The Universal Good Death

The idea of the “good death” is essential for every human to contemplate, not only those involved in sociological studies. Every human being will have to confront death, either their own or their loved ones’, at some point in their lives. If they have prepared for that moment, they will be more equipped to handle the stress at that time. In today’s modern world, a multitude of advancements in medical technology are rapidly changing the situation surrounding end of life care. While most cultures share fundamental standards about what constitutes a “good death”, it is our duty to stay informed and respectful about diverse and sometimes ambivalent thoughts about a good death depending on the country of origin. “Dying, like birthing, is a natural event, sometimes better witness than managed. Caregivers are called upon to put aside their own beliefs to discover what’s appropriate for a particular person in a particular situation.” (DeSpelder & Strickland, 2020, 184) In this paper, I will discuss general understandings of “good deaths”, equalities and inequalities of “good deaths”, differences and similarities between Western American and Eastern Japanese interpretations of “good deaths”, and my personal opinion of a “good death”.

Since the development of hospice, the end of life experience for many people has significantly developed. The care provided to sick and dying patients involves the “whole person”, tending to physical needs, as well as mental, emotional, and spiritual needs. (DeSpelder & Strickland, 2020, 184) The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” (DeSpelder & Strickland, 2020, 186) Stephen Connor lists six crucial parts of functioning hospice programs. One, the patient and his/her family are the unit of care. Two, care is provided in the home or in an impatient facility. Three, symptom management is the focus of treatment. Four, treatment is directed toward the “whole person.” Five, care is interdisciplinary. Six, services are available twenty-four hours a day, seven days a week. (DeSpelder & Strickland, 2020, 188) Among the spiritual needs, there is the need for meaning and purpose, the need for hope and creativity, and the need to give and receive love. (DeSpelder & Strickland, 2020, 285-286) In an interview, Ms. Pollman describes a good death. “With a good death, they are ready to take their last breath and they are comfortable. In my faith background, they are ready and really close to the other side.” (Pollman in Hemphill, 2021) She describes the hospice program’s interdisciplinary team of nurses, social workers, chaplains, home health aides or hospice aids, massage therapists, music therapists, admission nurses, and medical directors. “All of us together make a team.” (Pollman in Hemphill, 2021)

Unfortunately, the quality of end of life is unequal across socioeconomic groups. “Despite eloquent claims about the universality of death, empirical research shows conclusively that death is not an egalitarian transition.” (Carr, 2016, 331-332) According to a conceptual framework called Fundamental Cause Theory (FCT), disadvantaged socio-economic groups lack important resources that allow advantaged socio-economic groups to achieve “good deaths”. Without a sufficient amount of money, knowledge, power, prestige, and beneficial social connections, lower class individuals simply cannot obtain quality end of life care in their communities. (Phelan, Link, & Tehranifar, 2019 in Carr, 2016, 335) There are six core components of a “good death”: pain and symptom management, acceptance, medical care that is concordant with one’s preferences, dying at home, emotional preparation, and formal preparations for end-of-life care. Among these core components, there is particular social economic status (SES) disparities in pain and symptom management and advanced care planning (ACP). The discrepancies in pain and symptom management and ACP are interrelated. “These disparities in advanced care planning (ACP) may contribute, in part, to the higher levels of pain documented in the four samples analyzed here. For example, prior studies have documented low rates of palliative care use among patients living in poorer neighborhoods. (Nicholas et al. 2011 in Carr, 2016, 350) Luckily, at least psychological and interpersonal aspects of a “good death”, such as acceptance and emotional preparation, are accessible regardless of SES. (Carr, 2016, 349) As lower social economic groups are composed of many black and Hispanic people, it is imperative to rectify inequality in “good deaths” to reach racial justice. “African Americans are significantly less likely to prepare a living will, to talk to their doctors about end-of-life care, or to participate in a hospice programs.” (DeSpelder & Strickland, 191)

Not only does socioeconomic class affect a person’s experience of death, but a person’s surrounding culture. While Americans share certain values concerning “good deaths” with Japan, death experiences in Western culture can significantly differ from death experiences in Eastern cultures. Historically, Western culture endorsed the dominant curative medical model, which pressures patients to utilize medical technology to treat sickness without cessation even if there is slim chance of recovery. This emphasis on the dominant curative medical model negatively affects the ability of patients to realize an acceptance of death, an important component of the “good death”. “The decline in mortality rates in the past century and the medicalization of the dying process has meant that new meanings of death and dying have emerged within society that are not always compatible with the acceptance of death as anticipated by the Good Death Model. The dominant curative medical model, which embraces the medical technology imperative to cure and to treat at all costs, is often accepted unquestioningly by the majority for the members of our Western society.” (Mcnamara et all., 1994, 1507) In contrast, the Japanese have been extremely skeptical of the dominant curative medical mode and modern medical technology in general. “The attention of public health officials, the public, and the media consequently came to be focused on cancer and new public discourses about hospice, pain, and disclosure. Around the same time, organ transplantation become technically feasible, raising anticipation, fear, and distrust surrounding dying (Lock 1996, 1997, 2001; Lock and Honde 1990; Feldman 1996; Ohnuki-Tierney 1994). These issues provided the foci for alternative discourses to cultural notions of the good death, often giving prominent voice to opposing viewpoints based on or opposed to the ‘Western’ approach. Through media attention in particular and social change in general, another factor affecting cultural evaluation of hospital dying developed: a growing skepticism about doctors and about ‘progress.’” (Orpett, 2001, 273)

The Japanese have unique concepts and words concerning a “good death” that are not present in Western cultures. For example, pokkuri is the ideal of a sudden death. “American English might phrase it as to ‘just fall over dead’ as with a heart attack or, as one Japanese physician put it, ‘suddenly, like when you get up and you’re brushing your teeth and you have a cerebral hemorrhage and die.” (Traphagan 2000; Woss 1993; Young and Ikeuchi 1997 in Orpett, 2001, 272-273) Another ideal way to die is rōsui, which is a gradual death, akin to dying of old age. (Orpett, 2001, 273) Anrakushi is a complicated term that simultaneously refers to euthanasia and a peaceful death through pokkuri or rōsui. The word is related to the Greek roots of euthanasia: eu “well, good” and thanatos “death”. Japanese people are ambivalent about the idea of euthanasia. “In contemporary usage it thus carries the duality of meaning that the Greek term does, both the ‘good death’ and the purposeful ending of another’s life. Some of the Japanese ambivalence toward euthanasia and physician-assisted suicide in Japan seems inherent in the act itself, which pits deeply held values against each other: life versus pain, self-versus others, and burden versus self-reliance.” (Orpett, 2001, 280)

Collective ideals of Japanese society affect their perspectives of a “good death”. Because of the collective ideals of Japanese society the Japanese are very concerned about not becoming a burden at the end of life in comparison to Americans. “Among many Japanese patients I spoke with, it was the conflict between the desire to be cared for and the wish to not become a burden that was more agonizing than whether there was or was not life after death.” (Orpett, 2001, 284) Such struggles are not as highlighted in American discourses. Community decisions are honored in Japanese culture. As a result, the patient is commonly not the predominant decision maker about his or her medical care. (Orpett, 2001, 284) Communal ideals are so important to the Japanese that dying alone is an intense fear, expressed in the words kodoku na shi “lonely death” and the phrase shini me ni au “being there are the moment of death”. (Orpett, 2001, 273).

Personally, I believe Western culture could benefit by assimilating Eastern ideas. In the study of American hospice programs, nurses struggled to circumvent an assumed acceptance of the dominative curative medical model to enable patients to accept their deaths. In contrast, Japanese patients automatically questioned the model. Therefore, Western culture could benefit by assimilating Eastern ideas in order to reach death acceptance. The Japanese articulated six main goals for a “good death”. One, a peaceful death; two, a pain-free death; three, a death surrounded by family; four, a recognition of a continuity from living through dying; five, a personalized death experience suitable to that person’s values and life conditions; and six, a death that does not burden others. Additionally, there is the goal of dying with a “peaceful face” that expresses the dignity of the dying person. (Orpett, 2001, 273) Throughout all cultures, there are universal ideals for a “good death”. These universal ideals were evident in both the American and Japanese studies. Resembling the Japanese study, the importance of community was expressed in the American paper. “Ultimately, it is the individual who dies, yet the experience of death, ‘good’ or ‘bad’ involves family, friends and health professionals who become involved in the care of the dying person. Nimocks attempts a definition of a ‘good’ death that accommodates all the actors in the social process. ‘Goodness’ can therefore be defined in terms of: ‘the extent to which the interactants accept the impending death, receive mutual emotional care and support, mitigate the dying person’s discomfort and isolation and complete all ‘unfinished business’. (Mcnamara et all., 1994, 1502)

For my own death, I aspire to achieve all the universal ideals of a “good death” as present in the Western and Eastern interpretations. Through writing this paper, I learned of the varying nature of a “good death” across cultures. This was beneficial for the formation of my ideas of a universal “good death” for myself and others. I feel I am better prepared for my own death as well as my loved ones. I am respectfully informed about the differing perspectives about death from a foreign culture. For my funeral, I would prefer my burial to be as green and environmentally friendly as possible. I hope my loved ones are cared for and comforted by the community. In the future, I dream others will begin to understand the importance of universal ideals for a “good death” that will unite us all towards the goals of racial equality in “good deaths” and protecting each other and the planet.

References:

Carr, Deborah. (2016) Is Death “The Great Equalizer”? The Social Stratification of Death Quality in the United States. The Annals of the American Academy of Political and Social Science, 663, 331-354

DeSpelder, Lynne Ann and Strickland, Albert Lee. (2020) The Last Dance: Encountering Death and Dying. New York: McGraw Hill.

Hemphill, Amy. (2021). A Conversation on Death and Dying with a Hospice Social Worker.

Long, Susan Orpett. (2001). Negotiating the “Good Death” Japanese ambivalence about new ways to die. Ethnology. 40(4), 271-289.

Mcnamara, Beverly; Waddel, Charles; Colvin, Margaret. (1994). The Institutionalization of the Good Death. Soc. Sci. Med., 39(11), 1501-1508.