handbook of Death and Dying, individuals committed to reason may choose suicide for pragmatic reasons rather than moralistic ones. In some instances, suicide or euthanasia will serve as a reasonable alternative to living, and this issue will assuredly confront an increasing number of people in the United States during the early decades of the 21st century.
We concur with the argument presented by Hoffman and Webb (1981) that the regulation of suicide was, is, and will continue to be a representation of “an instrument of control, the subject of conflict, and a social construction reflective of different historical conditions” (p. 381). Whether this pattern shall continue to hold in the future, however, is an obvious matter of contention. Within this context, the words of Thomas Szasz (1999) are noteworthy:
For a long time, suicide was the concern of the Church and the priest. Now it is the business of the State and the doctor. Eventually we will make it our own choice, regardless of what the Bible or the Constitution or Medicine supposedly tell us. (P. xii)
A similar argument can be posed for the euthanasia issue.
Ethics became a focal point of discussion during the 1990s, especially in the arenas of business practices and medical research. Perhaps any future compromise for or resolution of this debate on suicide and euthanasia, if indeed such resolution is possible, will lie within a similar context—that is, a debate that Minois (1999:328) suggests could result in the creation of a thanatos ethic. As a starting point toward the eventual establishment of this phase in cultural development, the discussion can be initiated through the following question: Is life at any cost preferable to death?
The Increasing Intensity of Death Awareness
When historians write the history of the period in which we live, they may very well identify the 21st century as “The Age of Death.” Death is all around us, demonstrated daily by the intensity of media coverage of this phenomenon. Twenty-four-hour news cycles, instant-messaging services, and breaking-news segments all bring the story of death to us almost instantaneously. It is said that when Abraham Lincoln was assassinated in 1863, news of this event took a month to reach one-half of the American population. One hundred years later, as many as 98% of Americans knew of the assassination of John F. Kennedy in less than 1 hour.
In addition to an increasing awareness of death, a trend that shows no signs of abating, death occupies an ever-larger amount of cultural space. Questions pertaining to the social situation of dying patients, the role of caregivers, individuals who experience grief and mourning, and the widening circle of those who are affected by someone’s death are brought to our attention. Hospice advocates and practitioners have heightened the awareness of the plight of the dying and of those who provide care and comfort for them. Organizations such as the Society of Compassionate Friends promote an awareness of the trauma that parents and siblings experience when children die, and Widow-to-Widow programs increase awareness of the effect death has on women.
Other groups promote an agenda in which many of the issues relating to the death and dying process are identified. Examples include hospice organizations such as the Americans for Better Care of the Dying, cremation advocates such as the Ariodante Fabretti Foundation, tombstone research organizations such as the Association for Gravestone Studies, and No Greater Love, a group focused on public ceremonies to honor those who died in service of the United States or because of acts of terrorism. Perhaps less well-known is Celestis, a group that offers to launch cremated remains into deep outer space.
Still other organizations seek to identify death as a social problem. Mothers Against Drunk Driving (MADD), for example, transforms traffic accidents into moral crusades, complete with dramas of victimization, villainy, and innocence. MADD represents a model for others who seek to turn personal tragedies into social movements. As noted elsewhere in this series of essays, one such group, Parents of Murdered Children (POMC), lobbies for legal reform in addition to advocating bereavement support programs for parents. We may expect these kinds of groups to gain greater exposure in the future as death and its effects are increasingly defined as social problems to be resolved rather than circumstances to be endured.
Humans, of course, have always been aware of their own mortality. Indeed, in previous generations, death was more a part of everyday life than it is today. But there were important differences. Death in previous eras was not something that dominated the news, nor was it defined as a social problem to be managed or a political issue to organize against. It was simply death, an event about which no one could do anything. Large numbers of people died; infant mortality rates were very high. Death was essentially unexceptional and routine (Lesy 2000).
However, current advancements in medical technology have led to change. Death is no longer simply a private matter, but a highly visible social dynamic that is increasingly viewed as problematic. The ability to control death means that institutionally, bureaucratic procedures now account for its occurrence. No longer is death considered only the province of God; institutional committees convene when death occurs to ensure that proper procedures and preventive measures have been followed. Thus, with medical technology pushing the frontiers of the possible, death is currently defined as the intersect between individuals at risk and those whose occupations place them in a position of being accountable. Such trends will undoubtedly continue as the advance of technology allows professionals to treat death, in some instances, as a preventable disease rather than an unavoidable certainty.
Trends that increase our awareness of death are, of course, double-edged swords. Barney G. Glaser and Anselm Straus (1965) present a compelling argument that the dying process begins with one’s awareness of his or her own prognosis (typically communicated through medical authority). This means that the dying process includes social and psychological elements as well as the physiological. It may even be suggested that dying as an identity and a role is independent of a physiological condition, because, if a diagnosis is reversed by later medical opinion, as in the case of a mistaken diagnosis, this reversal does not eliminate the fact that the person lived as a dying person for a period of time. Early diagnosis and treatment of chronic illness is urged on the grounds that early diagnosis offers a greater probability of cure. Early diagnosis, however, also means those with a terminal condition will live for a longer period of time while occupying the status of dying. On the other hand, if information is withheld from patients about their own terminal condition, in effect their dying is stolen from them, and although they eventually will die, dying as a social and psychological phenomenon is effectively shut off.
Awareness of dying is likely to maintain its moral, ethical, and legal implications in the future. A question suggested by Bok (1999) is this: Should dying patients be told the truth about their condition? Or should this information be carefully managed by medical personnel on the basis of a host of arguments that can be brought into context? According to Glaser and Strauss (1965), there are four such awareness contexts involving death: open, closed, suspicion, and mutual pretense. Should this event then involve a process of negotiation including all who are party to the dying process? In the future, the management of information, based on bureaucratic rules, may well be more important to the quality of dying than the management of the underlying physical condition itself.
Because death is also used as a political tool, as in the case of international terrorist attacks, we may expect a future filled with incidents of highly visible deaths designed to attract attention to various global issues. We already live in a time when such events are anticipated, and many current political efforts are directed toward averting such deaths, a process that brings the awareness of such possibilities even more directly to our attention. Because war deaths are dissected and interpreted in such breadth and depth, and offer such dramatic fare, they are likely to be an increasing part of future cultural narratives.
Moreover, the gender factor will intersect with death in a much more dramatic fashion on all of these issues. By one account, men outnumber women as casualties of war by a ratio of 14,051 to 1. In other words, men constitute 99.993% of America’s wartime casualties, just as they constitute 95% of workplace fatalities, 82.4% of suicides, 79% of murder victims, and 60% of traffic fatalities. This imbalance may be expected to change in the future as women become more actively involved in the military and in other traditional male roles and are counted as victims of terrorist attacks. The death of those thought not to be at risk will heighten our awareness.
Finally, the awareness of death will increase because of the sheer weight of numbers. The demographics, as indicated above, project that the death rate will rise by 50% by the year 2060, and by the year 2080, the annual number of deaths in the United States alone is projected to be approximately 6.5 million. Increased advertising and competition among cemeteries, funeral homes, crematories, and other institutions devoted to body disposal and memorializing the past will literally inundate the public. Of course, the forthcoming routine nature of this end-of-life process also may engender some callousness toward death. Yet it is probable that the projected 17,800 deaths per day in the United States, most of them the result of chronic disease, will place enormous strain on medical facilities. The potential for increasing the financial burden for the living also presents a future reality with which we must learn to deal.
The Search for New Paths to Transcend Death
Until the 20th century, most Americans could face death secure in the knowledge that their religious faith, with its attendant eschatological scenarios of heavenly existence, would comfort them in transcending death. By the mid- to late-20th century, however, events began to erode traditional religious beliefs while enhancing the level of anxiety about and fear of death.
Darwin’s Origin of the Species, published in 1859, challenged theological dogma, and other scientific writing and discoveries followed this challenge. The pace of technological change accelerated for the next 150 years, given the many inventions and technical procedures created. Each of these contributed to dramatic social change, much of which was inimical to traditional religious beliefs and theological notions of the hereafter. Advances in medical technology also precipitated significant social change. Highly effective invasive surgical procedures, the discovery of treatment medications, diagnostic and treatment machines, and organ transplants redefined the destiny of the human species.
At the same time, however, the movement of people from the farm to the city and the attendant transfer of death from the home to the institution had a tendency to raise the level of death anxiety because of the diminishing exposure to death itself. Still, the brute fact of eventual demise requires a mechanism for transcending death. Religious scenarios of a heavenly existence no longer suffice, especially in view of the fact that traditional religious denominations increasingly modify their eschatological posture, in effect, exchanging the historical interpretation of heaven as a location with an eternal lifestyle to that of a philosophical interpretation. For many theologians associated with mainstream Christianity, heaven has evolved into a state of mind.
Such interpretations have not proven effective. Accordingly, mainstream religious denominations currently experience significant decline in active membership while fundamentalist faiths increase in membership. In the latter instance, these faiths offer simplistic explanations that seem to comfort many individuals in their search for adequate mechanisms by which to confront death.
The search for deliverance from death with absolute finality has taken circuitous paths. Near-death experiences attract a sizable number of followers who view the accounts from resuscitated patients as “proof” of after death existence. For some, near-death experiences have taken on the aura of a secular religion; others seek to transcend death through affiliation with new, exotic religious faiths.
In the future, technological change will further erode religious beliefs. A decline in traditional denominational membership will continue, and membership in fundamentalist faiths is likely to rapidly increase in size because of their simplistic scenarios of life eternal in heaven. There will be an increased interest in religions such as Buddhism because of their emphasis on reincarnation. Near-death experiences will serve as the basis of new religious beliefs with a concomitant increase in the number of visionaries seeking to assume leadership roles. Cults will proliferate in number, as will the configuration of belief systems. Cryonics postponing death through frozen “suspension” to await ultimate scientific salvation will attract an increased level of interest and involvement. An ideological basis for avoiding death with absolute finality may emerge as a result of cloning and whatever futuristic prospects for transcending death that it will offer. An array of symbolic immortality endeavors will evolve, and in the absence of efficacious after-death scenarios, people will likely pursue philosophical hedonism as a means of mediating their anxiety and fear of death.
The Future of Body Disposition
Cemeteries
In centuries past, Americans buried their dead largely because there were few alternatives, and in the United States, earth burial had been an almost exclusive mode of body disposition. Beginning in the l600s, for example, the Puritans unceremoniously buried their dead in “graveyards,” known to have been unkempt repositories located in the least desirable portion of the village commons where livestock and pigs grazed and rooted in the same area. Graves were generally marked with wooden crosses or a slab of wood on which crudely carved names of the deceased were affixed. By the 1700s, the colonials buried their dead in simple, unpretentious church burial grounds and in modest family farm plots, often marking the graves with small headstones. In the early 1800s, however, American cemeteries began to exhibit a semblance of dignity, serenity, and beauty.
In 1831, with the creation of the Mount Auburn Cemetery located near Boston, Massachusetts, the rural or “garden” cemetery concept came into being and, over the next 7 years, this idea spread across America. Cemeteries were located in lush wooded and shrub-covered areas as a tranquil resting place; such areas were ecologically attractive for visitors as well, serving to enhance individual reflection and contemplation of the life cycle. Garden cemeteries introduced elaborate tombstones and statuary to mark the final resting place. But in some areas of the country, the level of ground water prohibited ground burial, leading to the use of sarcophagi or mausoleums within which body vaults were placed.
Then, during the 20th century, cemetery styles again changed with the introduction of the treeless, lawn-style memorial park concept; graves were marked with bronze tablets mounted flush with the ground. A more recent variation is the green burial concept, a method designed to hasten decomposition of corpses in an ecological and environmentally constructive fashion. New configurations of burials will surely emerge in the future in light of environmental concerns and issues relating to cemetery crowding.
Although space for cemeteries has never been a problem in the United States, open space around cities is becoming scarce and more expensive because of land use for suburban expansion that includes new housing developments, shopping centers, strip malls, and highway enhancement. Future approaches to this problem could well be addressed in two ways. First, cemeteries may soon be located in isolated rural areas. Second, cemeteries may be built vertically rather than horizontally, as suggested more than 30 years ago by a Brazilian architect (“Raising The Dead” 1971:72). This idea already is in use at the three-story vertical mausoleum located in the Woodlawn Memorial Park Cemetery in Nashville, Tennessee. Moreover, there exist multistory columbarium buildings in Japan, where ash urns are stored in lockers. These cemetery buildings could be located near the center of the city, thereby affording easy access. High-rise cemeteries of the future could even be located in multiple-use buildings in which the elevated space would be shared with parking garages, hotels, and office facilities.
Finally, the computer will offer unique opportunities to honor the dead. The future of burial will include “virtual cemeteries” or Web sites where relatives will be able to post commemorations to the deceased. As noted by Roberts and Vidal (1999-2000), a Web cemetery is like a traditional cemetery in that “the web cemetery provides a site for memorializing and visiting memorials to the dead. Like obituaries or gravestone inscriptions, web memorials are primarily text based, although some cemeteries allow for pictures and sounds as well” (p. 522). More elaborate versions would include photographic, narrated biographies such as those online at www.forevernetwork.com, thus affording digital immortality to the deceased (Leibowitz 2001:21).
Cremation
Because of health and aesthetic considerations, the cremation of bodies first began as a new and innovative means of body disposition in the United States, Great Britain, and throughout Europe. Initially, cremation was considered a novel, unusual means for disposing of dead bodies; it was also contrary to custom. In the United States, religious objection to the practice of cremation significantly inhibited the use of this method. Then during the decades following World War II, religious objections began to diminish; at the same time, the increasing mobility of the American population pushed against whatever cultural reticence to cremation remained.
As shown in Table 3, during the period 1876 to 1884, only 41 cremations occurred in the United States. By 1892, a total of 562 cremations were recorded, and by the turn of the century, there were only 2,414 cremations. The numbers of cremations continued to rise annually, but the percentage of deaths that resulted in cremation remained small in comparison with burials. For the period 1934 to 1938, cremations totaled 2.56% of the total body dispositions. For the period 1949 to 1953, the percentage rose to 4.05% and, in 1973, the proportion of cremations reached 5.60%. By 1987, the percentage rose to 15.23% and then to 25.04% in 1999.
| Table 3 Historical Cremation Data: United States Versus Canada | |||||||
| Year | United States | Canada | |||||
| Deaths | Cremations | Percentage | Deaths | Cremations | Percentage | ||
| SOURCE: Cremation Association of North America. Copyright © CANA November 6, 2002. Used with permission. For additional statistics on cremation, see www.cremationassociation.org. | |||||||
| a. Figure from the National Vital Statistics Report, Vol. 50, No. 15. | |||||||
| b. Preliminary figure. | |||||||
| N/A = Not available. | |||||||
| 1963 | 1,814,000 | 67,330 | 3.71 | 147,400 | 5,792 | 3.93 | |
| 1964 | 1,798,000 | 67,658 | 3.76 | 145,900 | 6,382 | 4.37 | |
| 1965 | 1,828,000 | 70,796 | 3.87 | 148,900 | 6,906 | 4.64 | |
| 1966 | 1,863,000 | 73,339 | 3.94 | 149,900 | 7,388 | 4.93 | |
| 1967 | 1,851,000 | 77,375 | 4.18 | 150,300 | 7,991 | 5.32 | |
| 1968 | 1,930,000 | 83,977 | 4.35 | 153,200 | 8,081 | 5.27 | |
| 1969 | 1,922,000 | 85,683 | 4.46 | 154,500 | 8,408 | 5.44 | |
| 1970 | 1,921,000 | 88,096 | 4.59 | 156,000 | 9,188 | 5.89 | |
| 1971 | 1,928,000 | 92,251 | 4.78 | 157,300 | 9,406 | 5.98 | |
| 1972 | 1,964,000 | 97,067 | 4.94 | 162,400 | 11,717 | 7.21 | |
| 1973 | 1,973,000 | 112,298 | 5.69 | 164,000 | 15,880 | 9.68 | |
| 1974 | 1,934,400 | 119,480 | 6.18 | 166,800 | 17,415 | 10.44 | |
| 1975 | 1,892,900 | 123,918 | 6.55 | 167,400 | 20,694 | 12.36 | |
| 1976 | 1,910,900 | 140,052 | 7.33 | 171,000 | 22,615 | 13.23 | |
| 1977 | 1,902,100 | 145,733 | 7.66 | 167,500 | 24,713 | 14.75 | |
| 1978 | 1,924,100 | 163,260 | 8.49 | 171,000 | 28,456 | 16.64 | |
| 1979 | 1,905,000 | 179,393 | 9.42 | 170,600 | 30,274 | 17.75 | |
| 1980 | 1,989,841 | 193,343 | 9.72 | 172,000 | 32,423 | 18.85 | |
| 1981 | 1,977,981 | 217,770 | 11.01 | 173,000 | 34,884 | 20.16 | |
| 1982 | 1,974,797 | 232,789 | 11.79 | 183,700 | 37,222 | 20.26 | |
| 1983 | 2,019,201 | 249,182 | 12.34 | 184,000 | 41,887 | 22.76 | |
| 1984 | 2,039,369 | 266,441 | 13.06 | 185,500 | 44,630 | 24.06 | |
| 1985 | 2,086,440 | 289,091 | 13.86 | 190,500 | 49,216 | 25.84 | |
| 1986 | 2,105,361 | 300,587 | 14.28 | 195,000 | 54,482 | 27.94 | |
| 1987 | 2,123,323 | 323,371 | 15.23 | 197,000 | 53,867 | 27.34 | |
| 1988 | 2,167,999 | 332,183 | 15.32 | 186,600 | 57,568 | 30.85 | |
| 1989 | 2,150,466 | 352,370 | 16.39 | 195,500 | 60,087 | 30.74 | |
| 1990 | 2,148,463 | 367,975 | 17.13 | 193,000 | 62,797 | 32.54 | |
| 1991 | 2,169,518 | 400,465 | 18.46 | 195,000 | 66,087 | 33.89 | |
| 1992 | 2,175,613 | 415,966 | 19.12 | 185,211 | 64,557 | 34.86 | |
| 1993 | 2,268,553 | 448,532 | 19.77 | 193,557 | 70,017 | 36.17 | |
| 1994 | 2,278,994 | 470,915 | 20.66 | 195,331 | 75,489 | 38.65 | |
| 1995 | 2,312,132 | 488,224 | 21.11 | 210,545 | 79,206 | 37.62 | |
| 1996 | 2,314,690 | 492,434 | 21.27 | 207,772 | 81,960 | 39.45 | |
| 1997 | 2,314,245 | 533,773 | 23.06 | 209,395 | 85,196 | 40.69 | |
| 1998 | 2,337,256 | 563,384 | 24.10 | 213,004 | 90,200 | 42.35 | |
| 1999 | 2,391,399 | 598,721 | 25.04 | 222,538 | 102,702 | 46.15 | |
| 2000 | 2,403,351a | 629,362 | 26.19 | 229,138 | N/A | N/A | |
| 2001 | 2,409,000a | 651,176b | 27.25b | N/A | N/A | N/A | |
Over the final 75 years of the 20th century, cremations in Great Britain and throughout Europe gained significant acceptance as a body disposition option. By 1999, cremations represented 70% of the body dispositions in Great Britain, 48% in the Netherlands, and 39% in Germany. In other portions of the world, cremation is even more prevalent. In Japan, for example, 90% of dispositions are by cremation.
Future trends in body disposition will include an increase in the proportion of cremations. The Cremation Association of North America, for example, projects that by the year 2025, cremations will rise to 47.55% of all body dispositions. There is little reason to believe that this trend will not continue beyond 2025, perhaps even reaching a level similar to that of Great Britain and Japan. Religious opposition to cremation will continue to decline, and economic considerations will likely serve as an important factor in the continued rise in cremation.
Legal constraints in disposing of cremains are minimal. Traditionally, such remains have been buried in cemeteries, entombed in a columbarium, or scattered. Americans tend to fancy novelty, however. Some of the more unusual configurations include scattering cremains at sea, placing cremains into cast concrete modules for use as “Eternal [artificial] Reefs,” loading the cremains into shotgun shells and firing these in a hunting location, making fireworks from cremains, inserting cremains into capsules to be lifted by rockets to orbit the earth, and placing cremains in keepsake lockets to be worn by relatives. No doubt the future will give rise to even greater variation with new and perhaps even more unique means of cremains disposition emerging.
Alternative Modes
New forms of body disposition will develop to compete with current styles, of which mummification is one recent example. Using a technique similar to that of the ancient Egyptians, individuals can be preserved and enclosed in an encasement similar to the highly decorated versions in which Egyptian Pharaohs were placed. Because this method offers the advantage of preserving DNA, mummification likely will become a more frequent mode of body disposition in the future. There have been a few instances of taxidermists freeze-drying deceased pets at the insistence of grieving owners. Freeze-drying is essentially a modern high-tech version of mummification. It is likely that in the future, there will be efforts to freeze-dry humans as a mode of body disposition.
Another unusual mode of body disposition is cryonics. As noted by Bryant and Snizek (1972), cryonic suspension affords the advantage of near-perfect preservation of the body in liquid nitrogen for an indefinite period, leaving open the prospect of eventual thawing and reanimation. Because cryonics offers the prospect of a scientific reversal of the cause of death, future cryogenic technology may encourage public interest and enhance participation.
In the past, the relationship between altruism and the disposition of one’s remains was limited to donations to science. This generally took the form of willing one’s body to a medical school for dissection by students’ eager to gain practical knowledge of human anatomy. At present, advances in medicine, surgery, and biochemical technology offer an expanded set of venues for an altruistic form of body disposition. Organ transplantation permits the individual to offer the gift of life to others through permitting one’s body parts to be “harvested” at death and then donated. The practice is still modest in terms of actual numbers, but organ donation will probably increase in the future, perhaps even becoming a routine procedure for recycling body parts to benefit the living.
In summary, in the past, few options existed for body disposition. Today, however, many such options exist. In the future, the range of alternatives will expand even more, and the choices people make will reflect diverse ideologies that encompass innovation, individualism, and purposeful and, in some instances, even altruistic actions.
Funerals in the Future
Historically, funerals conducted in the United States have occupied a central position within the panoply of death-related behavior. As with all rituals, however, these change over time. According to Stephenson (1985), funerals have experienced a metamorphosis in both form and content. He depicts this change as evolving through three phases, each of which are marked by distinctive characteristics: (a) the era of sacred death, which spanned the 17th and 18th centuries; (b) the era of secular death, covering the 19th and early 20th centuries; and (c) the era of avoided death, a period from the mid- to late-20th century (pp. 21-46). During the era of sacred death, the Puritans eschewed ceremonialism as “popish,” celebrating death without benefit of ritual, formal prayer, or service. The body was prepared and buried by the family, with the passing of an individual receiving mention during church services. The orientation toward death was a simple, fatalistic acceptance of the inevitability of God’s plan and as a tribute to their Christian faith (pp. 203-5). Later, funerals became more ritualistic but remained simple in structure and content. The funeral service continued its focus on the deceased, and the tenor of death remained a sacred event (pp. 204-20).
During the second phase, the era of secular death, funerals were longer in duration, more structured, commercially elaborate, and highly emotional in content, thus allowing for public display of secular symbols. But in light of the religious certainty of eternal life in heaven for the deceased, the focus of the funeral was more on the survivors and their grief (Stephenson 1985:205-7).
Finally, the era of avoided death reflects the ideological posture of death denial operating during this period. Funerals are increasingly secular, commercial in nature, and seemingly intended to create an aura of an avoidance of death (Stephenson 1985:207-12). Currently, funerals are shorter than in the past and appear somewhat routine and perfunctory even to the point of being scripted and superficial in manner. Sermons often are quasi-religious with eulogies being delivered by family members and friends. Often, services are held in a funeral home chapel rather than in a church. And in comparison with the past, funerals currently constitute a lesser economic burden as well as exhibiting a reduced level of emotional display.
All these trends will likely continue in the future. That is, funerals will become even more routine and perfunctory. Funerals will become standardized, with uniform pricing intended to accommodate public expectation. Such nontraditional trends may also involve a larger proportion of memorial services. With such arrangements, the body can be quickly cremated and a memorial funeralization service may be held at any time with informal, individualized procedures. Secular music will also become a regular feature with the service itself generally devoid of religious symbolism.
Time and money will become ever more important considerations in the future. Accordingly, funerals will be structured to fit into the busy schedules of the living such as is currently demonstrated with “drive-through” funeral homes. Drive-through windows, where the deceased individual is displayed in a casket, allow friends and relatives to view the body without leaving their automobiles. This type of facility or similar arrangements may well proliferate in the future.
The future will include a greater emphasis toward practical funerals, with the financial emphasis becoming less a factor. The use of discount funeral homes will increase, as will do-it-yourself activities, such as purchasing caskets through discount sources and providing transportation for the deceased to the cemetery. Fewer people will actually attend funerals, and the obligation to assemble family members will be assigned a lower priority, if not completely diminished.
The practice of virtual attendance is already taking place and will doubtless increase in the future. The economic benefits of virtual funerals will not be unnoticed by the public, as funerals will be conducted with a greater use of computers, television, videotapes, and other electronic techniques. Online funerals will also become a major component with videotape and digital recordings stored and available for retrieval at any time.
Finally, future funerals will be individualized and idiosyncratic. Less inhibited by custom and social norms, people will likely seek to create unique configurations of funeralization aspects. Indeed, individuals may well choose to make their legal and social exit a statement of the ultimate individual expression.
The Future of Thanatology
In the preceding sections, we have identified several areas of change that will occur in death-related patterns and practices during the 21st century. These changes also will have an effect on the future study of thanatology. Dramatic changes emerging in the study of the demographics of death, particularly in the United States, are likely to thrust thanatology into greater prominence. As death rates increase, interested scholars and the general public will seek a greater understanding of the social, economic, ethical, and emotional implications of death. Moreover, as a growing number of people occupy a dying status, new support and advocacy groups are likely to organize. These groups, obvious sources of interest to thanatologists and practitioners alike, are also likely to serve as crucial mediating organizations, helping people come to terms with dying and death, secure available resources and medical treatments, and decide on appropriate directives regarding end-of-life care.
Other emerging trends, such as globalization and the cross-cultural contact and the exchange it fosters, are also likely to be a source of future thanatological research. In the wake of this trend toward globalization, a growing number of terrorist attacks, war, and genocidal events will remain a matter of concern. Thus thanatologists will examine changes in broad political views and ideologies prompted by globalization and conflict and how these views reshape perceptions of death and death-related behavior.
Students of death and dying will fashion a new research agenda and create new research questions. Among these questions is, What effects will mass violence impose on the experiences and images of death? A related question might be, To what extent will the future of death take the form of mass killing or violence as opposed to natural causes or disaster? The events of September 11, 2001, are likely to be repeated. How will society cope with death of such magnitude?
Thanatologists will be called on to investigate how future scientific and technological advances shape people’s experiences and their understanding of death. They will explore how cloning, stem cell research, organ harvesting and transplants, and cryonic storage technologies will affect the treatment of terminal or debilitating illnesses, the nature of the life span, and prevailing conceptions of aging, health, illness, and death. Moreover, thanatologists will examine how advances in drug therapies, particularly in the areas of pain relief and palliative care, affect attitudes regarding end-of-life treatments, procedures, and directives.
Finally, thanatologists will focus attention on how computer technologies alter or reshape death-related beliefs and practices. One avenue for this research will be to explore how people, using these new technologies, create “immortal” or enduring virtual selves. These selves will assume a variety of forms, including the use of digitalized video, audio clips, and computer chips to store memories, experiences, and personality traits, thereby allowing the deceased to live on in cybernetic reality. Most important, advances in computer technology will enable people to construct new types of postmortal identity and a new reality that will challenge the prevailing belief that humans experience only one earthly life and death.
Ultimately, however, whatever topics thanatologists choose to explore in the years ahead, death and death-related issues will clearly represent a source of public concern. As a result, the overall impact and success of thanatological research will be determined by what thanatologists choose as their central mission. If thanatologists commit themselves to crafting analyses that are useful to scholars, practitioners, and the dying and bereaved, then future efforts will assuredly build on the important theoretical, therapeutic, and policy-making contributions of recent decades.