Death and Dying

Death and Dying. Starting in the 1980s, social historians began to trace the history of death in America, a subject once considered outside the realm of historical analysis. Their contributions rescued the subject from oversimplification and clichés, including the stereotype—reinforced by such books as Jessica Mitford's The American Way of Death (1963)—of Americans as a death‐denying people, too optimistic, energetic, or youth‐obsessed to accept its finality. Instead, this new scholarship established critical phases in the history of death and demonstrated the links between this history and broader themes in the nation's development.

The Colonial and Antebellum Eras.

Although Americans experienced death in very different ways over the course of two hundred years—pioneering families did not respond to death on the nineteenth‐century frontier in the same way as immigrant families responded in early twentieth‐century urban ghettos—two distinct stages mark the history of death in America. In the first stage, death was a religious and communal event, part of a shared experience. In the second, death was a medical event, isolated and hidden behind institutional walls. The experience in antebellum New England under the influence of evangelical Christianity well represents the first stage. The experience of death in the modern, scientifically based, twentieth‐century hospital captures the second.

Many of the precepts of Puritanism survived well into the nineteenth century, particularly in New England, and these precepts, even in modified form, framed the society's fundamental encounter with death and dying. Religious doctrine established the definition of the good death: one that was fully and consciously prepared for. The bad death, as the injunction in the Anglican Book of Common Prayer declared, was the unexpected and quick death: “From sudden death, good Lord deliver us.” No document better expresses the need for preparation than Cotton Mather's 1710 treatise addressed to pregnant women (Elizabeth in Her Holy Retirement). Its essential message was that the pregnant woman should prepare herself for her death. This was not only because of the actual risks involved, but also because preparation for death was so vital a task that any occasion, and especially one as fundamental as childbirth, was made to serve this purpose. Indeed, well into the nineteenth century, textbooks for young children carried such exhortations as: “Look in the graveyard and you shall see, Children buried there shorter than thee.”

Early nineteenth‐century physicians as well as clergymen shared this outlook. Thus, one noted Boston physician advised a patient suffering from tuberculosis that it was time for her to prepare for death, not to combat it through more visits to doctors. “Submit and be content,” he counseled. Such medical reliance upon the influence of religion persisted through much of the nineteenth century. “In serious illness,” a leading medical textbook instructed doctors, “you can very properly prepare the way for the introduction of the clergy. We are physicians of the physical body, the temporary life. They are the physicians of the soul, the eternal life. Never belittle anything that your patients earnestly believe.”

Death in antebellum New England was a communal event. The dying person called in neighbors, made formal farewells, distributed personal effects, and selected those who would watch over his or her final hours. In this same spirit, the actual moment of death was critically important. The dying person was to pass over “without struggle.” This constituted the most telling sign that salvation and a heavenly reunion could be anticipated. Thus, the religious‐communal death, with the two features very much interconnected, was the central feature in pre‐modern America. Death was not hidden and death was not the enemy. It was the testing ground of faith, to be witnessed by family and a wide circle of friends.

From the Civil War to the End of the Twentieth Century.

The transition to a second and very different encounter with death came in the Civil War, because death in war contradicted all the inherited religious and social definitions of the good death. Soldiers died alone on the battlefield, violently, often without witnesses, or in military hospitals, far from family and friends. The enormous effort made by both the Union and Confederate armies to locate the bodies of dead soldiers and transport them home—an effort that gave rise to the practice of embalming—testified to just how radically death in war violated prevailing beliefs and conventions.

However atypical the war experience, it became the prototype of the modern experience of death, that is, death in the hospital. This institution took death out of the home, away from the family, and gave it over to strangers. Why did hospitals over the course of the twentieth century assume a monopoly over death? Part of the reason was their growing ability to treat illness; since their therapeutic efforts were not always successful, the patient under care sometimes turned into the dying patient. Some of the hospital's centrality also reflected the facts of urban life, including smaller apartments, scattered families, and weakened community relationships. Whatever the cause, the results were unequivocal. The hospital sequestered death and rendered it nearly invisible, not only from the community and friends, but from family as well.

William Osler of the Johns Hopkins University Medical School, a giant of early twentieth‐century clinical medicine, was highly critical of the change. “The tender mother, the loving wife, the devoted sister, the faithful friend and the old servant all are gone,” Osler observed: “Now you [health‐care professionals] reign supreme and have added to every illness a domestic complication of which our fathers knew nothing. You have upturned an inalienable right in displacing those who I have just mentioned. You are intruders, innovators and usurpers.” Osler's critique remained equally valid in the post‐World War II period. Studying death in public hospitals in the 1960s, the sociologist David Sudnow found that institutional routines enforced the separation of dying patients from their social support network. “While patients in critical conditions technically have the right to round the clock visitors,” he noted, “nurses strove to separate relatives from those patients about to die. They urged family members to go home or insisted that they wait outside in the corridors, not in the patient's room. Why? If a relative was present then it was necessary for someone from the staff to be present to demonstrate continuing concern which was inefficient as well as futile.” And what was true for nurses was still more true for physicians.

Although the demographics of death had changed in many ways by the closing decades of the twentieth century—men living, on average, well into their seventies and women, almost to their eighties—the most central social development related to death in these years was the broad‐based effort to recapture death from the hospital and the health‐care professional. The rise of hospices, the emergence of advanced directives and living wills, and even the movement for physician‐assisted suicide, all represent a rebellion against the prevailing system. The goal was now to facilitate death at home among family and friends and give decisionmaking about death to the patient. As a new century dawned, neither religion nor organized medicine commanded the authority they once did and many Americans appeared determined to sieze control over the process of dying, even if biology ultimately placed that goal beyond reach.
See also Demography; Health and Fitness; Life Stages; Nursing; Urbanization.

Bibliography

David Sudnow , Passing On: the Social Organization of Dying, 1967.
Philippe Ariès , The Hour of Our Death, 1974.
David E. Stannard , The Puritan Way of Death: A Study in Religion, Culture and Social Change, 1977.
Norbert Elias , The Loneliness of Dying, 1985.
Ruth Richardson , Death, Dissection, and the Destitute, 1987, 2d ed., 2000.
Gary Laderman , The Sacred Remains: American Attitudes toward Death, 1799–1883, 1996.

David J. Rothman