Death: V. Death in the Western World
V. DEATH IN THE WESTERN WORLD
This entry, by the late Talcott Parsons, is reprinted from the first edition. It is followed immediately by a Postscript, prepared by Victor Lidz for the purposes of updating the original entry.
That the death of every known human individual has been one of the central facts of life so long as there has been any human awareness of the human condition does not mean that, being so well known, it is not problematical. On the contrary, like history, it has needed to be redefined and newly analyzed, virtually with every generation. However, as has also been the case with history, with the advancement of knowledge later reinterpretations may have some advantages over earlier ones.
Some conceptualization, beyond common sense, of a human individual or "person" is necessary in order to understand the set of problems presented by death. Therefore, a few comments on this topic are in order before proceeding to a reflection on some of the more salient features of death as it has been understood in the Western world.
The Person and the Problematic of Death
The human individual has often been viewed in the Western world as a synthesized combination of a living organism and a "personality system" (an older terminology made the person a combination of "body" and "mind" or "soul"). It is in fact no more mystical to conceive of a personality analytically distinct from an organism than it is to conceive of a "culture" distinct from the human populations of organisms who are its bearers. The primary criterion of personality, as distinct from organism, is an organization in terms of symbols and their meaningful relations to each other and to persons.
Human individuals, in their organic aspect, come into being through a process of bisexual reproduction. They then go through a more or less well-defined "life course" and eventually die. That human individuals die as organisms is indisputable. If any biological proposition can be regarded as firmly established, it is that the mortality of individual organisms of a sexually reproducing species is completely normal. The death of individuals has a positive survival value for the species.
As Sigmund Freud said, organic death, while a many-faceted thing, is in one principal aspect the "return to the inorganic state." At this level the human organism is "made up" of inorganic materials but is organized in quite special ways. When that organization breaks down—and there is evidence that this is inevitable by reason of the aging process—the constituent elements are no longer part of the living organism but come to be assimilated to the inorganic environment. Still, even within such a perspective on the human individual as an organism, life goes on. The human individual does not stand alone but is part of an intergenerational chain of indefinite durability, the species. The individual organism dies, but if he or she reproduces, the line continues into future generations.
But the problematic of human death arises from the fact that the human individual is not only an organism but also a user of symbols who learns symbolic meanings, communicates with others and with himself or herself through them as media, and regulates his or her behavior, thought, and feelings in symbolic terms. The individual is an "actor" or a "personality." The human actor clearly is not born in the same sense in which an organism is. The personality or actor comes into being through a gradual and complicated process sometimes termed "socialization."
Furthermore, there is a parallel—in my judgment, something more than a mere analogy—between the continuity of the actor and that of the organism. Just as there is an intergenerational continuity on the organic side, so is there an intergenerational continuity on the personality or action side of the human individual. An individual personality is generated in symbiosis with a growing individual organism and, for all we know, dies with that organism. But the individual personality is embedded in transindividual action systems, both social and cultural. Thus the sociocultural matrix in which the individual personality is embedded is in an important sense the counterpart of the population-species matrix in which the individual organism is embedded. The individual personality dies, but the society and cultural system, of which in life he or she was a part, goes on.
But what happens when the personality dies? Is the death of a personality to be simply assimilated to the organic paradigm? It would seem that the answer is yes, for just as no personality in the human sense can be conceived as such to develop independently of a living organism, so no human personality can be conceived as such to survive the death of the same organism. Nevertheless, the personality or actor certainly influences what happens in the organism—as suicide and all sorts of psychic factors in illnesses and deaths bear witness. Thus, although most positivists and materialists would affirm that the death of the personality must be viewed strictly according to the organic paradigm, this answer to the problem of human death has not been accepted by the majority in most human societies and cultures. From such primitive peoples as the Australian aborigines to the most sophisticated of the world religions, beliefs in the existence of an individual "soul" have persisted, conceivably with a capacity both to antedate and to survive the individual organism or body. The persistence of that belief and the factors giving rise to it provide the framework for the problematic of death in the Western world.
Christian Orientations toward Death
Because the dominant religious influence in this history of the Western world has been that of Christianity, it is appropriate to outline the main Christian patterns of orientation toward death.
There is no doubt of the predominance of a duality of levels in the Christian paradigm of the human condition, the levels of the spiritual and the material, the eternal and the temporal. On the one hand, there is the material-temporal world, of which one religious symbol is the "dust" to which humankind is said to return at death. On the other hand, there is the spiritual world of "eternal life," which is the location of things divine, not human. The human person stands at the meeting of the two worlds, for he or she is, like the animals, made of "dust," but is also, unlike the animals, made in the image of God. This biblical notion of humanity, when linked to Greek philosophical thought, gave rise to the idea in Catholic Christianity that the divine image was centered in the human soul, which was conceived as in some sense an emanation from the spiritual world of eternal life. Thus arose the notion of the "immortal soul," which could survive the death of the organism, to be rejoined to a resurrected body. The hope of the resurrection, rooted in the Easter faith of the Christian community, was from the beginning a part of the Christian faith and provided another dimension behind the teaching on the immortality of the soul.
The Christian understanding of death as an event in which "life is changed, not taken away," in the words of the traditional requiem hymn, Dies irae, can be interpreted in terms of Marcel Mauss's paradigm of the gift and its reciprocation (Parsons, Fox, and Lidz). Seen in this way, the life of the individual is a gift from God, and like other gifts it creates expectations of reciprocation. Living "in the faith" is part of the reciprocation, but, more important to us, dying in the faith completes the cycle. The language of giving also permeates the transcendental level of symbolism in the Christian context. Thus, Mary, like any other woman, gave birth to Jesus, God also gave his only begotten Son for the redemption of humankind. Finally, Jesus, in the Crucifixion and thus the Eucharist, gave his blood for the same purpose. By the doctrine of reciprocation humankind assumes, it may be said, three principal obligations: to accept the human condition as ordained by the Divine Will, to live in the faith, and to die in the faith (with the hope of resurrection). If these conditions are fulfilled, "salvation," life eternal with God, will come about.
This basically was the paradigm of death in Catholic Christianity. Although the Reformation did collapse some elements in the Catholic paradigm of dualism between the eternal and the temporal, it did not fundamentally alter the meaning of death in societies shaped by the Christian faith. Still, the collapse of the Catholic paradigm did put great pressures on the received doctrine of salvation. The promise of a personal afterlife in heaven, especially if this were conceived to be eternal—which must be taken to mean altogether outside the framework of time—became increasingly difficult to accept. The doctrine of eternal punishment in some kind of hell has proved even more difficult to uphold.
The primary consequence of this collapsing was not, as it has often been interpreted, so much the secularization of the religious component of society as it was the sacralization of secular society, making it the forum for the religious life—notably, though by no means exclusively, through work in a "calling" (as Max Weber held).
Though John Calvin, in his doctrine of predestination, attempted to remove salvation from human control, his doctrine could not survive the cooling of the effervescence of the Reformation. Thus, all later versions of Protestantism accepted some version of the bearing of the individual's moral or attitudinal (faith) merit on salvation. Such control as there was, however, was no longer vested in an ecclesiastical organization but was left to the individual, thus immensely increasing religious and moral responsibility.
The concept of a higher level of reality, a supernatural world in which human persons survived after death, did not give way but became more and more difficult to visualize by simple extrapolation from this-worldly experience; the same problem occurred with the meaning of death as an event in which one gave life back to its Giver and in return was initiated into a new and eternal life. In addition to the changes in conceptualization set in motion by the Reformation, the rise of modern science, which by the eighteenth century had produced a philosophy of scientific materialism, posed an additional challenge to the Christian paradigm of death, manifesting itself primarily in a monism of the physical world. There was at that time little scientific analysis of the world of action, and there was accordingly a tendency to regard the physical universe as unchanging and hence eternal. Death, then, was simply the return to the inorganic state, which implied a complete negation of the conception of eternal life, since the physical, inorganic world was by definition the antithesis of life in any sense.
Contemporary Scientific Orientations
The subsequent development of science has modified, or at least brought into question, the monistic and materialistic paradigm generated by the early enthusiasm for a purely positivistic approach. For one thing, beginning in the nineteenth century and continuing into the twentieth, the sciences of organic life have matured, thanks largely to placing the conception of evolutionary change at the very center of biological thought. This resulted in the view, which has been already noted, that death is biologically normal for individual members of evolving species.
A second and more recent development has been the maturing of the sciences of action. Although these have historical roots in the humanistic tradition, they have only recently been differentiated from the humanistic trunk to become generalizing sciences, integrating within themselves the same conception of evolutionary change that has become the hallmark of the sciences of life.
The development of the action sciences has given rise, as already noted, to a viable conception of the human person as analytically distinct from the organism. At the same time these sciences, by inserting the person into an evolutionary sociocultural matrix analogous to the physico-organic species matrix within which the individual organism is embedded, have been able to create an intellectual framework within which the death of the personality can be understood to be as normal as the death of the organism.
Finally, the concept of evolutionary change has been extended from the life sciences (concerned with the organism) and the action sciences (concerned with the person-actor) to include the whole of empirical reality. And at the same time we have been made aware—principally by the ways in which Einstein's theory of relativity modified the previous assumptions of the absolute empirical "givenness" of physical nature in the Newtonian tradition—of the relative character of our human understanding of the human condition.
Thus there is now a serious questioning of absolutes, both in our search for absolutely universal laws of physical nature and in our quest for metaphysical absolutes in the philosophical wake of Christian theology.
The Kantian Impact and the Limits of Understanding
The developments in a contemporary scientific understanding of the human condition are both congruent with, and in part anticipated and influenced by, Immanuel Kant, whose work during the late eighteenth century was the decisive turning point away from both physical and metaphysical absolutism. Kant basically accepted the reality of the physical universe, as it is humanly known, but at the same time he relativized our knowledge of it to the categories of the understanding, which were not grounded in our direct experience of physical reality but in something transcending this. At the same time Kant equally relativized our conceptions of transcendental reality, whose existence he by no means denied, to something closer to the human condition. Indeed, it may be suggested that Kant substituted procedural conceptions of the absolute, whether physical or metaphysical, for substantive propositions.
While relativizing our knowledge both of the physical world, including the individual human organism, and of the metaphysical world, with its certitude about the immortality of the soul, Kant nonetheless insisted on a transcendental component in human understanding and explicitly included belief in personal immortality in the sense of eternal life.
With respect to the bearing of Kant's thought and its influence through subsequent culture on the problem of the meaning of death, I have already noted that he prepared the way, procedurally, for the development of the action sciences and their ability to account intellectually for the personality or actor experienced as one aspect of the human individual without the need to infer, of necessity, the existence of a spiritual soul existentially and not merely analytically distinct from the living organism. The action sciences, in a very real sense, attempt to provide a coherent account of human subjectivity, much as Kant attempted to do in his Critique of Judgment, without collapsing the difference of levels between the physical and what may be called the telic realm.
The framework provided by Kant's thought is indeed congenial to the scientific perspective on the normality of the death of a person, conceived as an actor whose coming into existence is in symbiosis with a growing individual organism and whose individual personality, while continuing into a new generation in the same sociocultural system, can be understood to die in symbiosis with the same organism. Nonetheless, if Kant was right in refusing to collapse the boundaries of the human condition into the one vis-à-vis the physical world, the meaning of human individual death can no more be exhausted by that of the involvement of the human individual in a sociocultural system of more comprehensive temporal duration than can the meaning of our sensory experience of empirical reality be exhausted by the impressions emanating from that external world, or even the theoretical ordering of those impressions.
If Kant's fundamental position is accepted, then his skepticism about absolutes must apply to both sides of the fundamental dichotomy. Modern biology certainly must be classed as knowledge of the empirical world in his sense, and the same is true of our scientific knowledge of human action. In his famous terminology, there is no demonstrable knowledge of the thing in itself in any scientific field.
In empirical terms organic death is completely normal. We have, and according to Kant we presumably can have, no knowledge of the survival of any organic entity after death, except through the processes of organic reproduction that enable the genetic heritage to survive. Kant, however, would equally deny that such survival can be excluded on empirical grounds. This has an obvious bearing on the Christian doctrine of the resurrection of the body. If that is meant in a literal biological sense (though this is by no means universally the way in which Christians understand it), then the inference is clearly that it can never be proved, but it can still be speculated about and can be a matter of faith, even though it cannot be the object of either philosophical or scientific demonstration.
The same seems to hold for the personality-action component of the human individual. Empirically, the action sciences can account for its coming-to-be and its demise without postulating its survival. But they cannot exclude the possibility of such survival. Thus the eternal life of the individual soul, although metaphysically unknowable, can, like resurrected bodies, be speculated about and believed in as a matter of faith.
Thus, included in the victims of Kant's skepticism or relativization is belief in the cognitive necessity of belief in the survival of human individuality after death as well as belief in the cognitive necessity of belief in the nonsurvival of human individuality after death. Kant's relativization of our knowledge, both empirical and metaphysical, both closed and opened doors. It did, of course, undermine the traditional specificities of received beliefs; but at the same time, and for the very same reason, it opened the door, by contrast to scientific materialism, not merely to one alternative to received Christian belief but to a multiplicity of them.
This leaves us with the position that the problem of the meaning of death in the Western tradition has, from a position of relative closure defined by the Christian syndrome, been "opened up" in its recent phase. There is above all a new freedom for individuals and sociocultural movements to try their hands at innovative definitions and conceptions. At the same time, the viability of their innovations is subject to the constraints of the human condition, both empirical and transcendental, noted by Kant.
The grounding of this door-opening process lies in Kant's conception of freedom as the central feature of what he called "practical reason." In essence, the human will, as he called it, can no more be bound by a set of metaphysical dogmas than a person's active intellect can be bound by alleged inherent necessities of the empirical, relevant Ding an sich. This doctrine of freedom, among other things, opens the door to Western receptivity to other, notably Oriental, religious traditions. Thus, Buddhist tradition, on the whole by contrast with Christian, stresses not individuality except for this terrestrial life but, rather, the desirability of absorption, after death, into an impersonal, eternal matrix (as opposed to a personal eternal life). The recent vogue of Oriental religion in Western circles suggests that this possibility has become meaningful in the West.
The problem of the meaning of death in the West is now in what must appear to many to be a strangely unsatisfactory state. It seems to come down to the proposition that the meaning of death is that, in the human condition, it cannot have any "apodictically certain" meaning without abridgment of the essential human freedom of thought, experience, and imagination. Within limits, its meaning, as it is thought about, experienced for the case of others, and anticipated for oneself, must be autonomously interpreted. But this is not pure negativism or nihilism, because such openness is not the same as declaring death, and of course with it individual life, to be meaningless.
So far as Western society is concerned, I think the tolerability of this relatively open definition of the situation is associated with the activistic strain in our values, the attitude that human life is a challenging undertaking that in some respects may be treated as an adventure—by contrast with a view that treats human life as a matter of passively enduring an externally imposed fate. Even though Western religion has sometimes stressed humanity's extreme dependency on God, and indeed the sinfulness of asserting independence, on the whole the activistic strain has been dominant. If this is the case, it seems that humans can face their deaths and those of others in the spirit that whatever this unknown future may portend, they can enter upon it with good courage.
Insofar as it is accessible to cognitive understanding at all, the problem of the meaning of death for individual human beings must be approached in the framework of the human condition as a whole. It must include both the relevant scientific understanding and understanding at philosophical levels, and must attempt to synthesize them. Finally it must, as clearly as possible, recognize and take account of the limits of both our scientific and our philosophical understanding.
We have contended that the development of modern science has so changed the picture as to require revision of many of the received features of Christian tradition, both Catholic and Protestant. This emergence of science took place in three great stages marked by the synthesis of physical science in the seventeenth century, that of biological science in the nineteenth, and that of the action sciences in the nineteenth to twentieth.
The most important generalizations seem to be the following. First, the human individual constitutes a unique symbiotic synthesis of two main components, a living organism and a living personality. Second, both components seem to be inherently limited in duration of life, and we have no knowledge that indicates their symbiosis can be in any radical sense dissociated. Third, the individualized entity is embedded in, and derives in some sense from, a transgenerational matrix that, seen in relation to individual mortality, has indefinite but not infinite durability.
From this point of view, death, or the limited temporal duration of the individual life course, must be regarded as one of the facts of life that is as inexorable as the need to eat and breathe in order to live. In this sense, death is completely normal, to the point that its denial must be regarded as pathological. Moreover, this normality includes the consideration that, from an evolutionary point of view, which we have contended is basic to all modern science, death must be regarded as having high survival value, organically at least to the species, actionwise to the future of the sociocultural system. These scientific considerations are not trivial, or conventional, or culture-bound but are fundamental.
There is a parallel set of considerations on the philosophical side. For purposes of elucidating this aspect of the problem complex, I have used Kant's framework as presented in his three critiques. On the one hand, this orientation is critical in that it challenges the contention that absolute knowledge is demonstrable in any of the three aspects of human condition. Thus, any conception like that of the ontological essence of nature, the idea of God, or the notion of the eternal life of the human soul is categorized as Ding an sich, which in principle is not demonstrable by rational cognitive procedures.
At the same time, Kant insisted, and I follow him here, on the cognitive necessity of assuming a transcendental component, a set of categories in each of the three realms, that is not reducible to the status of humanly available inputs from either the empirical or the absolute telic references of the human condition. We have interpreted this to mean that human orientation must be relativized to the human condition, not treated as dogmatically fixed in the nature of things.
The consequence of this relativization that we have particularly emphasized is that it creates a new openness for orientations, which humans are free to exploit by speculation and to commit themselves in faith, but with reference to which they cannot claim what Kant called apodictic certainty.
If the account provided in the preceding sections is a correct appraisal of the situation in the Western world today, it is not surprising that there is a great deal of bafflement, anxiety, and downright confusion in contemporary attitudes and opinions in this area. Any consensus about the meaning of death in the Western world today seems far off, although the attitude reflected in this entry would seem to be the one most firmly established at philosophical levels and the level of rather abstract scientific theory.
A very brief discussion of three empirical points may help to mitigate the impression of extreme abstractness. First, though scientific evidence has established the fact of the inevitability of death with increasing clarity, this does not mean that the experience of death by human populations may not change with changing circumstances. Thus, we may distinguish between inevitable death and "adventitious" death, that is, deaths that are premature relative to the full lifespan, and in principle preventable by human action (Parsons and Lidz). Since about 1840, this latter category of deaths has decreased enormously. The proportion of persons in modern populations over sixty-five has thus increased greatly, as has the expectancy of life at birth. This clearly means that a greatly increased proportion of modern humans approximate to living out a full life course, rather than dying prematurely. Individuals living to "a ripe old age" will have experienced an inevitably larger number of deaths of persons who were important to them. These will be in decreasing number the deaths of persons younger than themselves, notably their own children, and increasingly deaths of their parents and whole ranges of persons of an older generation, such as teachers, senior occupational associates, and many public figures. Quite clearly these demographic changes will have a strong effect on the balance of experience and expectations, of the deaths of significant others, and of anticipation of one's own death.
Second, one of the centrally important aspects of a process of change in orientation of the sort described should be the appearance of signs of the differentiation of attitudes and conceptions with regard to the meaning of the life cycle. There has already been such a process of differentiation, apparently not yet completed, with respect to both ends of the life cycle (Parsons, Fox, and Lidz). With respect to the beginning, of course, this centers on the controversy over the legitimacy of abortion and the beginning of life. And concomitant with this controversy has been an attempt at redefinition of death. So far the most important movement has been to draw a line within the organic sector between what has been called brain death, where irreversible changes have taken place, destroying the functioning of the central nervous system, and what has been called metabolic death, where, above all, the functions of heartbeat and respiration have ceased. The problem has been highlighted by the capacity of artificial measures to keep a person alive for long periods after the irreversible cessation of brain function. The main point of interest here is the connection of brain function with the personality level of individuality. An organism that continues to live at only the metabolic level may be said to be dead as an actor or person.
Third, and finally, a few remarks about the significance for our problem of Freud's most mature theoretical statement need to be made. It was printed in the monograph published in English under the title The Problem of Anxiety. In this, his last major theoretical work, Freud rather drastically revised his previous views about the nature of anxiety. He focused on the expectation of the loss of an "object." For Freud the relevant meaning of the term "object" was a human individual standing in an emotionally significant relation to the person of reference. To the growing child, of course, the parents became "lost objects" in the nature of the process of growing up, in that their significance for the growing child was inevitably "lost" at later ages. The ultimate loss of a concrete human person as object—of cathexis, Freud said—is the death of that person. To have "grown away" from one's parents is one thing, but to experience their actual deaths is another. Freud's account of the impact on him of the death of his father is a particularly relevant case in point.
Equally clearly, an individual's own death, in anticipation, can be subsumed under the category of object loss, particularly in view of Freud's theory of narcissism, by which he meant the individual's cathexis of his or her own self as a love object. Anxiety, however, is not the actual experience of object loss, nor is it, according to Freud, the fear of it. It is an anticipatory orientation in which the actor's own emotional security is particularly involved. It is a field of rather free play of fantasy as to what might be the consequences of an anticipated or merely possible event.
Given the hypothesis that, in our scientifically oriented civilization, there is widespread acceptance of death—meant as the antithesis of its denial—there is no reason why this should lead to a cessation or even substantial diminution of anxiety about death, both that of others and one's own. Indeed, in certain circumstances the levels of anxiety may be expected to increase rather than the reverse. The frequent assertions that our society is characterized by pervasive denial of death may often be interpreted as calling attention to pervasive anxieties about death, which is not the same thing. There can be no doubt that in most cases death is, in experience and in anticipation, a traumatic event. Fantasies, in such circumstances, are often characterized by strains of unrealism, but the prevalence of such phenomena does not constitute a distortion of the basic cultural framework within which we moderns orient ourselves to the meaning of death.
Indeed, the preceding illustrations serve to enhance the importance of clarification, at the theoretical and philosophical levels, to which the bulk of this entry has been devoted. This is essential if an intelligible approach is to be made to the understanding of such problems as shifts in attitudes toward various age groups in modern society, particularly the older groups, and the relatively sudden eruption of dissatisfaction with the traditional modes of conceptualizing the beginning and the termination of a human life, and with allegations about the pervasive denial of death, which is often interpreted as a kind of failure of "intestinal fortitude." However important the recent movements for increasing expression of emotional interests and the like, ours remains a culture to which its cognitive framework is of paramount significance.
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Talcott Parsons's entry "Death in the Western World" addresses the changing and conflicting orientations toward death in contemporary culture. Parsons sought to connect these orientations to broad cultural frameworks that have shaped Western civilization over hundreds of years. His effort was an extension of his previous writings on American orientations toward death and on more general patterns of Western civilization (Parsons and Lidz; Parsons; Parsons, Fox, and Lidz).
In the 1960s and 1970s, a number of authors argued that Americans "deny" death in a defensive manner (Mitford; Becker). They cited particular funeral and mourning customs as evidence, especially the preparing of remains to appear lifelike and peaceful for ritual viewing and the expectation that formal mourning need divert the family of a deceased person from other social obligations for only a brief time. Parsons, however, perceived that if there were a generalized denial of death, it would conflict with the pragmatic realism rooted in American culture since Puritan times.
Parsons drew on German sociologist Max Weber's (1864–1920) characterization of the Puritan religious ethic as an "inner-worldly asceticism" that sought to engage the harsher realities of life to transform them into elements of the "kingdom of God on earth" (Weber, 1930). While agreeing with Weber's analysis, he preferred the term instrumental activism to characterize the basic values and worldview of American society. This term underscored that American civilization had secularized the Puritan emphasis on mastery over the given conditions of life and made it the ethical basis for a wide range of worldly social institutions. Thus, secular variants of the mastery ethic now guide the formation of institutions in science and technology, formally rational law and bureaucracy, the market system and entrepreneurship, and motives of personal self-discipline and improvement (Parsons). Highlighting consistency with this basic cultural theme, Parsons found not "denial" of death but mastery over its disrupting effects on personal and social life.
While death is inevitable, its social impact is meliorable. Parsons explored two respects in which this is true (Parsons and Lidz; Parsons, Fox, and Lidz). First, medical and public health technologies have reduced premature death and now typically enable members of society to use "God-given" talents to advance their vocations in good health over long lives. The demographic changes of the late nineteenth and twentieth centuries, and related efficiencies in the use of human talents, thus flowed from an effort to master death. Second, when individuals die, the resulting experiences of social loss can be controlled. Measures ranging from life insurance to retirement planning in business to estate planning in personal affairs to psychotherapy for grief and loss reduce harms ensuing from death (Zelizer, 1983). Similarly, American mourning customs emphasize austerely supporting the bereaved in overcoming grief and guilt, so they are able to return to their routine social obligations without long delay.
Parsons recognized that, despite sharing the values of "instrumental activism," Americans disagree over many matters related to death. Abortion, capital punishment, licensing of firearms, euthanasia, medical care for the terminally ill, and organ transplantation, for example, were matters of public controversy when Parsons wrote and remain so today. "Death in the Western World" attempts to explain why this particular domain of contemporary culture has been chronically ridden with controversy. Parsons sought an answer in the rationalism of the Enlightenment, focusing on its synthesis in the philosophy of Immanuel Kant (1724–1804).
Kant epitomized the Enlightenment's elevation of Reason as a force of human betterment and a method of transforming culture (Cassirer). Ever since the Enlightenment, Reason has provided a principle for critique of traditional culture, social institutions, and customary practices. Over time, critique of the traditional has gradually given way to the articulation of new principles of legitimacy. Since the eighteenth century, the appeal to Reason has given rise to a secular moral culture as the primary ground of legitimation for the major institutional frameworks of modern society—for the institutional complexes that Weber characterized as having "rational-legal" legitimation (Weber, 1968; Lidz, 1979a, 1979b). Parsons epitomized this long and complex process of cultural change by focusing on Kant's writings and their long-term impact on the creation of new intellectual disciplines and moral-political ideologies.
In Parsons's view, Kant's critique of Newtonian physics became a model for assessing the intellectual legitimacy of new disciplines. It led to the opening of the domain of methodically developed and evaluated knowledge to new forms. Thus, from Kant's time to ours, there has been continuous growth in specialized scientific and scholarly disciplines. Kant's critiques of the human faculties of judgment and practical reason proved no less important, as they legitimated the voice of moral Reason and, as Parsons emphasized, undercut all claims to ultimate moral certainty. Ever since, Western civilization has been engulfed in everrenewed moral and ideological controversies on almost every topic of social import. As Parsons expected, orientations toward death, given their irreducible significance to humanity, have been caught up in a range of the controversies.
Across the Western world, one observes considerable variation in the adoption of principles of instrumental activism and secular rationalism. Parsons concentrated on a predominant American pattern, but one that many parts of Western civilization, including important groups in American society, have adopted only with qualifications. Catholic societies have generally shown more attachment to tradition, to historical continuity, and to sustaining community structures, and thus less activism in transforming traditional institutions and less individualism. Lutheran societies have given more emphasis to the inner moral cultivation of the individual and less to mastery of the outer world. Fundamentalist Protestantism has been less accepting of secular rationalism and has tended to maintain the emphasis of the Reformation on immediate mastery of morally problematic situations. Anglo-American versions of Enlightenment rationalism have been profoundly individualistic, while French rationalism has been more collectivistic, and German rationalism more focused on transcendental frames of judgment (Mead). In an article published in 2002, Hans Joas criticized Parsons's treatment of the gift of life as a basis of religious ethics in Western Christianity for having overlooked the continuing variation in worldviews. One may add that the variation in outlooks contributes importantly to contemporary controversies, sustaining the disagreements and adding to the anxiety over difficulties in resolving them.
Parsons's emphasis on Enlightenment rationalism as a foundation of modern intellectual disciplines and public moral discourse helps one to understand the nature of contemporary bioethics. Research on the history of bioethics shows that the field has emerged in the mold of an academic specialty that, although interdisciplinary, is dominated by philosophers (Messikomer, Fox, and Swazey). Philosophers trained in the field of ethics have successfully asserted the centrality of their expertise for resolving bioethical issues. Although the relevance of issues of life, death, illness, suffering, incapacity, and worry would seem to create a large role for theologians and religious philosophers in the field of bioethics, they have in fact been marginalized by the prestige of academic philosophy (Messikomer, Fox, and Swazey). Moreover, given the extent to which key innovations in biomedicine have been concentrated in the United States and that the issues created by such innovations have been suffused with the problematics of American moral discourse, the individualism and positivism of Anglo-American philosophy has predominated in bioethics internationally. This process has been further supported by the strategic role that American governmental regulations have assumed in the international structures of biomedical research, in particular regarding clinical trials for new medications and medical devices.
Recent Evolution of Cultural Conflicts
Although Parsons expected death-related matters to remain controversial, he could not foresee the recent evolution of cultural conflicts. The intense social criticism of funeral and mourning customs has subsided, though practices have changed little. How "life" and "living being" should be defined before birth and at the approach of death remain effervescent issues. Public debates over abortion not only have persisted but have grown in intensity, bitterness, and political importance. Issues of end-of-life care and the use of extreme measures to maintain life continue to figure in public discussion, often in connection with legal cases. Procedures once viewed as extreme, such as kidney, liver, and heart transplants, have become routine at many medical centers, but discussion continues around such issues as who should be treated—for example, whether persons with alcohol dependence should receive new livers or smokers new lungs, or whether HIV-positive patients qualify for organ transplants. The public attends with ever greater interest to advances in medicine, with new findings and procedures featured routinely on television and in newspapers. Coverage of heroic lifesaving procedures in particular resonates deeply in American moral culture, dramatizing shared beliefs in the unique value of each life. Themes of self-improvement pervade reports on the health food, antismoking, physical exercise, environmental, and even animal-rights movements.
Despite impressive institutions to master death, contemporary civilization remains acutely insecure over life (Fox and Swazey). The mass media's increasing attention to medicine, and especially to life-threatening conditions, has left the public less secure about health and more readily made anxious over environmental threats and even endemic conditions. The intensity of public fears over apparent "hot spots" of breast cancer in particular communities, over risks of anthrax infection following "terroristic" mailings of a small number of letters containing anthrax spores in the autumn of 2001, and over small risks of West Nile virus in the summer of 2002 are instances. In the context of anxiety over health, matters of personal habit and lifestyle, including diet, exercise, work schedules, and even sexual practices, are adjusted by many whenever new knowledge suggests possible effects on well-being or longevity. Parsons would have viewed such changes in personal habits as efforts to extend mastery over the conditions of life, including death.
In attending patients with highly cultivated medical insecurities, physicians have a limited fund of trust to draw upon, a situation that promotes the practice of "defensive medicine." When the lives of patients are genuinely at risk, pressures build to use the most advanced technologies and extreme measures to show that everything possible is being attempted. This is sometimes the case even when the chances of success are small and when the quality of the lives that may be extended will be quite limited. These tendencies persist while the public also worries over the rising aggregate costs of medical care and health insurance.
In the context of post-Enlightenment secular beliefs about human rights, Western societies have generally established a right of citizens to receive medical care. Different institutions have been established to secure this right, including government single-payer, publicly subsidized private, employer-paid, and combined health insurance systems. The United States stands out among Western nations for not having established universal healthcare or health insurance, although Medicare for the elderly and Medicaid for the poor cover many economically vulnerable citizens.
From the mid-1990s, U.S. national policy has engaged the issue of further democratization of access to medical care. The public has become aware that large sectors of the population lack medical insurance and, hence, access to healthcare independent of personal ability to pay for it. Although the desirability of providing better care to citizens of modest means and the poor is generally accepted, proposals about how to manage the costs while protecting the freedom of doctor–patient relationships are controversial. Proposals that appear to restrict the freedom of relationships between patients and practitioners, whether rights of patients to select their practitioners or the rights of practitioners to treat patients as they believe correct, are widely opposed. Moreover, new plans for cost containment have not directly confronted public sentiments favoring use of "heroic measures" and experimental procedures regardless of cost—sentiments that become especially forceful when physicians and family members face a patient's impending death. Eventual policy remains uncertain, but a system of national health insurance would extend "instrumental activism" in medicine by offering more secure protection from illness, suffering, and death for less affluent citizens.
Shaken Optimism about Modern Medicine
Parsons believed, along with many scientists in the 1960s and 1970s, that modern medicine verged on conquering all major infectious diseases, at least for societies with effective systems of sanitation and public health. The appearance in the 1980s of the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) has shaken such optimism. It has now become clear that humankind faces a major pandemic that, despite modern science and technology, will take scores of millions of lives globally (WHO). Twenty years of research has failed to produce an effective vaccine. New antiretroviral medications are extending the life and health of many patients with HIV/AIDS, but not all patients are helped, and how long the others will benefit remains unclear (IAPAC). In the meantime, many patients do not receive the new treatments because they have not been diagnosed, are not willing to face the consequences of an HIV/AIDS diagnosis, lack access to care or means of paying for treatment, or do not trust medical institutions to help them (Klitzman).
The costs of the new medications for HIV/AIDS are prohibitively high for most of the populations in non-Western nations, and an active controversy in the early 2000s concerned ways of making them available at reduced cost in African, Asian, and Latin American societies. Until there is an effective vaccine or a less expensive cure, prevention programs must play a prominent role in overall HIV/AIDS policy. In the United States, prevention programming still faces challenges in communicating effectively with sectors of the population most seriously at risk, in part because of political constraints on frank communication with adolescents and young adults regarding sexual practices and condom use and on laws affecting availability of sterile injection paraphernalia.
Western nations have had the public health resources to stabilize rates of HIV infections at low or moderate levels. According to World Health Organization (WHO) data from 2002, Thailand and Uganda had managed to reduce formerly high rates of infection. In a number of nations in sub-Saharan Africa, however, the continued rapid spread of HIV, as of 2003 affecting more than 28.5 million people, in some countries over 30 percent of adults in their reproductive years, is radically changing demographic structures and life-cycle patterns. In Parsons's terms, a major feature of the epidemic is that it afflicts mainly youths, young adults, and people in early middle age. People who become diseased and die are losing their most productive years. Their deaths represent unfulfilled lives, with future achievements, relationships, and experiences all lost. The economic impact on whole regions and nations is becoming immense, as is the burden of caring for children whose parents have died. WHO reported in 2002 that India, China, Burma, Indonesia, and perhaps Russia also had rapidly growing epidemics and were at risk of experiencing similar effects on regional if not national bases.
In Western societies, where HIV infection is concentrated in homosexual men, injection drug users, and, increasingly, women sex partners of injection drug users and of men who have sex with men (CDC), its transmission has often involved stigmatized behavior. HIV, with the ugly image of a wasting, disfiguring, and dementing disease, has added vastly to the burdens of prior stigmas. Many people with HIV disease have experienced intense feelings of guilt, shame, and self-blame as an added dimension of their suffering (Klitzman). Moreover, many have experienced great loss. In social circles where HIV has become common, many individuals still in early adulthood have lost many friends and associates, an otherwise rare experience in modern societies, given the generally thorough control of death before old age. Many are burdened by the "survivors' guilt" typical of people who live through disasters that have claimed the lives of many others (Erikson). They often find that any attempt at a spirited resumption of everyday activities is complicated by feelings that their futures are hopeless or meaningless without the individuals who have been lost. People not infected but aware of being at risk of infection may feel that they will inevitably become diseased—even that they are already "dead," although still walking around. Efforts to change personal conduct in order to avoid exposure to HIV may be complicated by beliefs that it is impossible to stay well or that it would be better to accompany friends in heroic suffering and death (Weitz). In some Western communities and in African and Asian nations, lassitude engendered by the HIV epidemic, through social loss, fear of death, and guilt, is causing immense social dislocation and will likely cause more in the future.
Parsons's entry highlighted the distinctive pattern of Western institutions relating to death. In comparative perspective, Parsons argued, the modern West has uniquely endeavored to "master" death. Such mastery has involved a range of institutions, including scientific medicine and public health services designed to protect life; insurance, retirement, and estate planning to manage the practical consequences of deaths; and mourning customs that emphasize recovery of survivors' abilities to perform ordinary social roles soon after the death of family members, friends, and associates. Some elements of these institutions remain closely tied to the "instrumental activism" of Western cultural values, while other elements, such as the techniques of scientific medicine or the actuarial tables and formulas of the insurance industry, have transcultural validity now that they have been developed. A matter for future investigation concerns the ways in which these universal elements will be institutionalized in sociocultural settings where they may be disconnected from Western value orientations. Scientific medicine is now practiced almost the world over, but in some non-Western societies it is generally reserved for patients from elite status groups, combined with traditional healing in ways that create different doctor and patient roles, or may be linked to personal relationships of political patronage (Kleinman; Scheper-Hughes). In these settings, the bioethical cultures that emerge in the future may prove to be very different from Western frameworks of the past several decades, not least because they will rest on different value orientations toward life and death. Comparative study of bioethical cultures may become a powerful way of building on, correcting, and refining the analysis developed by Parsons in his writings on Western orientations toward death.
victor lidz (1995)
revised by author
SEE ALSO: Autonomy; Body: Cultural and Religious Perspectives; Christianity, Bioethics in; Grief and Bereavement; Harm; Holocaust; Human Dignity; Infanticide; Islam, Bioethics in; Judaism, Bioethics in; Life; Life, Quality of; Life Sustaining Treatment and Euthanasia; Literature and Healthcare; Narrative; Palliative Care and Hospice; Pastoral Care and Healthcare Chaplaincy; Pediatrics, Intensive Care in; Right to Die, Policy and Law; Suicide; Triage;Value and Valuation; Virtue and Character;Warfare; and other Death subentries
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