Grief and Counselling PDF

Edited by
Laura Cruz
Making Sense Of:

Dying and Death
Edited by
Laura Cruz
Oxford, United Kingdom
Dr Robert Fisher
Series Editor
Advisory Board
Dr Margaret Sonsor Breen
Professor Margaret Chatterjee
Dr Salwa Ghaly
Professor Michael Goodman
Professor Asa Kasher
Mr Christopher Macallister
Professor Diana Medlicott

Revd Stephen Morris
Professor John Parry
Dr David Seth Preston
Professor Bernie Warren
Revd Dr Kenneth Wilson, O.B.E
Volume 18
A volume in the Probing the Boundaries project
Making Sense Of: Dying and Death
First published 2004 by the Inter-Disciplinary Press

Oxford, United Kingdom
Inter-Disciplinary Press 2004
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any
form or by any electronic, mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information storage or retrieval systrem,
without permission in writing from the publishers.
ISBN: 1-904710-17-4
Contents
Introduction
PART I
Cross-Cultural Practices of Mourning

Collective Emotions and National Mourning
Asa Kasher
African American Population in Grief
Penelope Johnson Moore
PART II
PART IV
11
Friends, Others, and a Postmodern Ars Moriendi

We Simply Walk Toward the Sliding Doors:
Don Delillos White Noise as a Postmodern
Ars Moriendi
Mikko Kallionsivu
PART III
ix
21
Images of Dying and Death

Death and Images of Womanhood and Manhood:
The Case of Serbian Epic Poetry
Mira Crouch
35
Extreme Makeovers and Reciprocal Relations

Between the Living and the Dead
Kathleen Young
43
Death Beyond Words: The Art, Music, and Poetry of

Dying
Death and Musical Transfiguration:
Writing the Disaster
Blake Hobby
Art Can Help Make Sense of Death and Dying
Michele Petrone
55
61
PART V
PART VI
Grief, Bereavement, and Counseling

Responding to Bereavement in an Acute Care
Setting
Siobhan ODriscoll
75
The Context and Countours of Bereavement

Counselling
Jeremy Weinstein
81
Survivors and Protagonists

Avoid This Crowd Like the Plague: Historical
Responses to Epidemic Diseases
Jennifer Hart
93
When the Protagonist is Death: Implicating Text and

Reader in Trilogies of Auschwitz and Hiroshima
105
Karen Thornber
PART VII
Palliative Care and Hospice Organization

A Rose By Any Other Name: The Palliative Care/
Euthanasia Continuum
Kay Mitchell
115
Cultural Interpretations of Delirium Symptoms in the

Terminally Ill: A Barrier to Psychiatric Evaluation
and Management
127
Antonio Sison
PART VIII
HIV and Grief

Comparison Between Dickens London in the 1850s
and South Africa Today in the Face of the HIV/AIDS
Epidemic
131
Sally Cameron and Sue Cameron
PART IX
Diagnosis: The Receiving End

Medics Facing Cancer
Angela Armstrong-Coster
143
Between Organizations, Family and Death: Caring

Creatively Within the Hospice Organization
153
Elizabeth Gill
PART X
Voluntary Death and Suicide

For Fear of What the Neighbours Might Say: Social
Networks and Suicide in Early Modern Holland
165
Laura Cruz
Voluntary Death in Japanese History and
Culture
Lawrence Fouraker
183
Gender, Youth, and Suicide: Life and the Meanings of

Death in the Jazz Age
197
Kathleen Jones
PART XI
At the End of Life

I Think Experience and Gut Feeling Go Together:
Hospice Nurses Accounts of the Hours Immediately
Preceding and Following Death
209
ET Waterhouse, C Exley, and M Lloyd-Williams
Notes on Contributors
219
Introduction
There is a powerful current in modern thought and practice, the
tendency to treat death as shameful and forbidden.1 Indeed, by the
twentieth century death had become so proscribed that one anthropologist
was prompted to call its status pornographic.2 Herman Feifel, a
psychiatrist working with the Veterans Administration in San Francisco,
is widely credited with breaking the taboo on discussions of death and
dying with his book, The Meaning of Death (1959). The collected articles
stemmed from a symposium on death and dying held in 1956, which
produced a surprising fervour amongst its participants. In his introduction,
Dr. Feifel lamented the profound contradictions this taboo had
introduced into contemporary thought processes.3 Recognizing that these
contradictions had broad implications and sources, his work drew from a
wide array of perspectives and turned scholarly interest once again
towards the ancient and profound question, what is the meaning of death?
The Making Sense of Death and Dying conference, held in Paris in 2003,
marks a continuation and expansion of the cross-disciplinary discussion
begun by Dr. Feifel more than forty years ago.
As a continuation, the discussion remains strongly
interdisciplinary. Contributors to the conference and this volume include
philosophers, historians, literary scholars, nurses, physicians, sociologists,
gerontologists and psychologists. As an expansion, the discussion crosses
many new borders, both figuratively and literally. While thanatology has
its roots in the United States, especially after the phenomenal popular
success of Elisabeth Kbler-Rosss book, On Death and Dying (1969), the
discussion has broadened geographically and contributors to the
conference came from New Zealand, Australia, and the Philippines, in
addition to representatives from Western Europe, Canada, and the U.S.
The discussion is also widening thematically. While Feifels original text
focused largely on death itself, most contributors employ a wider
understanding of death as a process, to include individual experiences of
dying, grief, and mourning, as well as the aggregate effects of these
processes on entire societies or groups.
The first paper from the conference, Asa Kashers Philosophy
and Practice in Israel neatly encompasses this tension between personal
and aggregate experience on several levels. After a rigorous dissection of
the logic of collective emotions, Kasher emerges with what he calls the
variable of diffusive meaning. In short, he faced head-on the idea that in
any given society, not every individual will feel the force of grief from
collective experiences the same way. Grief can and in fact, usually does,
have a differential impact, but if it is sufficiently diffused in a society,
even those who are not personally mourning a loss can recognize the
presence of grief in those around them. This recognition then serves as the
basis for policy makers, and also for scholars. By imagining the presence
Introduction
of grief that does not have to be ascribed to any particular individual, we

can talk about grief as a social phenomenon. In a lively question and
answer session at the conference, it was clear that, for example, Princess
Dianas death did not affect all Britons equally, yet none could quite deny
the social force that her tragic accident had on their shared identity.
Kasher was not alone in using the differentiating impact of death
as a tracer of larger social realities. In her contribution, Mira Crouch
argues that in the Kosovo cyclus, a body of Serbian epic poetry dating
from the late Middle Ages, the act of death served to separate the
perceived social roles of men and women. In these poems, the
relationships between men and women, though seemingly hierarchical or
patriarichical, are, in reality, interdependent and that interdependence
becomes most apparent through their respective attitudes towards death.
Interdependence is also the theme of Kathleen Youngs contribution.
Attitudes towards death are a product of national culture, she argues, and
as a nation experiences wrenching change, such as the prolonged war and
forced immigration faced in contemporary Croatia, it is only natural for
those attitudes to change dramatically as well.
Penelope Johnson-Moore uses the attitudes towards death within
a particular social group, in this case African-Americans, as the basis for a
project designed to recognize that the diffusion of values does not affect
all parts of the population equally. Based on their shared past, including
slavery and racism, African-Americans have created a church and a
community that are nearly synonymous with one another. Johnson-Moore,
through the Palliative Care/End-of-Life Care Training and Education for
Caregivers in Minority Communities project, proposes to build on the
recognition of this differentiating impact by providing counselling on endof-life matters to the pastors of the Black Church. By following rather than
fighting these historical traditions, she suggests, a more effective and
appropriate system of guidance and meaning can be established.
Antonio Sison, a psychologist in the Philippines, makes a similar
point about the practical value of cultural sensitivity. In his contribution,
Sison underscores the value for caregivers to put themselves in the same
shoes as their patients and to tailor advice and care so that it can be
interpreted by those whose mindsets may be radically different, either
because of their traditional culture, their age, or their religion. In the
Philippines, for example, when delirious patients claim to see dead
relatives, the vision is interpreted not as a need for psychiatric care, but
rather a spiritual sign that the dead relatives are coming to carry them
away. As this case shows, in order for the patient to receive proper
counselling, the empathetic provider must be aware of these
interpretations.
While both Johnson-Moore and Sison find value by
understanding the diffusion of beliefs, Sue and Sally Cameron (mother and
daughter) draw meaning from comparison between historical societies, in
Introduction
xi
this case nineteenth-century England and present day South Africa. By

surveying the literature, the authors conclude that the socio-economic
tensions that underlie both societies seem to have similar root causes and
both manifest themselves in attitudes towards the raging epidemics of the
day; typhus in England and AIDS in South Africa. The comparison serves
to downplay difference and to contextualise the reality of South Africa,
serving as a basis for identification with their plight. In the long run, the
source of difference in the two cases may be their resolution. Unlike the
contemporary western paradigm, the Victorians spoke willingly about
death, making their society more open to understanding the plight of the
afflicted.
Just as all parts of society are not equally invested in death
attitudes and practices, neither are all deaths treated equally. By its
aberrant or exceptional nature, suicide confronts and lays bare the gaps
and contradictions within the social order and understanding. In the
section entitled Voluntary Death and Suicide, three of the contributions
look at this confrontation in different historical settings: seventeenthcentury Holland, late nineteenth-century Japan, and early twentiethcentury America. Laura Cruz suggests that low suicide rates in the town of
Leiden show that, while possessing many of the outward trappings of
modernity, Dutch towns remained communal in the disciplining of
behaviour norms. Kathy Jones suggests that newspaper accounts of female
suicides in the 1920s indicate a fundamental conflict between modern and
traditional ideas of femininity. Finally, Lawrence Fouraker shows that,
ironically, suicide was less prevalent in Japans past that is often believed,
yet that very historical tradition informs a deep-rooted, often tacit,
acceptance of suicide in modern times.
Karen Thornbers paper, also dealing with Japanese literature,
takes a very different tack than the previous-mentioned contributors. She
examines two literary sources, one on Hiroshima and the other on
Auschwitz, and finds them not to be tracers of social values, but rather the
opposite. Each text is evidence of the authors individual rebellions against
the imposition of social norms onto horrific historical events that they had
witnessed first hand. Instead of trying to make sense of these events, or
tame them as she says, the authors both experimented with structure and
genre deliberately to obfuscate, which serves to keep the events from
being relegated to historys banal dustbin.
Elizabeth Gill, in her piece Between Organizations, Family and
Death, makes a similar point about individuals working against social or
institutional restraints, though from a very different perspective. She looks
at the role of contemporary hospice volunteers and delineates the creative
strategies they employ in order to make their work meaningful despite
drastic limitations placed on their effectiveness by their position
somewhere between the medical community, the institution, and the
families. Jennifer Hart notes nearly the same constellation of opposing
xii
Introduction
forces in her re-evaluation of the role of non-traditional medical

practitioners confronting the overwhelming challenge of the Black Death
in fourteenth- and fifteenth-century Europe. Hart finds that their desire to
help their patients also gave them the courage to work creatively within
the given institutional and social restraints and perhaps produce more
effective results than those whom they worked against.
Kay Mitchells paper also talks about individual strategies in the
face of conflicting social forces. The strategies she discusses, however,
take place inside our own heads. The hospice or palliative care movement,
she suggests, sets up potentially troubling conflicts between the
Hippocratic Oath on one hand and the desire to ease suffering on the other.
Because these two conditions cannot always exist at the same time, she
suggests that caregivers brains have found creative ways to reconcile the
oppositions, such as the adaptation of longstanding ethical standards,
including the double effect, or even the creation of the hospice movement
itself.
Reconciliation of experience and value systems is a common
theme in papers by Angela Armstrong-Coster and Esther Waterhouse.
Esther Waterhouses surveys show that nurses reactions to dead bodies,
such as placing a flower on their mortuary pillow, suggest contradictions
between their own personal beliefs and their professional obligations.
Armstrong-Coster looks at the psychological disjunction faced by health
care practitioners who find themselves on the receiving, rather than the
giving, end of health care. She explains their often seemingly inexplicable
behaviour, such as ignoring symptoms, in terms of an inner struggle
created by the perception of their own role as invulnerable physicians.
Both contributors suggest that recognizing the reconciliation process can
lead towards better care for both patient and professional.
Others are less optimistic that such reconciliation is possible or
even desirable. In his study of Dom DeLillos novel White Noise, Mikko
Kallionsivu portrays this vibrant and ironic work as a search by both the
author and his protagonist Jack for the meaning of death and dying in a
thoroughly modern, rational, consumerist world. In one of the most
memorable quotes from the conference, one character tells Jack that today
we dont die, we shop. The driving force of the novel is Jacks growing
dissatisfaction with this worldview and his search for a replacement,
which Kallionsivu argues he finds in not finding, i.e. when he recognizes
that there is no answer. Kallionsivu eloquently calls this the ars
moriendi, or good death, of the post-modern world.
Many of the medical practitioners at the conference echoed the
belief that a good death is not a thing of the past, as Philippe Aries has
characterized it. Defining a good death, however, is more problematic and
many of the papers given by physicians and nurses reflected the search for
a common vocabulary in order to build a conversation and a shared
repertoire of experience. The nurses in Esther Waterhouses study justified
Introduction
xiii
their actions as contributing to their rather vaguely defined ideas of what

constitutes a good death. Physicians Anna Taube and Garnet Crawford
each gave papers, regrettably absent from this volume, that sought to
contribute to this conversation. Kay Mitchell problematised definitions of
euthanasia and the discussion that followed her paper reflected the fact
that the same terms are not used the same way across the medical and
social spectrum. In their work in South Africa, the Camerons argue that
part of a good death is looking out for the basic needs of families,
including the acknowledged criteria of the desire for dignity and closure,
but also the practical issues, such as finding the means to send the
surviving children to school. Their paper ends with an evocative analogy
to the seemingly overwhelming challenge facing practitioners to define
and provide a modern version of the good death: a man picks up one
starfish among many and throws it back into the sea, with the justification
that he made a difference to that one.
The two papers by Siobhan ODriscoll and Jeremy Weinstein
discuss and evaluate concrete efforts to turn the modern idea of a
forbidden and shameful death around and to return to the provision of a
good death. In other words, both papers suggest that there is reason to be
hopeful about all the other starfish. Siobhans paper talks about the
evolution and implementation of bereavement counselling and services at
the Beaumont Hospital in Dublin, Ireland, and the contribution that such
services make to the community. Jeremy Weinstein compares the
effectiveness of bereavement counselling in different settings, from the
hospice, where counselling is given to everyone, to the community centre,
where services are voluntary. His findings suggest that the value of such
counselling, while not perfect, is broadly acknowledged by practitioners
and patients.
If it is acknowledged that talking about death is a good thing, as
the last two papers affirm, the final two papers discuss just how we
express our thoughts about something as complex and devastating as
death. In two eloquently written contributions, Blake Hobby and Michele
Petrone both look at the media through which ideas about death can be
expressed. Hobby focuses on the metaphor of music. Many writers, he
argues, seeking to address the profound contradiction in modern thought
between the experience and meaning of death, use music to explain what
ideology cannot. Hobby suggests the metaphor is appropriate because
music, like death, is experienced on an intensely emotional level and
because it is free from the conventional limitations imposed on other
forms of expression. Painting can be similarly liberating, as Petrone
illustrated in his moving presentation of his own near-fatal experiences
and his expression of those feelings through art. His paintings carry the
message of both his own personal struggles as well as the value of finding
outlets for talking about, and making sense of, death and dying for modern
society as a whole.
xiv
Introduction
To you, the reader, these contributors are just names on a page.

You will never learn, as we did, which of us abashedly confessed to liking
country-western music or which of us led everyone in a rousing chorus of
I Love Paris in the Springtime. This does more than the usual injustice
to the people who breathed life into these words. Perhaps more than any
other subject, studying death is very personal, as Petrones work especially
shows. In the scholarship as well as in the scholars, private, individual
ideas about death and dying are often tightly intertwined with ostensibly
objective treatments of the subject. The taboo against discussing death is
still sufficiently powerful that we moderns often feel obligated to bury the
personal, emotional side under rationality, theory, and footnotes. At times,
this essential tension is visible on the surface, but more often, and perhaps
more profoundly, it was the less visible manifestations that animated the
conference, as was likely the case when Dr. Feifel began the discussion in
San Francisco nearly forty years ago.
Laura Cruz, Cullowhee, North Carolina
Notes
1. Philippe Aries, Western Attitudes towards Death: From the
Middle Ages to the Present. Baltimore and London: The Johns Hopkins
University Press (1974), 85.
2. Geoffrey Gorer, The Pornography of Death, as reprinted in
Death, Grief and Mourning. Garden City, N.Y. : Doubleday, 1967.
3. Herman Feifel, Introduction. In Herman Feifel (Editor), The
Meaning of Death (pp. xi-xvi). New York: McGraw-Hill (1965).
Part I
Cross-Cultural Practices of Mourning

Asa Kasher
Abstract: The present paper is about collective emotions in general and
about collective mourning in particular. The first part of the paper will
outline a philosophical conception of collective emotions. The next part
will present an application of that conception to the case of public
mourning, as practiced in various states. Proposals will be mentioned for
the proper practice of national mourning, which have recently been made
by a public commission headed by the author.
I.
We seem to have no difficulty in using the same expressions for
describing both individual persons and human collectives:
(1a)
(1b)
(2a)
(2b)
(3a)
(3b)
John moved from the city to the country.

The family moved from the city to the country.
Mary is of the view that stem cell research should not be
banned.
The committee is of the view that stem cell research
should not be banned.
Bill wishes Suzie to be the mayor of town.
The townsfolk wish Suzie to be the mayor of town.
Speakers of English know how to use and understand simple sentences

that ascribe to a certain person some action, view or wish (1a-3a), but they
seem to know how to ascribe the same actions, views and wishes to groups
of persons (1b-3b). Similarly, speakers of a natural language ascribe the
same emotions to both individual persons and groups of persons:
(4a)
(4b)
Harry is very sad, having heard the news.

The nation is sad, having heard the news.
However, the similarity between ascription of collective actions,

views and wishes and ascription of collective emotions is only apparent.
There is a major difference between the meaning of sentences such as
(1b)-(3b) on the one hand and the meaning of sentences such as (4b) on
the other hand.
To see the difference, consider the conditions under which
sentences such as (1b)-(3b) are assertible. Sentences (1b) is assertible, by a
certain speaker in a certain context of utterance, only if the speaker
believes in that context that every member of the family or almost every
member of the family moved from the city to the country. Sentence (2b) is
assertible, by a certain speaker in a certain context of utterance, only if the
speaker believes in that context that the committee has followed a
procedure of deliberation. Moreover, the committees deliberation, so the
speaker believes in that context, has resulted in what counts as the
committee having made a decision that the view of the committee is that
stem cell research should not be banned. Sentence (3b) is ambiguous in the
following sense: it is assertible, by a certain speaker in a certain context of
utterance, only if certain conditions obtain - conditions that are similar to
those we mentioned with respect to the assertibility of (1b) or conditions
that are similar to those we mentioned with respect to the assertibility of
(2b). That is to say, the sentence The townsfolk wish Suzie to be the
mayor of town can be happily used for assertion, only if one of two
conditions obtains. First, everyone among the townspeople or almost every
one of them wishes Suzie to be the mayor of town. Second, the
townspeople have performed a procedure that resulted in what counts as
the town having established the wish that Suzie be the mayor of town.
Generally speaking, assertibility conditions of sentences that
ascribe an action, a view or a wish to a group of people, such as a family, a
committee or a town, are of the following kinds:
(CA1)
(CA2)
Distributive meaning: What is ascribed to the group

holds for it since it holds for every member of it or for
almost every member of it.
Formal meaning: What is ascribed to the group holds for
it since according to the norms of the practice that
regulates the group, the state of the group counts as one
in which what is ascribed to the group holds for it.
Of course, sentence (4b) does not lend itself to such an analysis,

neither in terms of assertibility condition (CA1) nor in terms of
assertibility condition (CA2). Imagine the following situation holding for a
town:
(S1)
(S2)
(S3)
The town consists of six large communities. Each of

them has its distinct form of life. Almost all interactions
of a person of the townsfolk take place within the
framework of ones community.
All members of different communities live in the
vicinity of members of all other communities, but also
quite separately from each other.
Among the casualties of a recent war are numerous
members of each of three communities.
Asa Kasher
(S4)
(S5)
(S6)
All members of a community that has suffered casualties

are sad. Their emotion is manifest in their daily
activities.
All members of a community that has not suffered
casualties behave cordially but are not sad.
The Town Council has not proclaimed any period of
Communal Mourning, nor has it decided to change any
aspect of the daily life of the townsfolk in a way that
expresses sadness.
Assume, furthermore, that the sentence The town is sad is

being used by a certain speaker as a description of the current situation of
the town. Obviously, it cannot be happily used in a distributive meaning of
ascribing sadness to the group of townsfolk, since condition (CA1) does
not hold. It is not the case that every one or almost every one among the
townsfolk is sad (S5). Similarly, the same sentence cannot be happily used
in a formal meaning of ascribing sadness to the group of townsfolk, since
condition (CA2) does not hold. It is not the case that a formal decision has
been made by the Town Council to proclaim a mourning period or change
any aspect of the daily life of the townsfolk in a way that expresses
sadness (S6).
However, the sentence The town is sad can be happily used as
a description of the current situation of the town, when it fulfils (S1)-(S6).
Imagine you are a tourist in that town. Wherever you go, you see people in
a sad mood, flags at half-mast, pictures of persons who died in the recent
war, centres of entertainment closed down, and other manifest features of
sadness and bereavement. You notice that there are people who seem not
to share the emotions of their neighbours, nor do they manifest any
features of grief or mourning, however in the vicinity of every such
person, you encounter sad persons, clearly in grief, commonly mourning.
The town is sad, you tell yourself, and you are right.
Thus, in addition to assertibility conditions (CA1) and (CA2),
which specify conditions for ascribing to groups of persons actions, views
and wishes, as well as emotions, we have an assertibility condition (CA3),
which holds for conditions not covered by (CA1) and (CA2):
(CA3)
Diffusive Meaning: What is ascribed to a group holds for

it since in the vicinity of every member of the group or
almost every member of it, there is a member of the
group for whom it holds.
Under circumstances (S1)-(S6), sentence (4b) The nation is sad, having

heard the news is assertible in the diffusive meaning.
The diffusive meaning is different from the distributive meaning

and the formal meaning in an important way. To grasp the difference, let
us consider the following pairs of sentences:
(1b)
(1c)
(2b)
(2c)
(3b)
(3c)
The family moved from the city to the country.

The family stayed in the city.
should not be banned.
should be banned.
The townsfolk wish Suzie to be the mayor of town.
The townsfolk wish John to be the mayor of town.
Clearly, none of such pairs of sentences can be asserted at the same time,
since what is asserted by means of one member of such a pair is
incompatible with what is asserted by means of the other member of the
pair. For example, the family cannot, at one and the same time, move from
the city and stay in it. Sentences such as (1b) and (1c) are used in the
distributive meaning (CA1). For (1b) to be assertible in some context of
utterance, every member of the family or almost every member of it
moved from the city to the country. For (1c) to be assertible in the same
context, every member of the family or almost every member of it stayed
in the city, that is to say, did not move. Thus, what is required for (1b) is
incompatible with what is required for (1c). Similarly, the pairs (2b)-(2c)
and (3b)-(3c) can be shown to involve a parallel incompatibility.
Now consider the following pair of sentences:
(4b)
(4c)
The town is happy. The war is over.

The town is sad. Casualties are numerous.
We take it that a single person cannot be both sad and happy, at one and
the same time. A person can have, at one and the same time, reasons for
being happy, such as The war is over, and reasons for being sad, such as
Casualties are numerous. A person can even show, at one and the same
time, both features of happiness and features of sadness, in his behaviour.
However, a person cannot be, at one and the same time, both happy and
sad. However, the town can be, at one and the same time, both happy and
sad. When the first sentence of (4b) and the first sentence of (4c) are used
in the diffusive meaning, under circumstances similar to those of (S1)(S6), the town is both happy and sad. The town is happy, since in the
vicinity of every member of the townsfolk there is a happy person and
there are public features of happiness. The town is sad, since in the
vicinity of every member of the townsfolk there is a sad person and there
are public features of sadness.
Asa Kasher
Generally speaking, it seems that when sentences that ascribe

emotions to a group of persons are used they can have the diffusive meaning.
Moreover, when they are used in the diffusive meaning seemingly
incompatible emotions, such as sadness and happiness, can be successfully
asserted to hold at one and the same time for the same group, which is not the
case when sentences are used in the distributive or formal meaning.
Our observation of the diffusive meaning of sentences that ascribe
collective emotions is of some practical significance. Consider circumstances
under which a population is described, in the diffusive sense, as both sad and
happy. Assume, furthermore, that under the circumstances, both emotions
appear to an extreme extent. A typical example would be the end of a war of
independence. Thus, when the State of Israel was founded and the War of
Independence was over, both happiness and sadness prevailed. Happiness was
natural, given the independence enjoyed by Jews in their homeland after
millennia of their being in exile. Sadness was natural, given that about one
percent of the Jews in the area fell during the war.
When and where extreme sadness prevails, it is reasonable to
assume that some people suffer to an extent that calls for clinical support
or intervention. However, when extreme happiness prevails, it is
reasonable to expect that attention to grief and suffering is going to be
lower than it would have been, if happiness did not prevail at all, and even
much lower than it would have been, if only sadness prevailed at the time.
Hence, the very possibility of diffusive collective emotion requires that
special attention be paid to the fate of those who suffer darkly, behind the
glittering curtains of collective happiness.
II.
In a nutshell, our view of collective emotions includes among its
conceptual ingredients the distinction between different meanings of
sentences that ascribe an emotion to a group of people. The simplest
meaning is the distributive one: The class is sad, in the sense that
everyone in the class or almost everyone in it is sad. The most intricate
meaning is the diffusive one: The town is sad, in the sense that in the
vicinity of everyone in the townsfolk there is a person who is sad. We turn
now to the third meaning, the formal one: The nation is sad, in the sense
that a national authority formally proclaimed what may be called national
sadness. A new practice will be described of proclaiming national
mourning, which involves manifesting a variety of features of sadness.
The new practice has been suggested by a public commission,
which was appointed by the government of the State of Israel. At the
background of the appointment is the sad event of two Israel Air Force
helicopters collision, several years ago, in which 73 IDF officers and
NCOs died on their way to missions in a military zone that Israel held at
the time in Southern Lebanon. Facing the wave of funerals that covered
the state, the government decided to proclaim a short period of national
mourning. The decision rested on no law or regulation but on a rarely

invoked tradition of proclaiming national mourning under appropriate
circumstances.
As much as the proclamation of national mourning on the
occasion of the helicopter accident did not raise public objections, it did
raise the problem of delineation of those occasions on which national
mourning ought to be proclaimed. Although the fall of so many persons at
one and the same time is very rare, the fall of a similar number of persons
during a period of some months or a few years is not rare at all. The
apparent principle that there ought to be a period of national mourning
when and only when many citizens die on a single occasion did not seem
justifiable.
Accordingly, the ministerial committee of emblems and
ceremonies appointed a public commission that was asked to propose a
characterization of the conditions under which the government ought to
proclaim an appropriate period of national mourning and suggest
appropriate ways of formal expression of national mourning. For some
technical reasons, the commission was replaced by another one, which
was assigned exactly the same duties and headed by the present author.
An international survey of practices that different states have for
proclaiming national mourning was conducted by the commission, but
turned out to be not very helpful. Many states do have some form of
national mourning. Usually, in such a state, a period of national mourning
may be proclaimed by the Palace, the president, the government, etc., but
the parameters of the decision to proclaim national mourning are not
specified in much detail. Hence, periods of national mourning vary from a
day or so to three months. Expressions of national mourning vary from
flags at half-mast during the funeral, through special educational programs
used by schools during the period of national mourning, to closure of all
entertainment institutes for the whole period. Most significantly, there
seems to be no established standard for the circumstances under which a
state ought to have a period of national mourning. If a state wishes to have
a well-justified criterion for proclamation of national mourning, such a
criterion has to be devised.
Before a proposal for some criterion is put forward, it is advisable
to set some constraints on any criterion to be proposed. Setting constraints
is, indeed, part of a delineation of the occasions on which national
mourning ought to be proclaimed. Our commission suggested two
constraints. The first one was:
(C1)
A criterion for proclamation of national mourning

should not be strictly numerical.
What is meant by this constraint is that a criterion for proclamation of

national mourning should not be of the following form: If more than X
Asa Kasher
citizens of the state die during the same circumstances, national mourning
ought to be proclaimed, where X is some number that is considered
large. To see the reasons for such a constraint, consider the difference
between a disaster in which X-1 persons died and a disaster of the same
nature in which X persons died. The difference between the case of X-1
casualties and the case of X ones does not seem to be of any significance
that would warrant a formal difference between the former, as not leading
to a national mourning, and the latter, as leading to it.
Sometimes we do use numerical criteria. For example, according
to any practice of elections, citizens are eligible to vote only if they were
born before a certain day. A one-day difference between the dates of birth
of two citizens does not seem to involve any significant difference in their
general qualifications with respect to those elections, but we still use it in
delineation of eligibility to vote. However, what fits eligibility criteria
does not fit national mourning criteria. The distinction is clear: eligibility
to vote naturally rests on considerations of age. Only the exact
specification of any particular age seems at least somewhat arbitrary,
though indispensable. National mourning does not seem to naturally rest
on any numerical consideration. Therefore, any specification of a
threshold X would be strictly arbitrary and completely unjustifiable.
The reason underlying constraint (C1) rests on principles of
human dignity. When we consider two events in which human life is lost,
it would be immoral to consider one of them as a disaster and the other
one as not being a disaster, on grounds of the numerical difference
between them. It would be immoral to consider an event to be a disaster
only if it involves the death of so many persons, as if the death of a single
person or of few persons is not a disaster. Strictly speaking, the death of
73 persons at one and the same time is not a single disaster but rather a
cluster of 73 disasters taking place at one and the same time. Moreover, a
cluster of 73 disasters can be created during a longer period. Again, it
would be immoral to draw a distinction, when principles of human dignity
and fairness should be strictly followed, between two clusters of 73
disasters, one that was created by a single collision, another that was
created by a series of battles, accidents and other disastrous events.
Our second constraint is of a different nature:
(C2)
National mourning should not be frequently proclaimed.
Notice that (C2) is a constraint on proposed criteria for proclamation of

national mourning. (C2) means that a criterion should pass the following
test: If it is used, under more or less ordinary circumstances, as the sole
grounds for proclamation of national mourning, chances are very high that
national mourning wont be frequently proclaimed.
The reason for constraint (C1) was strictly moral. The reason for
(C2) is of a different nature. A period of national mourning must be
exceptional for it to involve special and manifest respect paid to the
mourned. Respect should, indeed, be paid to every deceased person,
whether privately or within a community. National mourning is meant to
express respect for the deceased within a broader sphere. The only natural
reason for a move from the sphere of a community to the sphere of the
nation is that the occasion is unique to an extent that justifies special
attention of an appropriate kind. Hence, regular proclamations of national
mourning would involve regular attention. The distinction between the
attention paid on the national level to that paid on a communal level would
disappear and the whole idea of national mourning would become
superfluous.
On the background of these constraints the following two criteria
were proposed by our commission. Let us dub them the top down
criterion (TD) and the bottom up criterion (BU).
(TD)
National mourning ought to be proclaimed when one of the

following officers of the state dies during ones tenure in office:
The President of the State;
The Speaker of the Parliament;
The Prime Minister;
The President of the Supreme Court.
The reason for having a top down criterion is that some officers of a
state stand for it, whether directly or indirectly. The president of the state
stands, in a clear sense, for the whole state. The head of any of the three
authorities, the legislative, the executive and the judiciary, stands for a
major constitutive element of the democratic state. The reason for having
that particular top down criterion (TD) is that those four persons hold the
highest offices of the state, according to any conception of the nature of
the state and the structure of the regime. Notice that not every officer of
the state is on a par with the head of ones authority, as far as the symbolic
nature of standing for the state is involved. No minister, for example,
stands for the state in the same symbolic way and to the same practical
extent as the Prime Minister does.
To be sure, the list of officers according to some alternative to
(TD) could have included many other high-ranking officers, without
violating our former constraint (C2). However, any extension of the list
would have resulted in violations of the very rationale of a top down
criterion. An extension of the list to include justices, for example, beyond
the President of the Supreme Court, would have led to a required
extension of the list to include members of the parliament beyond the
Speaker. However, even the deputy speakers of the parliament are
generally viewed as directly standing for their parties more than indirectly
Asa Kasher
standing for the state. The only list of officers that is compatible with
common societal conceptions of the regime and conceptually justified is
that of criterion (TD).
We turn now to the second criterion for proclamation of national
mourning, a bottom up criterion. Naturally, a bottom up criterion
involves two steps, one at the bottom and one at the top:
(BU)(bottom)
(BU)(top)
Every municipality may proclaim a period of communal

mourning and its public expressions, on grounds of its
own statutes.
National mourning ought to be proclaimed when
communal mourning has been proclaimed in a group of
municipalities that covers the map of the state or almost
all of it in a diffusive way.
Since the idea of a diffusive cover of a map is not easily

understood and implemented, several practical approximations were
suggested:
(BU)(top-1)
(BU)(top-2)

communal mourning has been proclaimed in a vast
majority of the municipalities of the state.
communal mourning has been proclaimed in a group of
municipalities that counts as a cover
of the map
of the state or almost all of it, according to the view of a
public commission or a governmental officer in charge
of proclamations of national mourning.
The major justification for a bottom up criterion for

proclamation of national mourning, such as (BU)(bottom)-(up), is that
under the circumstances specified by such a criterion, it is assertible that
the nation mourns in the diffusive sense of the expression. It is also held
that when the nation mourns, in the diffusive sense of the expression, the
state, as an organization, ought to proclaim national mourning and specify
its official expressions. The move, from a situation in which the nation
mourns, in the diffusive sense of the expression, to a situation in which the
nation mourns, in the formal sense, is of significance in two respects. First,
it brings the expressions of mourning to each and every part of the state,
beyond the appearance of such expressions in the given diffusive way.
Such a step of extending the sphere of mourning broadens the respect paid
to the related deceased and to all those who mourn the deceased in the
diffusive way. Secondly, it shows in a symbolic way that the state is of the
people, on the special level of personal and collective emotions of grief
and bereavement. Facing so many citizens of the state mourning the
10
deceased, even if in a diffusive way and not a distributive one, the state
joins its citizens, so to speak, embraces them, and respects their emotions.

Penelope Johnson Moore, DSW
Abstract: This session will explore the historical context for
understanding African Americans in American society. For many African
Americans, the ability to cope with numerous societal assaults, including
death and dying is linked with their world view as influenced by slavery
and faith-the belief that trusting in God will get one through any adversity.
The cultural context of bereavement will be established by exploring the
role of the black church and religion in shaping African Americans
beliefs about life after death.
Key Words: Bereavement, Oppression, Positive Self-Identity, Black
Church, Black Worship, Hospice
1.
Introduction
My thesis is that the context of racism emanating from slavery

and continuing to the present time is one of the major obstacles for
mainstream institutions to overcome in the provision of bereavement care
to African Americans. Increasingly, practitioners of bereavement care
have turned their attention to the Black Church, which is identified in the
literature as an alternative resource for the creation and development of
culturally sensitive bereavement supports. The Black Church is considered
a viable alternative resource because it has long been recognized as the
one genuine place where African Americans experience freedom of
expression and basic trust in fellow worshipers.1
Since slavery, the church has represented a place where African
Americans sense of justice, faith, endurance, and hope of freedom from
oppression are experienced and supported. It also represents a place where
parishioners go for self-help, social and emotional support, spiritual
leadership, financial support, opportunities for educational advancement,
and empowerment through participation in social change activities.2
Hardman-Cromwell identify renewal of faith through the Black
Church experience as the basis of African Americans ability to positively
cope with societal racism, prejudice and discrimination, particularly as
these dynamics interact in traditional health, mental health, and human
service agencies serving this community.3 It is, therefore, necessary to
understand how to partner with the Black Church in order to forge new
therapeutic alliances that can potentially lead to culturally appropriate
bereavement care. The purpose of this paper is to identify the structure of
12
worship in the Black Church that provides meaning and sources of healthy
grieving to African Americans dealing with grief and loss.
2.
Overview of the Literature
There is a small but growing literature pertaining to bereavement

and the Black Church, of which, a major theme is the role of the institution
and the family in coping with societal oppression. Religion is perceived to
be an adaptive mechanism that enables poor and oppressed individuals and
groups to find spiritual compensation for the material and social benefits
that they are frequently denied. There are many positive aspects of faith
communities providing both health and mental health services. The clergy
holds a distinct advantage over professional counsellors because
parishioners are more likely to contact their pastor when faced with
bereavement and grieving. Spiritual counselling is a part of the clergys
responsibility to the congregation, for which, there is neither cost nor
stigma attached to the help provided. Relationships are based on trust.
Typically, parishioners do not seek the services of other professionals
concerning issues of death, illness, and emotional adjustment, if they
believe the spiritual counselling they receive has helped them.4
3.
What is the Black Church?
It is difficult to obtain a clear historical account of the level of

religious knowledge maintained by slaves who founded the Black Church
in America, since laws prohibited slaves from learning to read and write. It
is apparent, however, that the African slaves need for survival led them to
create their own style of worship separate from white churches.
Glazier describes the religion of the white planter class as
spurious compared to the genuine religion of slaves. Spurious refers to
whites use of religion to justify slavery for their own benefit. There was
nothing more sinful than slaves making an attempt to escape or
overthrow the system of slavery.5 On the contrary, genuine refers to the
slaves need to fashion Christianity to fit the unique experience of
enslavement. African American men and women saw the Lord as always
on their side, they indeed were His Chosen People, and God supported
their efforts to resist the dictates of blasphemous mortals.6
In order to preserve their spirit, slaves interpreted religious text
differently and modified Christian rituals, resulting in a blending of
African and Christian forms of worship. For example, Jones discusses
southern blacks interpretation of the Decalogue (The Ten
Commandments) and the conversion experience, during which slaves
insisted that one must experience visions in order to attain true salvation.
This idea sharply contrasted with the practices of whites that regarded
such manifestations as aberrant.7 However, slaves ability to retain
13
elements of African religious practices nurtured their own spiritual

identity; and their ability to beat back the demons of hope-less-ness,
meaning-less-ness, and love-less-ness, as well as helped them to sustain
their efforts to strive for excellence under adverse new world conditions.8
According to Kalish and Reynolds, African Americans tend to be
more accepting and less fearful of death than other ethnic groups, and have
significantly more contact with homicide, accidents, and war-time deaths
than any other group.9 Their experiences from slavery taught them that
death or any other form of personal loss could come at any time, at any
age, randomly, and often at the whim of someone else. These themes are
often reflected in the artistic expressions of African American artists
through music, poetry, novels, drama, and visual arts. From these themes
emerged a picture of African Americans belief that there is an after-life in
which the deceased will be free of sickness, disease, poverty, and hunger;
and in death, victims of injustices will be appropriately avenged by God.
Ideas about the after-life greatly influence the importance that
African Americans place on funerals. For example, Kalish and Reynolds
observed that, When society treats a people as objects, accords them only
minimal respect, and simultaneously blocks the channel by which respect
can be achieved, the result is a people who seek ways to confirm their
sense of self-hood and positive self-identity.10 Thus, the funeral ritual is
an important ceremony.
In more recent times, families view the funeral as an affirmation
that the spirit has been released and has crossed over and gone home.
Often times, the funeral will include prayers, songs, viewing of the body,
and eulogy by the minister. At the wake, there may be additional elements
of artistic cultural expressions including: jazz music, liturgical dancing,
poetry, personal testimonies of family and fiends, food, and social
gathering. The following (video) excerpt from the wake of a revered
minister provides insight about African Americans views about death:
I met a man in Pastor who did not bow down. He said,
like the Hebrew Boys, `you may change my name, but
you cant change who I am Sometimes as believers
we dont understand this. He has run the race, he has
finished the course. He has met his goal, which was to
see Jesus face to face without bowing down. Pastor
knew what season and time it was. I came to honour a
man that chose not to bow down to the image of pain,
sickness, disease or disappointment.... Death is not
about a disease. Death is about Gods ultimate choice of
the day and the time in which He calls us home. So,
when we bury him, go ahead and bury him. Because
when the trumpet sounds, he-Pastor-will be among the
first to rise up, and God will say `well done thy good
14

and faithful servant, you are welcome into the ranks to
live with Me.
4.
Structural Aspects of Black Church Worship
Black worship is a spiritual experience of the truth of black life.

The experience is spiritual because people encounter the presence of the
divine spirit in their midst. It is truthful because the Spirits presence
authenticates the experience of freedom by empowering African
Americans with courage and strength to bear witness in their present
existence. Faith is affirmed with the passion and ecstasy that comes with
having met the Spirit of God in the struggle for freedom. Components of
black worship include: Preaching, Singing, Shouting, and Presence of the
Holy Spirit, Conversion, and Prayer. The significance of the black church
is found in the people believing that the Spirit of Jesus is coming to visit
them in the worship service each time two or three are gathered in his
name and to bestow upon them a new vision of their future humanity.11
5.
African Americans, Hospice and the Black Church
Within this cultural context, it should not be surprising that

hospice researchers have found that African Americans do not believe in
hospice-a philosophy of caring for persons who are dying by management
of pain and not treatment of illness. Reese, et. al.s study of cultural and
institutional barriers impacting utilization of hospice services validated
that African and European Americans held opposing views of hospice.
African Americans believe that God determines who lives and dies and
will provide a miracle as He sees fit.12
The ability of the Black Church to impact on African Americans
attitudes about hospice is evident in a program funded by the Nathan
Cummings and Altman Foundations through the Memorial Sloan
Kettering and North General Hospital Affiliation for the Harlem
community in New York City. The Palliative Care/End-of-Life Care
Training and Education Program for Caregivers in Minority Communities
was designed to improve the quality of palliative and end-of-life care to
minority populations in the medically underserved area of Harlem. The
Project specifically focused on integrating spiritual and psychosocial
aspects of palliative and end-of-life care into the medical management of
patients facing life-threatening and terminal illness. To accomplish this
goal, an education and training program targeting clergy in minority and
medically underserved areas was implemented.13 At the end of a threeyear training grant, this initiative resulted in over 100 trainees (clergy, lay
leaders and allied professionals) completing a twelve-week training
program that resulted in their ability to bring back to their respective
religious organizations ideas to create health ministries, bereavement and
15
memorial programs. Through networking with the Harlem Palliative Care

Network, trainees also learned how to make referrals to the hospice
programs in the Harlem community and educate parishioners about the
continuum of end-of-life resources available to their families.14
6.
Summary and Recommendations
Racism emanating from slavery has and continues to negatively

impact African Americans, who may self-select to avoid seeking help
when it comes to death and dying based on their past history of abuse and
traumatic deaths during slavery. Since the Black Church evolved as an
alternative resource and primary institution of support, the clergy is ideally
situated to influence African Americans personal decision-making
regarding end-of-life care, planning, and bereavement. For bereavement
facilitators, counsellors, and support group leaders interested in a
culturally sensitive engagement with the African American community, it
is imperative to become knowledgeable of African Americans belief
systems related to death and dying; assess the extent to which they turn to
spirituality and the Black Church to address issues of concern; and
develop partnerships with the faith community in order to create
bereavement services.
Notes
1
Penelope Moore and Lucretia Phillips, Black American

communities: Coping with death. (In AIDS and the new orphans, Eds. B.
O. Dane & C. Levine. Westport, CT: Auburn House. 1994), 101-120.
2
Moore & Phillips. Black American communities: Coping with
death. 109.
3
Youtha Hardman-Cromwell. Freedom From. Negro
Preaching of the Nineteenth-Century. 2000. 14. 4. 2.
4
Robert J.Taylor, Christopher G. Ellison, Linda M. Chatters,
Jeffrey S. Levin, and Karen D. Lincoln. Mental Health Services in Faith
Communities. The Role of Clergy in Black churches. Social Work. 2000.
45.1. 74.
5
Stephen D. Glazier. New World African Ritual: Genuine and
Spurious. Journal for the Scientific Study of Religion. 1996.35. 3.
6
Norrece T. Jones, Jr. Born a Child of Freedom Yet a Slave.
(Hanover and London: Weslayan University Press of New England. 1990).
136.
7
Ibid. 137.
8
Cornel West. Nihilism in Black America: A Danger that
Corrodes from Within. Dissent. 1991. 3. 225.
16
Kalish and Reynolds. Death and Ethnicity: A Psycho-cultural

Study. (Los Angeles, University of Southern California Press. 1976). 110.
10
Ibid., 110.
Ibid.
12
Dona J.Reese, Robin E. Ahern, Shankar Nair, Joleene D.
OFaire, and Claudia Warren. Hospice Access and Use by African
Americans: Addressing Cultural and Institutional Barriers through
Participatory Action Research. Social Work. 1999. 44. 6. 553.
13
Richard Payne and LaVone V. Hazell. A Training and
Education Program in Palliative and End of Life Care for Clergy and
Allied Caregivers in Minority and Medically Underserved Communities.
(Proposal to the Nathan Cummings Foundation. New York. 2001). 2.
14
Richard Payne and LaVone V. Hazell. Palliiative Care/Endof-Life Care Training and Education Program for Caregivers in Minority
Communities. (Final Report to the Nathan Cummings and Altman
Foundations. 2003). 3.
11
References
Cone, J.H. Speaking the Truth: Ecumenism, Liberation, and Black
Theology. Grand Rapids, Mich.: Wm. B. Eerdmans Publishing Co. 1986.
Glazier, S.D., New World African Ritual: Genuine andSpurious. Journal
for the Scientific Study of Religion. 1996. 35. 420-31.
Haight, W.L. Gathering the spirit at First Baptist Church: Spirituality as a
protective factor in the lives of African American children. Social Work.
1998. 43. 3. 213-221.
Hardman-Cromwell, Y.C. (2000). Freedom From. Negro Preaching of
the Nineteenth-Century. 14. 4. 277-95.
Jones, N. T. Born a Child of Freedom Yet A Slave. Hanover and London:
Wesleyan University Press & University Press of New England. 1990.
Kalish, R. A. & Reynolds, D.K. Death and Ethnicity: A Psycho-cultural
Study. Los Angeles: University of Southern California Press. 1976.
Moore, P. J. & Phillips, L. (1994). Black American communities: Coping
with death. In AIDS and the new orphans, Eds. B. O. Dane & C. Levine.
Westport, CT: Auburn House. 101-120.
17
Payne, R. & Hazell, L.V A Palliative Care Training and Education

Program: Final Report to the Nathan Cummings and Altman Foundations.
New York. 2003.
Payne, R. & Hazell, L.V. A Training and Education Program in Palliative
and End-of-Life Care for Clergy and Allied Caregivers in Minority and
Medically Underserved Communities: Proposal to the Nathan Cummings
Foundation. New York. 2000.
Reese, S. J., Ahern, R. E., Shankar, M., OFaire, J.D., & Warren, C.
Hospice Access and use by African Americans: Addressing cultural and
institutional barriers through participatory action research. Social Work.
1999. 44. 6: 549-559.
West, C. Nihilism in Black America: A danger that corrodes from
within. Dissent. 1991. 3: 221-226.
Part II
Friends, Others, and a Postmodern Ars Moriendi
We Simply Walk Toward the Sliding Doors:

White Noise as a Postmodern Ars Moriendi
Mikko Kallionsivu
Ars Moriendi proper is an old genre of books that was designed
to instruct common people how to die right, that is, to die a good Christian
death.1 This article, however, is not about Ars Moriendi proper. I analyse
here Don DeLillos White Noise (1985), a famous example of
postmodernist fiction. In this article I suggest that it is possible to interpret
White Noise as a kind of postmodern Ars Moriendi. The novel is a perfect
example of a text that is illuminating the postmodern approach to death
the good death of the postmodern life strategy.
At first glance White Noise seems to be offering nothing positive
to the debate about the good death, or our mortality in general. The most
prominent attack on the shallow world in which Jack Gladney lives comes
from an article written by Mark Conroy. Conroy claims that the loss of
convincing authority is the problem of the protagonists life, and
moreover, that it is the problem of the society as a whole:
His life is falling apart because it needs several registers
of traditional authority in order to stay together. And all
of them are coming under attack in the America of
DeLillos text: not from revolution, of course, but
simply from those acids of modernity.2
Conroy portrays Jack Gladneys need for existential stability as a crisis,
and denies that a revolution is going on in DeLillos world. For Conroy,
the story of Jacks fear of death is a sad one. It is a story about a liberal
humanist scholar, who is succumbing to the fallen state of the consumerist
society around him. Conroy sees the America of White Noise as a place
where the former master narratives of cultural transmission are in serious
decline without a good substitute. Jacks community, the little collegetown Blacksmith, is merely a stage for the protagonists career as a Hitler
scholar, filled with sleepy and somewhat zombie-like consumerists, who
prefer watching the television instead of really engaging in communal
activities of which the only remaining are the regular visits to the
church-like supermarket. The humanist master narrative is also a sham.
Conroy declares the whole College-on-the-Hill as a mockery of the real
one, a place of people raising their pay checks by studying cereal boxes
and media figures. Above all, he condemns Jacks career as a false one, as
Jack, the Chairman of the Hitler Studies Department, cannot even speak
German. Furthermore, as a representative of certain values, the protagonist
22
We Simply Walk Toward the Sliding Doors
himself is unable to find any solace in the humanistic values in any part of
the book.
So what is left? What does Conroy offer us to make the
protagonist of White Noise happy? With the connection to the past
generations broken, Conroys reading offers us only celebrity and status.3
After all the struggles to find some stability in his life, after he has been
exposed to the cloud of harmful chemicals, and found out that his wife
Babette is cheating on him in order to get the secret wonder-drug that is
claimed to keep the fear of death at bay, Jack is reborn as the image of the
times:
Only as that quintessentially passive figure, the
consumer, does Gladney have the faint glimpse of
immortality now allowed him.4
Conroy does not acknowledge the prevalent ambiguity, the difference
between Jack (as the more or less unreliable and biased first-person
narrator of the events) and DeLillo. We must realize that for DeLillo as an
author, the search is more important than the final resolution. The
groundbreaking study on DeLillos novels by Tom LeClair, In the Loop:
Don DeLillo and the Systems Novel (1987), emphasizes that DeLillos
characters
try to understand new information rather than cause
events to happen; they learn the processes in which they
participate, rather than dictate circumstances.5
In other words, these characters are more in the process of
constant search than in the actual fulfillment that the modernist novel, for
example, seems to grant the protagonist(s) as the narrative unfolds.
However, LeClair does not discard the prevailing criticality that the author
harbours.6 In a rare interview that the usually reclusive author gave, Don
DeLillo tells about his motives as a writer. For him, certain American
realities have a characteristic that his novels try to grasp time after time.
DeLillo speaks about the combination of frustration, fear and violence in
some of his characters and connects it to the overabundance of material
goods:
I see this desperation against the backdrop of brightly
colored packages and products and consumer happiness
and every promise that American life makes day by day
and minute by minute everywhere we go.7
As such, DeLillo denies having any political agenda, left-wing or
otherwise.8 One remarkable feature prominent in his novels is an irony
Mikko Kallionsivu
23
that often self-consciously deflates his pathos. DeLillo is a novelist who

brilliantly mixes humour and terror, awe and wonder, as well as triviality
and seriousness. In fact, White Noise is a perfect example of the
ambiguities that the author is so eager to foster. At the core of DeLillos
world is not some sort of moralism, but mystery. Daniel Aaron notes
concerning the authors works in general:
The protagonists are usually troubled intelligent persons
already poised to kick over the traces and susceptible to
intrigue. He sets them tunneling deeper and deeper
toward some unreachable solution or explanation, then
shows them to be players in a game manipulated by
unknowable forces.9
In White Noise the protagonist is looking for a way, a code, to
solve his sense of emptiness. There is the deep sense of awe and terror, a
sense of lingering dread behind normal things. DeLillo himself tells us:
I think it is something we all feel, something we almost
never talk about, something that is almost there. I tried
to relate it in White Noise to this other sense of
transcendence that lies just beyond our touch. This
extraordinary wonder of things is somehow related to
the extraordinary dread, to the death fear we try to keep
beneath the surface of our perceptions.10
As I see it, Jack Gladney finds some comfort in the cornucopia of material
things. This comfort, however, is deeply saturated with ambiguity.
Consumerism, in my reading, is more a reaction to the menace, than the
cause of the trouble. It also binds Jack to the fate of material things.
While looking through the family waste, Jack finds a banana skin
with a tampon inside and wonders if this is the dark underside of
consumer consciousness.11 But the stinking waste does not horrify Jack in
some ecological sense. He is more obsessed by the fact that he himself
will end up the same, at least if we believe what Ernest Beckers The
Denial of Death (1973) is stating about human nature. The Denial of
Death is one of the few influences that Don DeLillo confirms to have upon
his own work; Tom LeClair points out that the whole of White Noise can
be read as a dialogue with Beckers Pulitzer-prize-winning book.12 Becker
argues that the fear of death is absolute, more primal than the Oedipal
Complex of Freudian psychology. Our way of life is (always) a vital lie,
because of our repression of the knowledge of our own mortality. Mans
greatest illusion, then, is the denial of the bodily reality of his destiny.
Becker writes about the automatic cultural man with deep pathos:
24

[T]he automatic cultural man[ ], man lulled by
the daily routines of his society, content with the
satisfactions that it offers him: in todays world the car,
the shopping center, the two-week summer vacation.
Man is protected by the secure and limited alternatives
his society offers him, and if he does not look up from
his path he can live up his life with a certain dull
security [ ] . Why does man accept to live a trivial
life? Because of the danger of a full horizon of
experience, of course.13
Conroy, as I previously showed, argues that Jack is heading this

way when he no longer has any contact to the past. But Becker sees that
this dull security offered by the daily routines of the society is the normal
behaviour of the species. For him, tradition is not the path to salvation. In
fact it is always quite the opposite; all the things that bind us together,
whether institutionalized religion or materialism, society-approved
hedonism or idealism, are always the opiate of the masses. Waking up is
an individual response to the mortal situation, albeit not a pleasant one:
[A]s soon as a man shifts his nose from the ground and
starts sniffing at eternal problems like life and death,
the meaning of a rose or a star cluster then he is in
trouble. Most men spare themselves this trouble by
keeping their minds on the small problems of their lives
just as their society maps these problems out for them.14
DeLillo is, fortunately, a much better writer than Becker or
Conroy. Jacks story of awakening is not a lecture. Becker does not allow
any humour to enter the discussion about serious things. Conroy does not
include irony in his analysis. DeLillo, on the other hand, can afford the
imagination and playfulness in his writing. Furthermore, I suggest that
unlike DeLillo, Becker and Conroy are modern thinkers, deeply involved
with the epistemological game that tries to find a rational solution to the
problem of human mortality. As I see it, White Noise is a book that
illustrates Jacks development from the confining modern view of death to
a more open one.
I now turn to sociologist Zygmunt Baumans ideas about the
different strategies people engage in. Bauman is interested in the relation
between cultural patterns and the need to cope with our death. He sees that
human mortality is a crucial aspect of social and cultural organization.15 In
Don DeLillos White Noise the protagonists academic colleague, Murray
Jay Siskind, seems to be thinking in a similar way.16 Murray understands
death as a fluctuating part of the symbolical network of the society, a thing
not to be pinned down. For the protagonist, however, death is a threat that
Mikko Kallionsivu
25
needs a solution at first, at least. So there are these two views, Jacks and
Murrays, which I will concentrate on in turn. Bauman compares the two
present strategies of approaching the idea of ones own death and sees
them to be in many ways the very opposites of each other. The older one
the modern strategy, and as I claim, Jacks strategy tries to diminish the
fear of death and anxiety of over our mortal condition by slicing the
problem into manageable little bits. This approach, however, does not
eradicate death from the world but makes it all-pervasive, as life becomes
a continuing rehearsal to live in a rational way.17 Needless to say, this is of
course a very instrumental approach, bound to over-emphasised
rationality, prone to the language of science, with elements of mixed
paranoia and hubris.18 Natural death has become unnatural, something
outside the system. Only death with an explanation is tolerable, as we can
then put the blame on a specific cause. Jacks wife Babette, who is also a
firm believer in the modern life strategy, formulates her approach in the
following way:
Given the right attitude and the proper effort, a person
can change a harmful condition by reducing it to the
simplest parts. [ ] I know how to break things
down, how to separate and classify. We can analyze
posture, we can analyze eating, drinking and even
breathing. How else do you understand the world, is my
way of looking at it.19
It happens that Babette is in fact teaching older people how to
stand, sit and walk, eat and drink. Bauman would identify this kind of
action as a part of
the strategy long established by modern medicine and,
more generally, by modern therapeutic society deeply
influenced in its world-image and its pragmatic
principles by medical discourse.20
Bauman judges this strategy to be ultimately ineffective, because medical
practices are surrogate solutions to the existential predicament that allows
no solution.21 The problem with the Gladneys is that although they
believe in the modern strategy, DeLillo doesnt. So the modern life
strategy can only lead to denial. As Bauman puts it, death is the ultimate
Other of the modern project, and so it
has no meaning that can be expressed in the only
vocabulary we are trained and allowed to use; the
vocabulary geared, above all, to the collective and
26

public denial or concealment of that limit to our
potency.22
Jack needs a new language of death. Without it, he is bound to wake up in

the night:
I woke in the grip of death sweat. Defenseless against
my own racking fears. A pause at the center of my
being. I lacked the will and physical strength to get out
of bed and move through the dark house, clutching
walls and stair rails. To feel my way, reinhabit my
body, re-enter the world.23
Death is the strange and alien wilderness that looms outside the boundaries
of Blacksmith, outside the familiar landscape. Death, however, also makes
the normal life strange and incomplete.
In the course of the novel Jack has several fantasies about his
death. Hitler is the fantasy he uses to not to think about his death as an
individual, but to confront the whole concept as an academic. But Jack
also starts to imagine his own personal death. He tries to mould the
language and images around him to meet the special needs that he has.
John Frow notes that Jacks fantasies of dying are projected through
advertisements, movies and television.24 Indeed, these clichs have their
source in a chain of prior representations. This is of course one of the main
things that makes White Noise so amusing. But the mechanism used here
is also the key to Jacks new strategy of confronting his own end, the life
strategy that Bauman labels the postmodern life strategy. Jack tries to
imagine what dying could be, how it should feel and look. What does this
mean in practice, then? The protagonist of White Noise and his thought
patterns serve as a vehicle of identification and personal growth or more
accurately, typification and mere mental change. What sets Jack in motion
is the decorous and pompous speech his friend Murray gives to the
Gladneys at the supermarket:
Tibetans try to see death for what it is. It is the end of
attachment to things. This simple truth is hard to
fathom. But once we stop denying death, we can
proceed calmly to die and then go on to experience
uterine rebirth or Judeo-Christian afterlife or out-ofbody experience or a trip on a UFO or whatever we
wish to call it. We can do so with clear vision, without
awe or terror. We don't have to cling to life artificially,
or to death for that matter. We simply walk toward the
sliding doors. [ ] Here we don't die, we shop. But
the difference is less marked than you think.25
Mikko Kallionsivu
27
At first Jack does not notice the main point that Murray is making that
death is the end of attachments to things, and not a problem. But he
starts to imagine death at a personal level. This leads to the fantasy of
Attila the Hun, who was younger than Jack when he died:
I want to believe he was not afraid. He accepted death
as an experience that flows naturally from life, a wild
ride through the forest, as would befit someone known
as the Scourge of God. This is how it ended for him,
with his attendants cutting off their hair and disfiguring
their own faces in barbarian tribute, as the camera pulls
back out of the tent and pans across the night sky of the
fifth century A.D., clear and uncontaminated, brightbanded with shimmering worlds.26
The irony here is, of course, that Jack is using the media imagery. He is
not choosing religious figures after all, Christ is the most prominent
model for brave death in Western history and Imitatio Christi would be a
long and well-marked tradition to follow but ones from a movie epic.
But the attempt to see death as an experience that flows naturally from
life is honest. Later on Jack has more personal death fantasies, but they
tend to be more philosophical and intimate in nature.27
And so Jack has arrived at Zygmunt Baumans second life
strategy, which he claims to be prevalent at the moment. This life strategy
differs from its modern predecessor and counterpart in that it attempts to
resolve the haunting issue of survival by making it less frightening. As we
learned before, in the modern life strategy, immortality is defined as a
prospect, and so the future has a modality of a product.28 The prize is
always there to be seen, but it is never ours to grasp. The postmodern
strategy differs from its modern counterpart in that it promises instant
satisfaction:
It deprives mortality of its vile terror by taking it out of
hiding, and tossing it into the realm of the familiar and
the ordinary to be practiced there day in, day out.
Daily life becomes a perpetual dress rehearsal of death.
What is being rehearsed in the first place, is
ephemerality and evanescence of things humans may
acquire and bonds humans may weave.29
Baumans views of the postmodern life strategy are not altogether
positive. Whereas modern strategy causes paranoia, postmodern strategy
has another side effect: The prize of exorcising the spectre of mortality
proved to be a collective incapacity to construct life as reality, to take life
seriously.30 But this is the media-saturated world of White Noise already.
28
It is such even before Jacks conversion, so there is no point turning

back.31 But we must realise that Jack is not a false character, at least no
more than his colleagues and wife. He is the image of the times, not so
much as a consumer as such, but as a person that lives in a society that is
more and more fascinated with endlessly repeated images and shimmering
appearances, everyday simulations with no clear origin.
Baumans ideas about our cultural models in general resonate
interestingly with Brian McHales ideas about the specific relation
between modernist and postmodernist literature. McHale suggests that the
main difference between these two are that modern fiction tends to
foreground epistemological issues, whereas postmodernist fiction deals
mainly with the ontological structure of literally constructed world(s).
Jack, trapped in one strategy that doesnt work, needs to rehearse another.
He needs a new language with which to approach the ultimate ontological
boundary from a fresh angle, one free of the modern tendency to hide
death from life and make it an outsider. Here is where McHale comes in:
Postmodernist writing enables us to experiment with
imagining our own deaths, to rehearse our own deaths.
We have all but lost the ars moriendi; we no longer
have anyone to teach us how to die well, or at least noone we can trust or take seriously. Postmodernist
writing may be one of our last resources for preparing
ourselves, in imagination, for the single act which we
must assuredly all perform unaided, with no hope of
doing it over if we get it wrong the first time.32
So postmodernist fiction, as McHale sees it, is a healthy way of dealing
with our final boundary. This is what I think White Noise is all about, as it
transcends the modern project by telling the story of Jack. Through
rehearsal Jack realizes that he cannot avoid death. After rehearsing dying
time after time in different ways, in imagination as well as in the form of
philosophical argumentation, he is finally able to see the same thing
Murray sees in the supermarket. It is impossible find any solution to the
problem of death in the world of White Noise.
The novel ends with three separate short episodes. In the first one
the Gladneys youngest child miraculously survives tricycling over a
highway. Jack comments on this episode with an attitude Id like to label
as a critique of the one-eyed thinking patterns of the modern life strategy,
where everything always points beyond the here-and-now. Certainly he is
not trying to find any hidden meaning in it, no epistemological riddle, as
he would have done before:
The drivers could not quite comprehend. In their
knotted posture, belted in, they knew this picture did
Mikko Kallionsivu
29
not belong to the hurtling consciousness of the

highway, the broad-ribboned modernist stream. In
speed there was sense. In signs, in patterns, in splitsecond lives. What did it mean, this little rotary blur?33
LeClair writes about this episode:
Perhaps Jacks achievement a possible new
relationship to death is implied by his drawing no
conclusions from Wilders feat. He simply reports it as
a fact of uncertain cause and effect, finding in it no
evasion or mastery.34
In the end of the novel Jack has adjusted himself to the
uncertainty of life. The world of White Noise is the same as it has been
from the start. Only Jacks ontological stance is different. And this is how
we are taught to die: by using words only in order to show that the truth is
beyond them. DeLillos irony is inseparable from his wisdom.
Notes
1. For more on the subject, see Nancy Lee Beaty, The craft of
dying: A study in the literary tradition of the Ars moriendi in England
(New Haven: Yale University Press, 1970). See also Mary OConnor, The
Art of Dying Well: The Development of the Ars Moriendi (New York:
AMS Press, 1966 [1942]).
2. Mark Conroy, From Tombstone to Tabloid: Authority
Figured in White Noise, in Don DeLillos White Noise, ed. Harold Bloom
(Broomal: Chelsea House Publishers, 2003), 154.
3. Ibid, 164.
4. Ibid, 166.
5. Tom LeClair, In the Loop: Don DeLillo and the Systems Novel
(Urbana & Chigaco: University of Illinois Press, 1987), 17.
6. Ibid, 27.
7. Anthony DeCurtis: An Outsider in This Society: An
Interview with Don DeLillo, in Introducing Don DeLillo, ed. Frank
Lentracchia (Durham: Duke University Press, 1999), 57-58.
8. Ibid, 65.
9. Daniel Aaron, How to read Don DeLillo, in Introducing Don
DeLillo, ed. Frank Lentricchia (Durham: Duke University Press, 1999),
70.
10. DeCurtis, p. 63.
11. Don DeLillo, White Noise, in White Noise: Text and
Criticism, ed. Mark Osteen (New York: Penguin Books, 1998 [White
Noise was originally published in 1985]), 259.
30
12. LeClair, p. 212.

13. Ernest Becker, The Denial of Death (New York: The Free
Press, 1973), 74.
14. Ibid, 178.
15. Zygmunt Bauman, Mortality, Immortality & Other Life
Strategies (Cambridge: Polity Press, 1992), 9.
16. DeLillo, p. 291-292.
17. Bauman, p. 140.
18. Ibid, 145.
19. DeLillo, p. 191-192.
20.Bauman, p. 159.
21. Ibid, 159.
22. Ibid, 130.
23. DeLillo, p. 47.
24. John Frow, The Last Things Before the Last: Notes on White
Noise, In Don DeLillos White Noise, ed. Harold Bloom (Broomal:
Chelsea House Publishers, 2003) 39.
25. DeLillo, p. 38.
26. Ibid, 100.
27. Ibid, 216, 267-268, 273, 288, 315, 317.
28. See also Bauman, p. 111.
29. Ibid, 187.
30. Ibid. 199.
31. As I have tried to show, DeLillos work is more a critique of
the modern project, and not a book about the decline of the other
metanarratives narratives that are so long gone in White Noise that the
protagonist has no connection to them whatsoever.
32. Brian McHale, Postmodernist Fiction (New York: Methuen,
1987), 232.
33. DeLillo, p. 322-323.
34. LeClair, p. 223.
Works Cited
Aaron, Daniel, How to Read Don DeLillo. In Introducing Don DeLillo,
edited by Frank Lentricchia, 67-81. Durham: Duke University Press, 1999.
Bauman, Zygmunt. Mortality, Immortality & Other Life Strategies.
Cambridge: Polity Press, 1992.
Beaty, Nancy Lee. The craft of dying: A study in the literary tradition of
the Ars moriendi in England. New Haven: Yale University Press, 1970.
Becker, Ernest. The Denial of Death. New York: The Free Press, 1973.
Mikko Kallionsivu
31
Conroy, Mark: From Tombstone to Tabloid: Authority Figured in White

Noise. In Don DeLillos White Noise, edited by Harold Bloom, 153-168.
Broomal: Chelsea House Publishers, 2003.
DeCurtis, Anthony: An Outsider in This Society: An Interview with
Don DeLillo. In Introducing Don DeLillo, edited by Frank Lentracchia,
43-66. Durham: Duke University Press, 1999.
DeLillo, Don. White Noise. In White Noise: Text and Criticism, edited by
Mark Osteen, 1-326. New York: Penguin Books, 1998 [White Noise was
originally published in 1985].
Frow, John. The Last Things Before the Last: Notes on White Noise. In
Don DeLillos White Noise, edited by Harold Bloom, 35-49. Broomal:
Chelsea House Publishers, 2003.
LeClair, Tom. In the Loop: Don DeLillo and the Systems Novel. Urbana &
Chigaco: University of Illinois Press, 1987.
McHale, Brian. Postmodernist Fiction. New York: Methuen, 1987.
OConnor, Mary. The Art of Dying Well: The Development of the Ars
Moriendi. New York: AMS Press, 1966 [originally published in 1942].
Part III
Images of Dying and Death
Death and Images of Womanhood and Manhood: The

Case of Serbian Epic Poetry
Mira Crouch
Abstract: This paper rests on the assumption that community ideals exert a
powerful influence on orally transmitted (folk) epic poetry. In the Serbian case,
most of the poetry of the medieval Kosovo cyclus highlighted the deeds of
men who defended their country and people from the invading Turks. In these
poems, men went into battle and perished while women waited at home, in due
course to mourn. There are some earlier poems, however, which deal with
emblematic life-events where women, too, die in a violent manner, albeit in
peacetime. Thus women and men die under different circumstances and in
different ways, and from this significant difference emerges an image of
profoundly moral womanhood that is an indispensable condition for the
bravery of men. Through an analysis of several poems, the paper will examine
the role of death in the portrayal of courageous men and virtuous women, and
through those images search for a deeper meaning that may even enlighten
some of our present-day quandaries.
Notes:
1. This paper is a revision of a previously published paper.
2. The paper is not intended to have any relevance to the recent war in
Kosovo.
The past is another country. From a Western standpoint,

medieval Serbia is another country twice over: another culture, long ago.
Yet we of todays world may have much in common with the
people in that other country. Then as now, we all die, and we all know
about death, both our own and that of others. We know that it will come to
pass and we recognise when it has taken place. Death casts a long shadow
over human existence, since our lives matter only by virtue of their
impermanence.
Death, then, is a universal signifier and a powerful collective
predicate. Because of it human lives have meaning. It is therefore
reasonable to expect that death will have a telling part in a cultures
imagery of its own morality, as every death questions the value of the life
ended by it.
In the poetry discussed here, heroism and death are intertwined
core threads around which the poets weave their images. While these
images project many aspects of our complex human existence, I shall
focus specifically on the ways in which the poets have shown men and
women to stand delineated from one another through death.
36
Death and Images of Womanhood and Manhood
One great battle has been the focus of much of this poetry. On the
15th day of June 1389, the Ottoman army met and was engaged by the
defenders of the lands threatened by it. Serbian princes, dukes and sundry
other clan-leaders assembled under the command of Prince Lazar,
acknowledged Tsar of all the Serbs for the purposes of the occasion. The
battle took place at Kosovo, a wind-swept undulating valley surrounded by
medieval monasteries.
At the end of that day most of the warriors were dead. The Turks
had won, with their remaining forces managing to establish supremacy
over the Serbs, for whom Kosovo was the decisive mortal blow. The battle
had wiped out most of the able-bodied men of the generation, including
almost all sons of the patrician military families - the great warrior clans of
the powerful 13th century state.
These dead men are the legendary heroes of the Kosovo cyclus
poems which have been recited and passed on through 500 years of
Turkish rule, and thereafter, too - and thus, in a sense, have been culturally
embalmed. Much lauded by the whole populace for both their beauty and
their meaning, the poems came to constitute a major component of the
common stock of knowledge within which the identity of the emerging
nation was formed. As Mircea Eliade points out, the fidelity of a people
to one or another mythical scenario, to one or another exemplary image,
tells us far more about its deeper soul than many of its historical
accomplishments.1
This deeper soul is my main concern here. I will attempt to
identify some salient features of female and male protagonists in Serbian
heroic poetry, with particular attention to the ways in which death
differentiates between women and men. The interpretations offered in this
paper are based on the assumption that the poets have given indirect
expression to implicit social knowledge, the non-discursive knowing
about what moves people, which is essentially inarticulable and
imageric.2
1.
Part I
The Kosovo cyclus is huge. Many of the poems concern the same
set of characters: Tsar Lazar, his wife Milica and their clan. Some
typical examples:
On the eve of the battle, Milica beseeches each of her nine
brothers to stay in the castle with her, so that she would have one male
head left to her. (Note anticipation that all will be killed in battle.) Of
course, all the brothers ride off, looking like this:
Upon a stallion, in shining garments;
his cross-bearing banner covers him,
Oh brother, down the horses belly;
Mira Crouch
37
Atop his flagpole a knob of gold,

On it golden crosses are affixed,
From the crosses golden braids hang
And toss about on (his) shoulders.3 (Repeated nine times)
In many other poems, heroes are similarly resplendent:
Beatific hero, yet of this world,
His sabre clangs on the paving stones,
Precious plumes tremble upon his head,
Embroidered robes adorn his body,
A silken kerchief caresses his neck
Or
(He ) is dressed in gossamer fabric,
Above the waist, of pure woven gold,
below the waist, of palest white silk;
over his shirt he wears three vests
and a topcoat of thirty buttons;
engraved armour encloses the coat,
golden armour, three layers strong;
his legs are covered in hide and studs
These brilliant images, I suggest, point to the lasting impression
the heroes make on the community, and, at the same time, they emphasise
the enormity of the loss entailed by their death.
And now a poem about loss:
Nine falcons, nine horses, nine hounds, nine wives, all scream for
their nine dead heroes but the warriors mother does not cry.
Next day, she sits on the castles parapet, looking towards
Kosovo. Two ravens carry a severed arm from the battlefield and
drop it in her lap. It is her youngest sons arm. Only then she
sings a lament and dies of a broken heart.
In another, a maiden walks on the battlefield looking for three
young men, all of whom love her. Of course, all three have been killed.
She cries:
Oh, pity me and my ill fate!
If I held on to a green sapling,
It would wither and die.
38
The characters in these poems portray both the tragedy of the

people and the spirit with which they meet it, although men and women
have different ways of embodying this spirit. The complexities of
circumstance and action that are contained in these differences are
captured in the poetrys images.
Men are fiercely courageous and they go into battle knowing that
they will be killed. But the poems do not merely portray death in battle.
More poignantly, they celebrate sacrifice and through it, the values for
which life has been given away. Indeed, no victory could make so strong a
statement; only defeat underwrites the significance of the sacrifice.
Another poem speaks to this point:
The Holy Mother tells Lazar that he must choose between the
Earthly and the Heavenly realms. If he chooses the former, he must gather
his armies forthwith and rush into attack on the Turks; in this case, the
enemy will be defeated. If he chooses the heavenly realm, he needs to
prepare his armies by holding mass and offering communion to the men all of whom will then perish on the battlefield. He chooses Heaven,
assembles his army, and holds the ceremony. Just as soon as the men are
thus put to rights, the Turks attack and the Serbs are slaughtered yet,
according to the poem, in the end All was holy and all was honourable,
and the goodness of God was fulfilled.4 Implicit in this is a profound
dichotomy: victory is profane, but death as life given away is sacred,
especially in defeat.5 Here no one dies in vain; on the contrary, death is the
threshold of eternity for all that is holy and honourable.
Women, on the other hand, do not fight, and in the poems there
are few descriptions of womens appearance, particularly concerning
dress. It is as though the poet is making sure that only men the heroes
can be seen in the minds eye, shining bright. Women are sometimes
described in terms of beauty but unadorned; rather, beauty is of the
person herself. For example:
They say this maiden is magic;
Of slim waist but tall stature,
Her tresses a bunch of pure silk,
Her eyes two precious jewels,
Eyebrows like sea-leeches,
On her cheeks pink roses bloom,
Her teeth are two rows of pearls,
Her mouth a sweet sugar-bowl;
When she speaks, a dove calls,
When she smiles, diamonds shine,
Her teeth are two rows of pearls
Most often, though, rather than being envisaged, women are
given moral characteristics, either by attribution or through their own
Mira Crouch
39
words and deeds. In one poem, for instance, Tsar Lazar drinks and chats
with his friends and relations. Milica walks by and says
My Lord, renown Prince Lazar,
I cringe at the very sight of you,
And am loth to converse with you,
But it must be, I will address you.
She berates him for not spending his riches and effort on building
monasteries and churches, like his predecessors did. He is humbled, and
promises to build her a church. And here it is
The splendid men do and die; by contrast, the more subtle women
wait and grieve. Women are at home while men are on the move. Even in
poems not referring to the battle, men have numerous adventures: they
carry out errands, escort brides from abroad, negotiate deals and work on
military contracts. They undertake journeys for both business and
pleasure, visit one anothers homes, drink and argue. And always they
display strength and bravery.
Women, too, have courage. But this is not demonstrated in action;
rather, it is contained in their endurance of suffering. Overwhelming grief is as
inevitable a fate for them as death is for their men. And just as the death of men
and the pain of women are inextricably bound together, so mens flamboyant
and unsettled life determines womens monotonous and captive existence.
While men are roaming about on horseback, women are close to walls and
doorsteps, confined in their forts, alone, waiting and afraid for their men.
Where men drink and make merry, women ponder and keep watch.
Thus the poems recognise women and men to be creatures who
live their lives characteristically different ways. Men do not go into
skirmishes and battles purely in response to circumstances, but also
because they are adventurous and seek out action. Women, too, do not
simply wait and grieve; they have qualities of stoicism and wisdom that
enable them to endure their plight. But that is not all: as some poems of
the pre-Kosovo times show, deeper moral issues are at stake and these
are illuminated by the manner in which women die.
2.
Part Two
One nasty woman is jealous of her husbands sister, a virtuous

girl much loved by her brother. The wife kills her husbands horse, falcon
and finally her own baby son, making it appear that the sister is
responsible. On her brothers order, the sister is torn apart by wild horses.
Then
Wheresoever a drop of her blood fell,
Flowers and holy basil sprang forth;
40

And where her body last came to rest,
A church emerged, complete overnight.
Afterwards the wife becomes ill and lingers for nine years, and
Grass grows and tangles through her bones
And in the grass poisonous vipers dwell.
She asks her husband to kill her in the same way as sister, and he
does. Subsequently
Wherever a drop of blood fell,
Thorny bushes and nettles grew;
Where her body last came to rest
A lake of deep waters opened:
In the lake a black stallion swims,
On his back a golden cradle
With a grey falcon at its head;
In the cradle a boy child sleeps
With his mothers hand on his chest,
his own hands on the golden handles
of the two deadly daggers.
In another poem, three brothers are building a fort. An evil witch
destroys at night what work is achieved each day. Eventually she calls for
a sacrifice the wife of any one of the brothers. The brothers agree to let
fate decide: whoever brings food to the site next day will be the victim.
The two elder brothers let their wives in on the secret; and so the youngest
wife turns up. When she sees the walls going up around her, she realises
what is happening and asks for openings to be left in one wall so she can
nurse her baby son. After the entombment, her voice was heard, crooning
to her son, for another week, but the nourishment for her infant lasted for a
year. The poem concludes:
As things were then, so they are today,
Still the milk flows out of stone walls
A miracle and a medicine
For women who cannot nurse their own.
In these poems women are either good or evil, but it takes death
to make this clear. Unlike men who die in collective action and are then
valorised, one and all, women die singled out as individuals who are
evaluated and whose deaths flow from judgements passed upon them.
And, while saintliness follows unquestionably the heroes sacrifice,
Mira Crouch
41
womens godliness is precarious and has to be revealed or not, as the

case may be in the aftermath of death.
3.
Part Three
Women cannot escape the consequentiality of their deeds.

Appraisal must always obtain, notably following death. Such posthumous
judgements are moral lessons for the community whose principles of
justice are not human creations but rather Gods design, contained in the
living essence of the world. Because the springs of womens actions lie in
their very natures, they are judged by those principles and the judgements
are inscribed on their deaths, thus to become permanent, in this world and
the next. By contrast, retribution does not apply to men. No ill fortune
befalls the two deceitful builder brothers, nor is guilt ascribed to them.
Similarly, the man who kills his innocent sister is not deemed responsible:
he has merely acted in terms of the knowledge on hand.
There is an apparent contradiction here, since it is men who have
the power to dispense justice. In this process, however, they are often
mistaken. Not that this matters; clearly, they are merely instrumental in
bringing about the deaths of women though which morality tales are then
told. Hence guilt and responsibility have no place in the lives of men who
merely act out what they know. Unencumbered and unfettered, they are
free to do as they see fit and to be heroic by virtue of the power, prowess
and independence that are their birthright. Their presence in life is striking
but temporary; and so are its effects. Only in death are they truly valuable.
By contrast, women are entangled in the basics of existence; they
have little freedom and are barely visible, appearing out in the open only
every now and then. At the same time, women have influence: they
ennoble or corrupt, foster or undermine, nurture or kill; hence their lives
are always open to question and are evaluated by both earthly and
heavenly powers. While men act in response to circumstances, women
commit deeds following good or bad inner motives. Womens lives
embody Gods principles of morality and justice which merely inform, and
not always successfully, the actions of men. But men die in the full
knowledge of those principles, while women simply live them and are
killed so that their truth may be revealed. Men reach for the heavens only
in death, but the goodness of women is ever present; death merely supplies
the proof.
Perhaps, then, these poems suggest that women are societys
fundament, the entrenched inhabitants of its institutions for which they are
and are made to be responsible. Their roles are more profound than are
the tasks of the variably present, albeit more conspicuous, men. Yet the
visibility of men enhances the memory of them after they are gone, dying
dramatically in a blaze of glory bestowed on them by the community from
which they have had to absent themselves in order to defend it. And so the
42
records of their intermittent spectacular doings become, and are

perpetuated as, tales of significant events.
In these poems, men appear as phenomena of history but
women are the noumena of life, of the ineffable nature of the world. Men
are moving figures against a background of the seemingly inert female
existence - without which, however, they would not be seen at all. Men are
unconstrained, adventurous and self-indulgent, but they die, in exaltation,
for sacred ideals. Womens lives, on the other hand, are at all times
circumscribed within the quotidian, and their deaths often take place in a
web of desire and deceit; only after death is the truth about them revealed.
While mens glorious sacrifice is anticipated in the splendour of their
apparel, women signify good and evil in living matter that sprouts from
the ground soaked in their blood. Like rare gemstones, men glitter here
and there in that enriched soil. But it is the earth that abides and,
ultimately, sustains the everlasting spirit
Notes
1. Mircea Eliade, Zalmoxis: The Vanishing God (Chicago,
University of Chicago Press, 1972).
2. Taussig, Maurice, History as sorcery, Representations 7,
1984: 87-109; 87.
3. All translations are mine. Translations of the whole of The
Fall of the Serbian Empire, The Maid of Kosovo, The Death of the
Mother Jugovich and The Building of Scutari (Skadar) are available in
Butler, Monumenta Serbocroatica. The Serbo-Croation (as it was then)
versions of the poems have been sourced from Antologija Narodnih
Junachkih Pesama, ed. Vojislav Djurich (Beograd: Srpska Knjizevna
Zadruga, 1977).
4. West, Rebecca, Black Lamb and Grey Falcon (New York,
Penguin Books, 1982[1941]); 1145.
5. The sacred/profane distinction as it is made here draws on the
work of Durkeim; see Durkheim,Emile, The Elementary Forms of
Religious Life, Trans. Joseph W. Swain, 2nd edition (London, Allen and
Unwin, 1976).
Extreme Makeovers and Reciprocal Relations Between

the Living and the Dead
Kathleen Z. Young
Abstract: Based on fieldwork in the village of Komiza on the island of
Vis, along the Dalmatian Coast of Croatia, and five years of participantobservation among immigrants and refugees from the former Yugoslavia,
I discuss the effects of war, immigration, and gender on the way Croatians
experience death and sustained reciprocity with the dead. Relationships
between the living and dead transcend death and are often incumbently
forged, shaped or subject to a makeover by the circumstances and social
geography of death. The obligations of the living to the dead and the
perceived expectations of the disembodied are situated in the malleable
present and as such may be manipulated as a means to resolve, express, or
transform the experience of war and ethnic conflict.
Historical, social, and cultural perspectives shape-shift identity
as the living and the dead are expelled, picked up and moved, made-over or
remodelled. There is currently a popular television show in the United States
called Extreme-Makeovers, in which the audience voyeuristically
witnesses plural plastic surgeries and various makeovers with extreme
impact. The intention is to make the person look more culturally appropriate
or younger in a youth and beauty-obsessed society. In another environment,
where individual identity is more closely associated with family and
community, youthful, standard features, and ageing are less verboten. Death
is less likely to end a relationship lived in a less embodied realm. For the
purposes of this paper, I focus on various kinds of death and burial rites in the
village of Komiza on the island of Vis, a part of the Dalmatian Coast of
Croatia. In Komiza, the dead have been the beneficiaries of extreme
makeovers following the war that resulted in Croatias independence.
The island of Vis, almost halfway between the coasts of Italy and
Croatia, has been inhabited since about 3,000 B.C and extant archaeological
remains include an altar to the goddess Artemis. The island was called Issa
and then Lisa in past-times, a legacy of tribute to the goddess Isis, according
to local speculation. A winter solstice bon-fire ceremony, a pagan artefact
later converted into a Christian rite associated with Saint Nicholas, has been
an annual ritual for as long as anyone can remember. Ancient Celts, Illyrians,
Greeks, and Romans left their cultural influence and there are still extant
colloquial references to the evil-eye, spirits, demons, etc. From before
conception to the afterlife, prescriptions and prohibitions of behaviour are
often noted, if not followed. Even so, up until the Second World War Croatia
was an openly Roman Catholic country. Catholicism remained entrenched on
Vis during the communist-socialist era following the war. A picture of the
44
Reciprocal Relations Between the Living and the Dead
Virgin Mary hung next to picture of the communist ruler, Josip Tito, on the
walls of many homes in Komiza until the 1990s.
People, especially older women, meet for daily mass preceded by
recitation aloud of the rosary. There are two main churches in Komiza, one
on either side of the village. There is also a smaller chapel in the centre of
town for daily mass. Every evening at 5pm, the chapel fills with villagers as
older women dressed in black lead the rosary, chanting in an unusually highpitched register. Most of these women are widows routinely praying for their
dead. There are often a few older men at daily attendance. There is one male
priest for the approximately 4,000 people on the island but priests from the
mainland visit the approximately 1500 people in Komiza regularly. Although
traditional women usually defer to men, especially priests, the older women
are in charge of the chapel and the daily mass and rosary. Their age,
assiduous attendance, and customary ownership of their daily practices in
the small village church, requires the priest to defer to their schedule and
expectations.
The island of Vis belonged to Italy at various times historically.
The dialect is replete with Italian words most things Italian are met with a
sense of simpatico. It is a point of pride that the current peripatetic Pope has
visited Croatia more than any other country.1 There is a strong element of
Catholicism within Croat nationalism. On the island of Vis and the village of
Komiza on the island, that religious/national patriotism bears the emblem of a
unique blend of Catholicism with the communist-socialism of the former
united Yugoslavia. This is in part because many Komizans died in support of
the united communist-socialist Yugoslavia during World War II, but also
because the refuge of Catholicism has distinguished Croatia from the state
religion of Serbia, the Serbian Orthodox Church.
Komizans enjoy friendly relations with the dead if they know they
have fulfilled the obligation to send the soul on its way to heaven. Applying
van Genneps schemata on rites of passage (1960) to the death and dying
rituals of Komizans, rites of passage include separation, the communicative
isolation between the living and the dying during the process of dying and the
act of death (the death watch, a gathering in prayer at the bedside of the
dying), transition, preparation for burial and the funeral act, and reincorporation. The re-incorporation focuses on sending the dead properly
into heaven and establishing their new persona as deceased. The reincorporation includes religious rituals employing incense and candles,
specially sanctioned words and prayers led by a religious expert or experts,
proper handling of the body, and all the associated social features of public
burial. While dying may be ultimately an individually isolative act, death is
ultimately social.
The dead body is not static and the repercussions of death are not
terminated with the death of the body. Most funerary rites on Vis traditionally
involved a body that had not been embalmed. Non-embalmed bodies decay at
different rates and, depending on circumstance, may explode. The dead may
Kathleen Young
45
make rumbling noises in the grave in response to these natural processes of

decay, especially in the Mediterranean climate of the Adriatic Sea and
islands. The period of time wherein the body is in the process of decay is the
transitional or liminal phase. The period of mourning for the deceased
corresponds to this liminal phase. This is the time in which women
traditionally wore black, restricted social activities and engaged in specific
religious practices. What happens to the corpse of the loved one during this
liminal phase affects the living. In turn, the living should employ rituals of
dress and appropriate social behaviours.
It is consistent with women's familial role as caretaker and
nurturer that death rituals extend into the relationship beyond death. A
woman brought the deceased into the world through gestation, lactation, and
motherly service. A woman carries on the business of service to the dead
through her prayers in the spiritual realm and physical caretaking of the place
of internment. Similarly, a man was necessary for conception to take place
and a man, a priest or deacon, is necessary for the Catholic burial ritual. A
"good death" is made in time, over time, and with reciprocal relations.
Identity is both individual and collectively shared or "made"
through relationships built around reciprocal obligations. In extended families
and clan systems there is often a sense that what happens to one happens to
all individuals in differing and sometimes predictable ways. Death modifies
but does not obliterate these obligations. Individuals and groups incumbently
honour their association with the dead by social-religious rituals recognizing
they are separated only by the thin veil of flesh and bone. The body houses
the immortal soul but has sacred spiritual significance, too. As the corpse
decays, the period of mourning among the living corresponds to the
decrepitating of the deceaseds body and the closeness of the kinship ties
between the living and the dead.
Similarly, when a relative immigrated it was a kind of social
death. The emigrated relative would be kept alive through connections with
"someone who knew someone who knew someone" in the new land. The
ways of knowing were providentially enhanced when kin migrated to a
specific place and joined previously migrated kin from the same village of
origin. Pictures and letters from one relative were shared with everyone in the
village, or brought to someone who could read and write and then share the
information via over-lapping social networks of kin. Similar sharing of
information occurred with the news of the death of immigrant kin.
It was customary on the island, where there were few land phones
and cell phones were a luxury until recently, to send a picture of a
respectfully dressed corpse in a well-appointed coffin to the Old Country.
Gone to the West or gone to heaven or hell, the beloved no longer walked
among the living or lay with the dead in Komizas cemetery, but at least there
was proof of proper burial. For relatives who could not read or write, the
picture provided visual proof that the deceased was given the means to make
the spiritual transition from life to death and that the body of the corpse was
46
respected and cared for with the proper burial. The visual affirmation of the
propriety of the death and burial rituals was intended to comfort all connected
to the deceased through kinship or association.
The closeness of the kin relationship and the kind of death often
determined aspects of the length and kind of funerary rituals (and attendant
emotional, psychological, and social expressions). Gratitude towards the dead
or the familial obligation of gratitude also predicated involvement in the
death ritual, even by individuals who never knew the deceased in the flesh.
One informant recalled spending hours every day, for what seemed to her
like days on end, on the hard wooden pews of the Catholic Church in her
village on Vis in vigil prayer for some first generation American-Croatian
fishermen who had died in a fishing related accident in Alaskan waters. The
Mardesich brothers were related to many people in the village and although
the brothers had been born in the States and few in the village knew them
personally, the Mardesich family had continued to send money to kin in the
village. Their deaths were cause for extensive communal praying. Closer
relatives to the Mardesich brothers on Vis were expected to make a novena, a
nine day or nine week (depending on the closeness of the relationship) ritual
of temporal prayers morning and night.
Prayers for the dead are so important because, as a point of belief,
a dead person could move from purgatory to heaven, based on the prayers of
the living. Old prayer books and missals list plenary indulgences for different
prayers. According to informants, these plenary indulgences can be banked
like money and saved up to redeem or release a dead person from purgatory
and get them out early. There is no escape from the fires of hell, but those
with venal sins are kept in purgatory until cleansed of sin. Once in heaven,
the beloved dead can be called on to intercede in the heavenly realm for
favours for the living, especially those who prayed long and hard to get them
into heaven in the first place! When does a person stop praying for the
beloveds soul and start praying to them? Heavens time is not as easily
marked as a persons birthday, death, or a nations Independence Day. In the
realm of the spirit and relations of a spiritual nature, it is the communion of
spirits via prayer that consummates relations between the embodied and
disembodied. Time cannot measure the movement of souls.
The sense of shared identity modifies van Gennep's schemata of a
rite of passage as a finite act of separation, transition, and re-incorporation.
Death and disposal of the body are not so definitive or bounded by a
beginning, middle, and transformative end without regard to the on-going
social context. The sense of shared identity welds the living and dead,
sustaining the relationship over time. The circumstances of the individual
death are collectively discussed and shared. If the circumstances were
onerous, the sharing of the responsibility and the repercussions of the death
were also potentially onerous.
An individual who had the power of the evil eye (usually an
older woman who did not fit the social norm), a noted sinner, someone
Kathleen Young
47
considered selfish or marginal by social standards, those who had committed

suicide or murder, as well as those who had been denied proper Christian
burial, could all potentially and problematically complicate the social nexus
for the living. Bad behaviour makes for bad deaths and bad deaths (by
homicide or suicide) may complicate things for the living. It especially hurts
the living when a beloved is killed because of brutality, as in war. Without a
proper death and burial, the dead are owed an obligation by the living,
making it more difficult for the living to call upon the dead for their own
intercession.
Gossip, social pressures and the necessity for reciprocal
obligations are ways of exerting vigilance and keeping the social nexus
functioning even when physically separated by immigration or death. Talking
about immigrated relatives (alive or dead) and the actual dead is common
practice, especially at funerals. Funerals and cemeteries are the locus of
"spirit clubs," where stories are swapped affirming the transcendent aspects
of the social nexus. Relationships are no less "real" because one of the
individuals is not physically present.
Body and soul emigrate from one place to another; the body dies
and the soul emigrates again. Just as men and women adjust to loving a
friend or relative who has emigrated and is not physically a part of their
everyday lives, so too, the dead have a new home (presumably heaven). The
fact of the death of the body, especially through war, has been a major
precipitator of both emigration and cultural response to war death.
World War I fuelled the diaspora; many Croat-Dalmatians (Croats
living on the islands or the coast of Croatia, an area known as the Dalmatian
Coast) would not allow themselves or their sons to be conscripted into the
army of the Austro-Hungarian Empire. The Post World War I experience of
living under a Serbian monarchy was bitter for many, however, and areas of
Croatia were willingly co-opted into a Nazi puppet government know as the
Ustasha and civil war waged in other areas during World War II. Most
Croat-Dalmatians, fought with the Partisans who were eventually the victors.
The island of Vis was the base of operations for the Partisans, a point of pride
which lent nobility to the deaths of men and women from the island who
fought and died with the Dalmatian Brigade.
Deaths in World War II were viewed as heroic and meaningful in
that the dead "did not die in vain," they liberated the country. One devoutly
spiritual elderly woman on Vis, Katica, who never ever would swear, found it
normative to refer to the f**in-Ustasa. She was shocked when Serbs from
the Milosevich regime expected an apology from Croatians because CroatUstasha persecuted and murdered hundreds of thousands of Serbs during
World War II. Katicas husband fought the Ustasha and died a hero; she felt
that expecting an apology from Croatia placed her in the category of Ustasha.
It was an insult to her husbands soul, and therefore, an insult to her. Like all
relations, relationships with the dead are set in specific historical and social
48
contexts, the "social geography" of death relations. Upholding the reputation

of a dead spouse can be a complicated matter in the Balkans.
Mrs. B., who emigrated many years ago, suffers because her
mother, in the Old Country, died hungry. Mrs. B. feels the loss of her mother
and the requisite vestigial guilt that she emigrated to marry at age 17 and
never saw her mother again. What pains her physically, what she professes to
feel in her body, is the hurt of her mother's hunger. The circumstances of her
mother's death over 50 years ago are carried in her body, not from behaviours
she regrets or anything she would do differently, but because the misery of a
mothers starving to death is felt half-way across the world by a daughter,
long grown old herself, who loved her and was loved by her. A bad death
lingers, wounding again and again through expressions of grief. If Mrs. B.
had been able to at least feed her soul with attendant prayers and burial
witness she might have transformed the death (a kind of homicide by social
circumstance starving during World War II) through a kind of spiritual
psycho-therapy, at the very least.
There are risks that the recent dead will molest the peace of the
living, with or without the intention to do so. Fear is well-founded in a state
of siege. A metaphysical disquiet also obtains when the near-dead and the
traumatized collective call for help, articulating realistic assessment of
incipient war, actual war, or collective suffering because of the war. The
calling out in prayer for help is part of the transition, a kind of verbal arsenal
in the spiritual or metaphysical enlistment process. War has always been
expressed via language but these spiritual dimensions to dying and death
from war are less obvious. If one is attacked because of a characteristic
shared with others (ethnicity, nationality, gender, religion, etc.) then all who
share the characteristic are attacked. Further, the death of one because of a
shared characteristic (particularly the death of family members) requires a
proper response according to the expectations of reciprocal obligations.
The language used by anthropologists has associated war deaths
of young Croatians in the 1990s war with war deaths of Serbs generations
ago in reciprocal ways, as well. "The past is the present," (Hammel 1996)
denotes World War II as explanation for Serb soldiers killing Bosnians and
Croats in the 1990s. The killing of today's living is explained with reference
to past dead. In another example, Halpern and Kideckel write, It was
Croatia, not Serbia proper, that suffered killing, rape, and destruction in the
early 1990s. The Croatian people feel violated, not withstanding the horrors
visited on the Serbs by the Croatian state in World War II . . . (Halpern and
Kideckel 2000: 7). The language may seem more rational than explanations
of suffering or killing based on metaphysical relationships with the dead, but
both are part a similar rhetoric. From a cultural relativists position,
circumstances of past deaths explain killings manifest recently. A critique of
the relativists perspective seems to imply, The dead made them do it, or
More than 50 years ago, some Croatians killed Serbs and this explains why
a Croatian boy or girl born in the 1980s was killed by Serbs in the 1990s.
Kathleen Young
49
There is almost a vesting of the sins of the grandfathers on their

grandchildren.
Different groups express their resistance and mobilization in
different ways. Slavic women have traditionally worn black as a symbol of
mourning but other kinds of death and relationship with the damaged, the
near dead, and the socially dead or ethnically "cleansed," are also expressed
by women through black. When news of the rape camps in Croatia and
Bosnia became widespread news, one informant wore black in protest and in
mourning. Rape was another kind of social homicide, along with siege,
starvation, and forced immigration. Another example is "The Women in
Black," a pan-ethnic resistance movement in Serbia whereby women show
their solidarity and support for other women from any of the former
Yugoslav republics whose sons and daughters are dead or missing in war
(Zarkovic 1997).
Mothers and grandmothers I interviewed both before and after the
war of the 1990s expressed their mourning for their lost "flesh and blood" kin
and for their husbands with physical idioms. The death, both the predictable
and the inappropriate or untimely death, of a close loved one could cause
spiritual and emotional wounding and lasting physical trauma. Two women
both told me, "When he died the air went out of me." Both said they did not
breathe, and literally could not breathe, as easily as they could prior to their
husband's death. I took them at their word and also interpreted their words as
acts of protest and resistance to their husband's premature deaths. To breathe
is to have life, and without their husbands, their lives were diminished.
Those missing in war are associated with their own generation of
unease. It is incumbent upon the living to bury the dead properly and if the
living cannot fulfil this obligation, for whatever reason, the results are
unfortunate. A funeral mass may be performed in absentia, but there is no
atonement for less than "a good death." Mamma's or Grandma's pain,
experientially vested in her descendants, may stem from the homicidal acts of
war; it may be that circumstances did not permit funerary rites consistent
with her familial importance. Regardless, such disruption necessarily
interferes with the spiritual benefits for the living and the dead acquired
through appropriate death and proper burial.
It is impossible to bury the dead individually and properly
throughout areas of Bosnia and Croatia where there are mass graves waiting
study by forensic anthropologists and others for possible use in war crimes
trials. The corpses are mixed together, decayed one into another. Sufficient
rituals must be group rituals in the case of some mass graves. From the
perspective and experience of men and women with friends, relatives, and
countrymen in a mass grave the fact of their death and burial in this
illegitimate manner coalesces the grieving into a kind of spiritual family,
ethnic or national linkage, shared relations with the disembodied and the
poorly interred. It is fitting then that memorials be collective.
50
If death is never the end of relationship, however, some

refashioning of reciprocal relations with the dead is possible. Proud of their
dead Partisans, the Komizans erected a large memorial to them after World
War II bearing the communist star, the emblem of the unified Socialist
Republic of Yugoslavia and placed it as the centrepiece of the village of
Komiza on the island. The Communist Party was strong on Vis following
World War II. The island had become a military base for the Yugoslav
National Army and Navy post World War II and closed to outside visitors.
When Serbia attacked Croatia in June of 1991, the Yugoslav-Serb military
quarantined the island and imposed martial law. As Yugoslav-Serb military
and paramilitary were attacking other parts of Croatia, the people of Vis
could have been subject to the same killing, rape, and destruction as other
parts of Croatia but it did not happen. Perhaps, Vis was spared because it was
ridiculous to suppose there had been Ustasha on Vis, Titos Partisan
headquarters during World War II, or perhaps because Vis represented a
unified Yugoslavia to many in the Communist Party. The Serb dominated
Yugoslav army and navy left Vis, despite its strategic military position near
the coast of Croatia. Nevertheless, when the Yugoslav-Serb military left the
island, they attacked the nearest city on the coast, Split. The battleship,
Split, left Vis where it was berthed in November of 1991 and attacked its
namesake city of Split.
Split was only saved because the Serb military had not first taken
the hills above the city. Local men using weapons purchased illegally in
defiance of the United Nations arms embargo drove the gunboat away.
Komizans were shocked and terrorized by the attack along with the citizens
of Split. Komizans destroyed the monument to the local Partisans who died
for the Communist Party and the Socialist Republic of Yugoslavia. What had
been central to their identity for 50 years was dismantled leaving an empty
space where the monument had been. Headstones in Komizas cemetery that
bore the communist star were taken down and the star removed, often
replaced with a cross. This was not to symbolize the triumph of Catholicism
over Communism, since they had previously existed in tandem.
Families are buried together on the island of Vis, oftentimes in the
same deep burial crypt and it made no sense to bury the dead under the
symbol that had become the symbol of the murder of Croatians. Even the
long-dead would be insulted to lay under the word Yugoslavia when SerbYugoslavs had killed their kin in the 1990s. While Serbs were digging up
their own long dead when they left Sarajevo at the end of the war, rather than
leave them in what would become Bosnian soil, Komizans completely
remodelled the cemetery. Like a rite of passage at marriage or death, the
cemetery got a face-lift. There is no question that the dead would not approve
of this extreme makeover. Reciprocal relations between the dead and living
may, in extreme situations, require such revision.
Following the makeover of the cemetery, Komizans on Vis Island
look forward to a younger and better future. Before the recent war, more
Kathleen Young
51
people left the island than moved to it because there were few jobs. Since the
island had been closed to tourists following World War II, islanders were
deprived of the foreign currency enriching other areas along the coast. Vis
had been one of the least populated regions in the Republic of Croatia but
now that is all changing. The post-war years have seen a boon in tourist
dollars along the coast because more of the money is kept locally instead of
being siphoned off to Belgrade, according to the locals. Now that Vis is open
to tourists, people are moving on to the island instead of away. The legacy of
the communist past and the horrors of the recent war have not made the
people look backwards in anger or anticipate revanchism. The future looks
extremely different than the past.2
The extreme makeover began with the dismantling of the war
memorial. The cosmetic changes to the Komiza cemetery were more than a
surface makeover. Even the dead appear to enjoy a better future.
Notes
1. I was invited to join 6,000 Croatians in the Vatican prior to this
conference. Their visit and audience with the Pope in early November,
2003, was a thank you to the Pope for all that he has done in support of
Croatia.
2. The newly independent Croatia Airlines in-flight magazine
makes no mention of the devastation of the recent war (Ziof 2003).
References Cited
Halpern, Joel and David A. Kideckel, Eds. Neighbors at War. University
Park: The Pennsylvania State University Press. 2000.
Hammel, Gene. "Structural Factors in the Collapse of Yugoslavia and How
to Do It Right Next There and At Home," Paper presented to the American
Anthropological Association, November 20, San Francisco, California, 1997.
van Gennep, Arnold. The Rites of Passage. Chicago: University of Chicago
Press, 1960.
Young, Kathleen. The Diversity of Croat-Dalmatian Ethnic Identity in
Northern Puget Sound. Ph.D. Dissertation. Simon Fraser University., 1994.
Zarkovic, Radmila Manojlovic. I Remember. Writings By Bosnian Women
Refugees. San Francisco: Aunt Lute Books, 1997.
Ziof, Ksenja. Croatia. Zagreb: Croatian Airlines. Autumn, 2003.
Part IV
Death Beyond Words:
The Art, Music, and Poetry of Death
Death and Musical Transfiguration: Writing the Disaster

Blake G. Hobby
Abstract: All writers know that writing involves confronting life's
boundaries, the limits of expression and understanding. In short, writing
involves dying. Whatever lives when we write dies the minute our pens lift
off the page. Thus, the writer, if he or she is successful, coaxes readers
into bringing dead texts to life. In seeking to express what lies beyond our
understanding, writers often turn to music, that great bearer of emotion
accompanying the rituals by which we live and die.
By including musical references and musical forms, writers
facilitate an internal dialectic: the experience of recollecting, overhearing,
remembering, associating, linking, grouping, discovering, exploring,
reflecting, interpreting, and generating meaning that parallels how we
confront our mortality and seek to understand what lies beyond us. We
make sense out of living and dying through translating, taking what is
ultimately unknowable and placing it within the bounded-forms that
compromise our forms of knowledge: books, photographs, songs, poems,
eulogies, theories, diagnoses, medical reports, autopsies. For this
translation process, as Hans-Georg Gadamer puts it, contains that whole
secret of how human beings come to an understanding of the world and
communicate with one another.1
With this in mind, I explore how Marcel Proust, Thomas Mann,
and James Joyce express loss by including musical elements in their
narratives.
I want be begin with a confession: I teach literature for a living; I read
books. As I do not deal directly with the dying in my daily life, I write with a
great sense of humility. While teaching does not bring me into direct contact
with death, I have worked for twenty years as a church musician. In this calling
I have spent considerable hours with the bereaved and have played many
funerals. Knowing about these two aspects of my life may help you understand
my position.
One day in Dallas, Texas, where I taught soon-to-be-voting members
of Americas conservative middle class, I took my students to chapel day. A
monthly event, chapel day drew a mixed response. First, students would wiggle
with delight, realizing they would get out of class. But soon after this initial
thrill wore off, they would wince, remembering they would be held captive in a
dogmatic prison-house. There, students performed the role of penitent plebes in
painfully drawn-out prayer rituals. Moral lessons and calls to social action were
preached, delivered in guilt-ridden rhetoric and laced with decontextualized
biblical quotes, holy-roller one-liners, the likes of which street-corner prophet
aphorisms and bumper stickers are made. Ah, but this day was different.
56
Brother Lee was in charge. Lee, it had been rumoured, was attempting a
theological experiment, a fusion of disciplines designed to awaken the
secondary-student conscience and to keep zippers zipped and bras safely
fastened for quite some time. Donning beret and Left Bank persona, Brother
Lee waffled on, lisping aesthetic philosophy to the hormone-stricken crowd:
God is the artist, spoke Lee, the original who never paints by numbers.
The air was charged with energy. Laughter rippled under feigned
bronchial coughs and sneezes. Then it began. With a flick of a remote control
button, music filled the aira mystic, New Age mlange of earth sounds,
cicada creaks, flowing waters, and floating synthetic strings, all the sounds that
traditionally accompany health-food shopping, wellness workshops, guided
meditations, and massage therapy. The atmosphere for spirituality was set; the
crowd made its way to a lone easel, the locus of the schools corporate work of
art. Each student visited the work in progress whenever the spirit called,
dabbing paint on a canvas far too small to accommodate one thousand globs of
goo.
While Brother Lees art experiment was not a success, his
inclusion of music was effective. Even if the canned music accompanying
chapel day did not move students to new depths of spirituality, the music
drew the participants into the event. Like a movie soundtrack or hymn for
the dead, Lee's music helped the students appropriate the experience for
themselves. For his performance Brother Lee used a technique often
employed by writers and filmmakers. The technique? The inclusion of
aural elements that help facilitate a relationship between a text (a thing
capable of being woven or interpreted; a thing capable of being used to
generate meaning[s]) and its receiver.2
For several years, I've been thinking about how modernist
writers, who, in expressing loss, rely upon the affective power of music.
The writers I've consideredT.S. Eliot, Gunter Grass, James Joyce,
Thomas Mann, Aldus Huxley, E.M. Forster, Marcel Proust, and Viginia
Woolflived through a tumultuous time and created aesthetic
masterpieces. Attempting to upright a toppled world, they fashioned oneof-a-kind artifices like Joyce's Ulysses, Proust's la recherche du temps
perdu and T.S. Eliot's Waste Land that stand as testaments to the
imagination's ability to fuse disparate elements into comprehensive forms.
Often writing with each other in mind, these artists believed, perhaps
innocently, perhaps romantically, egotistically, that elaborate books might
remedy the world's failed attempts at meaning-making. If the world is
Humpty Dumpty and there is no way to get him back together again, then
the best you can do is reveal his fragmented pieces and ask readers to
reconstruct something from scattered shards.
While all these writers laboured to represent the modern
individual coming to terms with loss: the death of God, the death of
tradition, the death of purpose, I've chosen to discuss Marcel Proust,
Thomas Mann, and James Joyce here today. With literary modernism,
Blake G. Hobby
57
music, and this conference in mind, I've been asking a number of

questions, all of which deal with making sense of dying and death: is it
possible to confront death, especially the earth-shattering loss of over ten
million lives in World War I, without projecting presence? Is it possible to
create art without relying on the desire to transcend our mortal limitations?
Is it possible to respond to death without making meaning, without
erecting an interpretive framework, without belief, without faith? While
these philosophical conundrums may have no clear-cut answers, early
twentieth century writers engage these questions, especially when they
represent the thinking self. To represent the self beyond temporal
limitations, modernist writers often use music.
In Swanns Way, the first of his seven-volume novel, la
recherche du temps perdu, Marcel Proust captures the way we experience
time and loss: the strings of tensions and resolutions, the endless rhythm of
pain and well-being, of angst and joy, and of bewilderment and clarity that
also mirror the experience of listening to music. As Swann hears a musical
phrase from an impressionistic violin sonata (the "Vinteuil" sonata),
memories and feelings surface. He begins to associate Odette with the
phrase. His love for her grows as he remembers the music.
As we observe Marcel early in the novel, he strings together
sensory images. He remembers the smell and feel of his mothers kiss; he
recollects how a candle looked and smelled in the hallway; he recalls how
the aged wood on the stairwell used to smell. These associations trigger
memories and feelings. Marcel voluntarily assists in the process, as does
Swann when he listens to the Vinteuil sonata, splicing present moments
with memory, melding memory with desire, and ultimately making Odette
into an object of his longinga thing over which he jealously and
obsessively schemes. As when we come to terms with things we cannot
have or have lost, Swann swings between impassioned belief and
cosmological emptiness: anxiously planning his next move, losing faith,
and then distancing himself from what he cannot understand or control. In
Swann's Way, music becomes a metaphor for the ethereal world of
thinking and remembering. Swanns Way aspires to be mindmusic for the
reader, an aesthetic experience where consciousness can be felt, as in a
mystical religious experience or a musical performance. When we
accompany dying rituals with music, we, like Proust, draw participants in,
provoking thought, conjuring feelings, and encouraging the psyche to
process what is literally, insensible: beyond any of our senses to
comprehend. As we do, we facilitate the grieving process during which we
make sense out of dying and death. The process bears with it ambivalence,
the sort of disjunction that occurs when we attempt to bring ethics and
aesthetics together.
Like Thomas Mann, we understand that creating meaning out of
death is unsettling. As in the central character of Mann's Tristan, we know
interpreting death involves moral equivocation: the blessing and curse of
58
making sense of things we do not understand. In Tristan, a powerful literary

work dealing with the profound role music plays in coming to terms with loss,
Thomas Mann focuses on music, death, and the aesthetic experience. To
explore the relationship of the three, Mann recreates the love-duet from Act II
of Wagners Tristan und Isolde and then follows it with a dramatic death scene
echoing Isolde's love-death (Liebestod) aria that closes the Wagner opera.
Describing the love-duet note by note as Gabriele Klterjahn3 plays it on the
piano, Mann draws the reader into the narrating process while paying homage
to Schopenhauer, whose ideas about aesthetics haunted Mann throughout his
life. For Schopenhauer, aesthetic contemplation mirrors consciousness, a
survival tool for navigating life, which is ultimately a dream:
All this means, to be sure, that life can be regarded as a
dream and death as the awakening from it: but it must
be remembered that the personality, the individual,
belongs to the dreaming and not to the awakened
consciousness, which is why death appears to the
individual as annihilation. In any event, death is not,
from this point of view, to be considered a transition to
a state completely new and foreign to us, but rather a
return to one originally our own from which life has
been only a brief absence.4
Inspired by aesthetic ideas of Schopenhauer, Wagner, and
Nietzsche, Thomas Manns Tristan narrates a story of the modern artist,
the unsuccessful writer, Detlev Spinell.5 As a pathetic modern artist,
Spinnell seduces Klterjahn with aesthetics. She dies after performing
Tristan and Isolde at the piano. Mann places the reader of the novel in the
position of Frau Klterjahn, the Isolde figure seduced by aesthetics.
Behind the narratives outer framework, which is a story of patients in a
secluded asylum, lies Wagners opera Tristan und Isolde. In Mann's
Tristan, music becomes a metaphor for the role of aesthetics in art and in
the rituals by which we live and die. The novella comments on the way we
rely upon aesthetics in expressing what is beyond comprehension, and
they way we depend on music in processing death. As with Wagner's
Liebestod, Mann's Tristan paints death as a beautiful event accompanied
with lush, romantic harmonies. It certainly takes artistry to elevate loss
into beauty, but, of course, without the work of clever artificers, how
could we say we understand death or are able to share loss with others?
For when words fall short, we turn to art to reflect our lives and unite with
others.
Like Poldy Bloom in Joyce's Ulysses, we not only need art to help us
move through pain but also to place overwhelming realities into a manageable
framework. As he dines in the Ormond Hotel and listens to music trail in from
the hotel bar, Poldy Bloom adapts what he hears, turning popular songs and
Blake G. Hobby
59
operatic arias into a mirror reflection of his reality. Bloom weaves music into
his own experience. The bar sounds, given in a musical language, echo
Blooms interior experience as he listens. After pondering the affair his wife is
having and his own misfortune, Bloom's thoughts turn to all who have gone
before him, the dead, those whose memory the bar's music has conjured.
Bloom works within boundaries: an outhouses confines, the
distance between his daily destinations, a vacant space in a funeral
carriage, the limits of discourse and argument, and the music heard as it
trickles from another room. These boundaries become framings: the
essential limitations that comprise understanding.
We understand music and death by supplying lived experience to
account for what we cannot place in language. We cannot imagine
abstract, metaphysical entities like music and mortality without placing
these things in a present, temporal framework. If remembering is an
experience conditioned by random associations, by our selection of
random elements as they enter the mind, and by the feelings that surface
from the selections we make, then remembering may be said to be a
musical experience. Listening to music involves following chance
associations as well as intentionally selecting elements and attaching
significance to them in a voluntary act where cognitive puzzle pieces and
emotional responses eventually meld together to form understanding.
When we reference music in books and play music for the dying
and the bereaved, we facilitate an internal dialectic: the experience of
recollecting, associating, grouping, and generating meaning. We make
sense out of living and dying through translating, taking what is ultimately
unknowable and placing it within the bounded-forms that compromise our
knowledge: books, photographs, songs, poems, eulogies, theories,
diagnoses, medical reports, autopsies.
Whatever lives as we pour our experiences into words dies when we
lift our pens from the page. If we write well, we coax readers into bringing dead
sheets with ink marks to life. To bring things back from the dead involves
relying on another. Understanding this quandary, modernist writers present
music, an invitation for the reader to perform -to make and remake what their
narratives bind. But they also bring awareness of time, the ever-moving world
of change whose end is death, the one thing that we can never lose.
As we try to make sense of death and dying, we play a game that lies
beyond the printed page and cannot be described in terms of what it means or
produces. At stake is understanding, an experience that only a clever and
deceptive game can begin to convey. This game raises more questions than it
answers. When we are actively reading or lost in music, however, we
experience what Gabriel Josivopici calls a momentary freedom from
imprisonment.6 Here the confines of our lives and the limits of writing
intersect in the spiralling circle of interpretation that defines our existence. This
movement, as Maurice Blanchot observes, is indeed a dance with an invisible
partner in a different space.7 To enter this movement is to experience what
60
words cannot express -the very real and awe-inspiring way life presents itself,
impresses its joys and pains upon us, forces us to keep moving to survive, and
inspires us to make sense out of death and dying.
Notes
1. Gadamer, 1980, 548.
2. Here I play with the Latin root of text: the verb texere and its
participle textum, meaning to weave.
3. Anthony Heilbut notes that Klterjahn is a local idiom denoting
ample testicles, 158.
4. Schopenhauer, 70.
5. Richard Winston points out that Spinell is the German word for
an oxide of magnesium and aluminum. It has a red variety which
resembles and is often found with a ruby. Thus, the writer looks like, but
is not, a precious stone, 150.
6. Josipovici, 308.
7. Blanchot, 255.
References
Maurice Blanchot, The Sirens Song: Selected Essays by Maurice
Blanchot, ed. Gabriel Josipovici (Bloomington: Indiana UP, 1982).
Hans-Georg Gadamer, Truth and Method, trans. Joel Weinsheimer and
Donald G. Marshall (New York: Continuum, 1996).
Heilbut, Anthony. Thomas Mann: Eros and Literature (New York: Knopf,
1996).
Gabriel Josipovici, The World and the Book (Stanford: Stanford UP,
1971).
James Joyce, Ulysses, ed. Hans Walther Gabler, Wolfhard Steppe, and
Claus Melchior (New York: Vintage International, 1986).
Thomas Mann, Death in Venice and Seven Other Stories, trans. H. T.
Lowe-Poeter (New York: Vintage, 1930, 1989).
Marcel Proust, Remembrance of Things Past (three volumes), trans. C. K.
Scott Moncrieff and Terence Kilmartin (New York: Vintage, 1981).
Arthur Schopenhauer, Essays and Aphorisms, trans. R. J. Hollingdale
(New York: Penguin, 1971).
Richard Winston, Thomas Mann: The Making of An Artist (New York:
Peter Bedrick, 1981).

Michele Petrone
Well in the end I was glad to be coming to Paris. The last couple
of days have been awful. Who would have expected that at 10.44
Wednesday morning that my humour would be shattered by that phone
call. From my doctor. It was strange that they hadnt called earlier to say
that the PET scan was nothing. No. It would be something. Didnt expect
that. And my silence was shattered. And of course I imagined the worst
and back again. And I wondered how would I cope again. And I sank.
Deep. Death was at my door once more.
Art can help people affected by serious illness and death 'make
sense' of what is going on for them, whether dying, bereaved, caring for
someone who is dying or bereaved, and also for health professionals
working in these areas. Death and dying have such great taboo and fear
surrounding them, that people once confronted by this aspect are fearful,
feel isolated, are not very well understood, nor supported.
Art can help reduce this fear and isolation and improve
understanding and communication. That is the fundamental belief of the
MAP Foundation, a new charitable trust launched in March 2003.
As people paint, they externalise some of what they are going
through, onto the paper. This expression becomes like a mirror to reflect
upon, an opportunity to 'make sense' of what is going on. We all die
eventually. Why do we have so much fear about addressing this in our
society? Why can't we prepare ourselves? The MAP Foundation works to
address our own mortality and our feelings around life and death and
illness. Paintings and stories, by patients and carers from art workshops,
are used by the MAP Foundation to inform society and educate health
professionals about the complex issues and feelings of the people they
serve. And for health professionals also what does it feel like to break bad
news? To be with someone when they die?
The Emotional Cancer Journey

Images and words of the emotions and feelings experienced during the
cancer journey by artist and cancer patient Michele Angelo Petrone
(The paintings referenced in this piece can be accessed via the Internet at:
http://www.mapfoundation.org/exhib1.html.)
One for sorrow (painting)
Im frightened to feel sad,
Like the pouring rain
62
I dont know when it comes.

And I do feel sick with sadness
And tiredness.
Am I really going through this?
Like the windscreen glass (in the rain)
Im soaked in an ever-flowing film of tears
Washing my life over me.
Is this my life how I want it?
Or is this the best I can make of my life
And that is how it is.
I want to live my life to the full
If only its till tomorrow.
Or in another thirty two years
Im alive you see.
And thats all that should matter.
But I have this death sentence hanging over me
On 8th March 1994, I felt a taut tension and spasm from the
centre of my chest up my neck. The next day a lump appeared on the left
side of my neck. Little did I know that I also had tumours inside my chest
and in my armpit. I had been struck down with Hodgkin's disease, which
is cancer of the lymph glands. I was thirty years old.
Nothing I had already been through or been taught or heard from
other people prepared me for what I was about to go through in the next
nine years. It was more difficult and painful than I had ever imagined. But
part of that pain and difficulty came out of fear and ignorance. My fear
and then the fear of everybody around me. Illness and death are a part of
life, yet they are very much taboo subjects in our society.
The Island of Neutropenia (painting)
I was confined to my room while neutropenic, waiting for
infection to strike. In the door that separated me from the outside world
was a window, an empty frame, that if filled could say something of me,
something to me, something that would help transform my sterile and
institutionalised environment.
Suddenly, I was struck down with overwhelming septicaemia,
shocked, comatose, so close to death I had so long feared. My friends
thought I might die. I thought I had died. Im not ready yet. I leaned
against the tall red tree pulsating with the life force and the healing
properties I sought, as optimism and growth sprouted in the shape of green
leaves. I feel better, but sit and wait for the stem cells to rescue me from
the island of neutropenia to which I have been banished.
Imagine what it must belike when I talk of nearly dying - and of
sometimes wanting to die - because of what I was going through. Illness
Michele Petrone
63
and death are familiar to you. But what is it really like when its your own
illness? What is it really like when your life feels as if its being taken
from you?
The Journey (painting)
My journey has two intertwined threads elements which mirror
each other as exactly as the two chains of the double helix. One is the
medical history. The physical injury, the illness, the happening, the
happened, the inevitable and the unavoidable. The parallel thread is my
emotional response. The disbelief, the grief, the doubt, the flung out, the
anger, the banter, the bargaining, the accepting, the clenching of teeth, the
sick to the teeth, the pain, the no-gain. Why me? Why me now?
As time goes by, night follows day and day follows night - a
natural cycle without beginning, without end and without gaps. Lifes
cycle continues without interruption - or at least it should do so. Suddenly
illness arrives, uninvited, unexplained. I found myself caught between life
and death, light and dark, banished to an unknown place - between night
and day.
Cast Out (painting)
In the process of splitting night from day, the arrival of the lump
in my neck cast me out from my normal life. I should have been preparing
for two exhibitions; instead I was sitting in a hospital bed waiting for a
biopsy and being told I needed an AIDS test. Cast out? Outcast!
Marginalized, ostracised. Everyone else gets on with their life while the
freeze frame button is pressed on the video of my life. I wait, alone, to find
out if I have cancer or what. Will I fall to the ground or will someone
catch me in time. Has it been caught in time?
The Pain of It All (painting)
So now I have a diagnosis: Hodgkins disease. Lets call it
cancer. Ive heard of that. I know what it is - Fiona, a woman I live with is
having chemotherapy for breast cancer. This is different Im told. They
dont tell you that an 80% chance of a cure means a 20% chance of death.
Youre left to work that one out for yourself. Death. Life is bad enough,
thats what I thought. But who do I tell? Mum, I want to die. Hey, lover of
mine, I think forever might be closer than I thought. Hi, good friend, want
to talk about euthanasia and making a will?
Were all in pain, why cant we share our pain?
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Death and illness are almost taboo subjects even though we will
all die eventually. Who isnt frightened and doesnt find it difficult to talk
to someone they know might be dying? I wasnt prepared, neither were my
family and friends. Whos going to help me, listen to me, understand me,
be there for me - just for me. Not be frightened by my thoughts and
feelings of having my life threatened, changed and maybe dying at the end
of it all anyway.
Loss (painting)
Delilah cut Samsons hair and sapped his strength. My doctors
dont need to cut my hair; the chemotherapy just made it fall out and my
strength just fell out too. Was it just my hair they cut off or was I castrated
as well? The chemotherapy took my fertility away.
The journey of illness is not only about the physical illness but
also the emotional response. My doctor is attempting to cure me, but who
is going to help me deal with the emotional aftermath, to try and heal that
side of me and heal all of me? Its not easy, but counselling offers a space,
a place, some time and a face, a person to listen to me. Someone who will
not be frightened by me and will help me heal emotionally.
The Fragility of Life (painting)
Three months after completing treatment I got a pain in my
shoulder. Funny it should be worse after a drink. And why all this itching
again? A bone scan showed a hot spot. A biopsy was negative but my
doctor didnt believe it so he arranged another. That too was negative. I
didnt believe it. Another pain, my hip this time. Another bone scan,
another hot spot, another biopsy. Third time lucky - or unlucky. This was
positive. I had relapsed. Meanwhile Fiona after further chemotherapy
herself had died in our home. I needed more chemotherapy now. Not
gentle chemotherapy like last time. (Whoever said the last lot of
chemotherapy was gentle hasnt undergone it). This time it would be high
dose chemotherapy strong enough to kill all my bone marrow. It might
even kill me before the disease has a chance to. Here I am walking the
tightrope between life and death. If I wobble, if I slip, if I lose my nerve or
if my supporters fail me, Im gone.
The Maze of Trees (painting)
Im confused. Im lost as to which way to turn - who to turn to.
Before, everything seemed so clear. Now, which way to turn, which path
to follow? Help me please somebody show me the way.
I had an exhibition on then called Into the light. It was
designed as a celebration of my return to health - but in fact it marked my
Michele Petrone
65
relapse. Was the light into which I might be going, the great celestial
light?
Carry Me This Way (painting)
This illness has invaded my life, knocked me off balance and
made me feel out of control. I no longer feel the strength and direction I
once had. Im just a passenger being carried whichever way these arms
take me. But I still feel a need to direct my life, to feel this life of mine is
still mine. So please: carry me this way.
The Healing Touch (painting)
I need to know that this body is my body. And I need to know
everything that is happening to my body. But most of all I need to know
that you know that within my body there is me.
Healing is brought about not just by medicine, its not just
treatment which cures you, but all that encompasses the human touch. A
smile means more than an antibiotic injection, a hug means more than a
platelet transfusion. The face - of my friends, my family, my nurses and
yes - even my doctors, shows sympathy, compassion and understanding.
This human face contributes so much to healing of the tortured soul.
The Visible and the Invisible (painting)
The physical illness is visible and life threatening. The emotional
feelings, the electrical impulses of my soul cannot be seen. As they are
invisible it is easy to pretend that they are not really there. They dont at
first seem to be as important as the cancer on the microscope slide.
The Journey to Where? (painting)
I dont know where life will take me. I dont know how the river
bends or where the rapids may be.
My journey isnt finished, I dont know what lies upstream.
There are no certainties in life except death, and we have to accept this
unknowing and knowing into our lives. Something we find hard to do
and fail to do.
Colour Our Feelings (painting)
Painting can be a way of expressing one's emotions, almost
unknowingly. Every brush stroke is decided, if not consciously, certainly
subconsciously. What is wonderful about art, is that there are no rules, as
in the construction and expression of the written and spoken word. It is
66
free, for the artist, to express in whatever, and in whichever manner the
artist wishes to do so. 'Truth did not' One will not receive the truth in any
other way...one must enter through the image into the truth.' The Gospel of
St Philip Painting can be used as a tool of exploration, but it can also be
fun, be recreational, and almost dreamlike: close your eyes and see the
picture within. It can allow a freedom of expression, of emotions maybe
too difficult to express in words. As the saying goes, a picture can say a
thousand words. The expression through this medium is indirect, giving an
almost sideways glance into oneself, through the image. An image of the
invisible, made visible through paint. 'Colour Our Feelings', the project
from which these wonderful images and words are taken, provided an
opportunity for anyone affected by cancer, to come and 'colour' their
feelings. Those affected are not restricted just to patients, but also to
carers, loved ones, family and friends, and even professionals, who also
have emotional responses in such intense situations.
As a community, we fail to realise that one lives through illness
and dying. As an individual, the feelings that manifest in each of us, are in
fact, because we are alive. The feelings of fear, pain, disbelief and anger,
only give more importance to the feelings of love, happiness and the value
of life. How surprising it will be to some, that through illness and dying,
there can be very positive feelings, and the realisation that life is for
'living'. Sometimes the possibility of dying, gives permission for a way of
living, not previously allowed. This is not to diminish the trauma of
illness, the loss, the anger and the isolation. Freedom of expression, for all
one's feelings, is so important. A feeling also that one is not alone in
feeling these emotions. Who does not find it difficult to talk to someone
who might be dying? The person assumes an aura of fragility, that cannot
afford a mistake. We are all human, we all make mistakes, how else do we
learn and go forward. Everyone is different, choosing various ways of
coping, some want to know everything that is happening, others not at all,
some pick solitude, others search for contact with others who understand.
Some choose to believe that there is a reason for their illness/dying, a
metaphor for their life. Whatever the individual chooses to inform,
supplement and even heal their life should be respected. The medical
treatment only forms a part of the journey of illness. It is also important to
note that healing can exist in death as well as life. Healing can be a
coming to terms with illness, or death. There are so many facets to illness,
to cancer, and these paintings and stories here, provide a few. A few, I
hope that will help others to understand the feelings that one can
encounter, and a feeling that one isn't alone with one's feeling. The
language is universal, and I hope this will help to break down the barriers
of isolation, and help to heal in some way.
Michele Petrone
67
Tracy (painting)
This painting is a description of how they saw me, the me in the
hospital bed. I was considered to be a patient and I was treated like a
patient and this rather negated the rest of my life - the life that had been
going on outside up until the moment I was admitted. As soon as you're
diagnosed the medical profession sees you as being the illness with a
person attached. Actually you are an ordinary person, with something
dreadful that has happened to you, absolutely dreadful. That doesn't mean
that all the rest of your life isn't carrying on. Maybe you're going to have
to withdraw from some of it because of the physical limits, but things like
relationships will still be there. So this picture is about how you are
viewed: as the illness, a cancer patient in that bed, somebody who's had a
colostomy. I don't blame anybody; I'm just saying that's how it feels.
Katy (painting)
We were never ill. Yet you get cancer. My mum and sister died
from ovarian cancer, mum aged 54 in 1975, my sister aged 45 this March,
within a year and despite strong chemotherapy. Dad died, aged 69 in 1986,
prostate cancer and I get Motor Neurone Disease. Two brothers fine. Odd.
My four grandparents and their many siblings made very old bones and
mum's three sisters and their families are all fine. My neurologist reckons
it's a lottery - if your numbers come up you win the jackpot! Ho ho! I'd
like to do a painting for my sister. She was energetic, gregarious,
organised with a real zest for life. Good cook, loved a houseful. She
collected elephants (not real ones!) from their travels, so may I have that
outline with trunk high, in blue (her favourite colour), legs moving. Inside
outline, top middle, big yellow sun, below their house (wide bay window,
terraced). My sister, hubby, three kids (as stick people), steaming cooking
pot, glasses, balloons, friends all around, colourful. On the right, bed with
my sister. High above foot of bed, waning green moon, flowing tears to
river under bed. Yellow angel at bedhead. White dove above bed flying
upwards, twinkling stars. Clumps of white flowers. Outside colour, light
blue. You do have to work through the gamut of emotions and adjust and
move forwards. Life is full of challenges; Motor Neurone Disease has
been my hardest. I hate what it's done to my body, taken my 'doing' roles,
changed my life, forcing me to be dependant when I was so competent;
but I still give of myself. Despite all the difficulties through my adult life,
I'm happy and feel truly blessed. Obviously I do get angry, upset and
frustrated but thankfully not often. We just give up or fight? I believe that
with support we can live alongside the illness even if it claims us in the
end. It's trying that matters. I leave you with a poem I came across a year
ago and memorised. It says it all:
68

If you've never felt the sorrow of another person's grief; If you've
never felt an inner urge to want to bring relief to someone who's
in trouble with a kindly word or smile; If you've never loved your
neighbour as yourself with all your might; If you've never shed a
teardrop at a pure and holy sight; If others have not been blessed
by something you have said; You need have no fear of dying you are already dead.
Barbara (painting)
These compartments are the drawers to my soul. The first one is
very peaceful and calm like a colourful garden. The hearts and rings, this
was when I was very much in love. The next one is when you get days
when you feel pretty grim, a blank door with no on in there. The next one
is the nights, because sometimes they are not so easy to cope with.
Sometimes I find it harder at night time. I don't really think I'm afraid of
dying - well I hope I'm not. I think it is the fear of the unknown; that's
what it is. You hope that you'll cope with whatever gets thrown at you but
how do you know until you try. The next one, the cross, is my faith, which
I hope will be strong enough. The last one is a butterfly, the fragility of
things.. My illness has made me appreciate my life and my family much
more. I think I live from day to day, because I have to. Having a heart
condition, I've known for some years that it could be any moment now, so
the two added together make death more certain. I think you have to get on
and make the best of it. I've got two daughters, and I've got grandchildren
whom I would like to have seen grow up, but there's not a lot of hope of
that. Never give up hope. I'm sure that must be the answer. There is no
answer to why - none at all. It's just life. Gets hold of some and it doesn't
others.
Rose (painting)
The purple scene (bottom left) shows a different part of my road.
This is an image of my inner soul, the emptiness and desolation I
sometimes feel.
Pam (painting)
The soul painting, I found quite difficult to deal with, to release
what is inside. The squiggly bits at the bottom are anger, and things I don't
know. The pointy bits are peace, flying away, like the little bird, which is
how I see the soul. There is a real sense of release despite the angry bit.
Having cancer makes you realise how precious things are, especially your
family and nature and love. Often you don't feel these things when you are
well. Sometimes you need to have a big thing to contend with, in order to
Michele Petrone
69
release the feelings, which are deep down. It can be positive and not
negative, and most of the people that I have met feel positive. They
haven't been moaners and whiners; they have just got on with it. The main
thing is to have a purpose, a reason to get up in the morning, joy. Some
people never have that in their lives.
Pieta (painting)
The one word, 'isolation', sums up a lot for me. My husband
chose isolation. It was his way of dealing with his cancer. He was very
angry. He didn't want anybody to know, not his friends, his family or the
children, who were six and nine. For me that was not the way I function. I
found ways of talking with the children about illness and death at bedtime,
in story terms, answering their questions when they felt ready to ask them.
My husband was very strong, very capable, full of life and lived life to the
full. For him his cancer was just another challenge. It was something to
fight, find the best treatment, pay what was necessary, get himself better
and nobody need know. He was someone who really played with life. He
had lots of confidence, very different from me. I find life a struggle. It
struck me at the time and it has struck me since, we are each given a hand
of cards we'd find most difficult to play. This image came from a dream I
had moments before waking. I opened my hand and there was a butterfly
just sitting there. As I opened my hand fully the butterfly flew away. This
happened several months after my husband's death, but as I woke I knew
that the butterfly was really him. I don't know how, but that was the
feeling with the dream. The worst thing is running out of time, hoping for
an oasis of calm near the end - wanting the physical responsibility taken
off me to focus on our relationship and his death. In the last two or three
weeks he was having hallucinations. I think now that he died with a lot of
unspoken stuff. He really wanted to be a grandfather; it is a huge regret not
to see the children grow up.
There were regrets about not having enough time together. I felt I
was with him at the end, as he wanted, the nurse on one side and me on the
other. There were still ten minutes left of the workshop and I felt there was
something I needed to say before I left. Sometimes you're having a
conversation with someone and then you find yourself saying something
very important just before you go out. I started doing this long sweeping
curve which really is the incision on my husband's back where they took
his lung out. This involved cutting his vocal cords. Something neither of
us even suspected was that he would have no voice. He was a man who
needed a voice, to be in control. He wouldn't be seen as vulnerable. It was
very frightening to see him with this huge scar sitting up all night every
night. It's also like a train track and these are staples holding it together. I
was shocked: something so huge as having your lung taken out of your
body and all you see on the surface is this neat little pink line with the two
70
edges of flesh coming together like a couple of bacon rinds. It is really

quite absurd because it all looks so neat, with neat little staples. My feeling
now is that it was so at odds with my feelings, which weren't neat at all,
really spilling over, so stuff spilled over out of this bottle here. The waves
the bottle with the message is floating on are waves of emotion. There are
kisses on the label of the bottle - I'm taken back to when the children were
tiny putting kisses on cards - a kiss from each of us. Now there are the
three of us like the three kisses, and three kinds of waves. I am very
conscious of there being three of us now. The circles on top of each other
are the children on my shoulders. As I look at it now I get the feeling of
the weight of being a circus acrobat with a couple of people standing on
top of me. And as far as the message in the bottle goes, I can remember at
the time, I just burst into tears when I put the furled up message with some
writing on it in the bottle. I drew the red pain here - it is unfinished
because we didn't have the opportunity to have a peaceful time at the end.
During his cancer and all the way through it I had no idea what to expect. I
just found myself dealing with whatever happened as it happened. You
just do what you can.
Wally (2 paintings)
Wally, with terminal lung cancer, expressed his pain and rage, at what
was happening, through violent purple brush marks across the
paper. 'Negative' emotions that his wife and nurses, had inadvertently given no
space to, by advising him to 'be positive'. Having been allowed to express
these negative emotions, he was able to then 'come to terms', as he put it, with
his illness, expressed through a painting of him coming out of a black tunnel
into a beautiful green field, full of flowers and a rainbow above.
Sue, Nurse (painting)
The footprints in Sue's painting, follow her walking down the
corridor. As soon as she enters the room, through the door labelled illness,
she sinks, because there is no floor. She said 'as there was no support for
her.'
Being understood, validating feelings, shared and sharing
experience, expression and awareness, recreation, communication,
education and understanding, reducing fear and isolation, addressing our
own mortality are some of the ways creativity and the arts can make
sense of death and dying. The nature of illness, loss and dying will
always be difficult and painful. But perhaps we can reduce some of that
pain, fear and isolation if we are able to communicate more. The arts can
be this conduit, this language and bridge. How many of us find it difficult
to talk to someone who might be dying? Too often we hear stories of the
neighbour who crosses the road, or the friend who stops calling, when
Michele Petrone
71
someone becomes seriously ill, dying or is bereaved. And this increases

the isolation and hurt. Yet no one is too blame. It is fear and lack of
understanding. And this seeming lack of compassion exists within
healthcare for the same reasons: fear, lack of understanding, lack of
education and lack of support. Health professionals, also have an
emotional reaction to the intensely charged work they do. They not only
need education and support, to be sensitive to and address this issue of the
people they care for, but they also, in my mind, need their own
opportunity to express and explore their own feelings through the creative
arts. It has to go hand in hand, with the patients. Through art, the MAP
Foundation aims to bring light to this difficult area.
Issues arising are:
To what extent can health professionals interact with patients
emotional experience?
How can health professionals be supported emotionally in their
care of patients in order to allow patients to express their
emotional needs?
What is the role of the arts in creating dialogue between patients
and staff?
Can all patients gain from a creative arts experience?
And can arts help to deal with major life events?
References
The Emotional Cancer Journey by Michele Angelo Petrone (MAP
Foundation)
The Emotional Cancer Journey Report by Margaret Felton (East Sussex
Health Authority)
Touching the Rainbow: The Paintings and Stories of Patients and Carers
by Michele Angelo Petrone (MAP Foundation/St Peters & St James
Hospice/East Sussex Health Authority/Lewes District Council)
Moving Pictures exhibition (Michele Angelo Petrone/MAP
Foundation/St Michaels Hospice/Sara Lee Trust/East Sussex Health
Authority)
Healing is a Fine Art by Jonathan Richards The Times 25.03.03
72
Art of Healing by Lynne Pearce Nursing Standard 19.03.03
Part V
Grief, Bereavement, and Counselling
Responding to Bereavement in the Acute Care Setting A

Journey in Service Development
Siobhan ODriscoll
Abstract: This paper describes a model of bereavement care, which has
developed in an acute care setting over the past three years. I begin with a brief
description of the hospital concerned. The principles, which inform our work
in the area of bereavement, are outlined. Finally a model of service delivery is
presented and some of the services offered are discussed.
Beaumont Hospital, Dublin is an acute general hospital with 620
beds. It is the national referral centre in Ireland for neurosurgery, neurology,
renal and pancreatic transplantation and cochlear implantation. Beaumont
serves a local population of 250,000 in an urban area, which has a high degree
of social disadvantage. In Beaumont Hospital there are approximately 1,050
deaths per year. It is therefore a challenge to develop a person centred
bereavement service within such a busy environment.
However, in 2000 Beaumont Hospital was the first Irish hospital to
appoint a bereavement co-ordinator. This was facilitated by a changing culture
within the hospital since the appointment of a palliative care team and their
promotion of more holistic end of life care. It was also as a result of public and
media debate regarding the issue of organ retention which challenged acute
hospitals to have a more sensitive and person centred approach to the needs of
bereaved families. This part time post is held by a senior social worker who is
a member of the hospital's medical social work department.
1.
Principles of Care
The mission of the social work department, Beaumont Hospital

includes the provision of a bereavement service, which is responsive to the
needs of those bereaved by a death in Beaumont Hospital. We view our role as
facilitating those who have lost someone close to access information and
support or therapy, as they might want or need. It is a role of accompaniment,
of journeying with those who are bereaved while they try to make sense of
their loss. The aim of the bereavement service is to offer a continuum of care
from end of life care, which is informed by principles of hospice to a range of
support and therapeutic bereavement services.
At Beaumont Hospital we promote a person centred service, which
acknowledges individuals as having differing grieving experiences. This is
based in the belief that each griever has had a truly unique relationship with
76
Responding to Bereavement in an Acute Care Setting
the person who has died and therefore goes on to have a mourning experience
that is unique to them and to that relationship. Traditionally we have
understood grieving in terms of phase and stage models, which outline the
reactions, themes and the course of what is considered - dare I use the word normal grieving process. However these models do not I believe, account
for individual diversity and difference. This is especially important within
families where conflict often arises when members compare one expression of
grief to another and have difficulty understanding or tolerating difference.
Mourning is a life long process, I believe of making sense of both the
absence of someone close and also of their continuing presence in the life of
the mourner. The playwright Tom Anderson wrote after the death of his wife
that death ends a life, but it does not end a relationship (Anderson, 1974).
The intensity and nature of grief and sorrow changes and for many may lessen
over time. Nonetheless, the loss and its meaning remain something to be
struggled with and renegotiated again and again. Silverman & Nickman (1996)
speak of grieving as the paradox of letting go and remaining involved.
In terms of service development we believe that one size does not fit
all. Therefore, we have sought in our bereavement service to develop a
continuum of care which begins with end of life care, and is informed by the
hospice friendly approach within hospitals which is promoted by The Irish
Hospice Foundation. We are developing responses to the bereaved at a number
of different levels from information giving to one-to-one therapy, using both
individual and group approaches which I shall say more about later.
We work from a strengths perspective where the focus on what the
bereaved person is coping with daily (Saleebey, D., 1997). This does not mean
ignoring their story or minimising their pain. A strengths approach rather than
focusing on pathology means actively listening for anything that a bereaved
person does to endure following a loss and using this to promote a greater
sense of coping and mastery for the griever.
Information is knowledge, and sharing knowledge with those who
are bereaved instead of holding it to ourselves can empower them to have a
greater understanding of their grief and to take ownership of it. I believe this
approach helps in the process of trying to make sense of loss and it gives
people coping with loss a language with which to express and validate their
experience. This has been our experience particularly in the Bereavement
Support Programme where participants comment that the talk at the beginning
of each session helped them to put words on what they were experiencing
following the death.
Peer support and mutual help have been found to be beneficial. A
good example is The Compassionate Friends organisation for bereaved
Siobhan ODriscoll
77
parents. Such groups allow for legitimisation of survivor experiences, which is

not readily available in the larger society. Self help organisations also provide
role models for the newly bereaved of others who have survived the death of
someone close. They can be a place where practical information and advice is
shared on how to deal with a particular issue. For example how does a
bereaved parent answer the question how many children do you have? The
helped can become a helper. Reciprocal relationships are allowed for, are
possible. Participants in our Bereavement Support Programme have
consistently identified the support group element of the programme as the
most helpful in reducing feelings of isolation and in offering support.
We take a proactive approach to those bereaved in Beaumont
Hospital. At an early stage we send a letter offering condolences and support.
A bereavement information pack is included. This pack contains information
on practical issues and on how the death may impact on the individual and the
family. In some circumstances support will have been already offered in the
weeks or days leading up to the death or at the time of death itself.
Our service is free of charge. We offer our Bereavement Support
Programme in the evenings to facilitate those working or with family
commitments. However the service is hospital based and some may not avail
of it because they do not wish to return to the hospital. We are committed to
being culturally sensitive and non-discriminatory in terms of age, gender and
race. This commitment is rooted in our training as social workers in nondiscriminatory practice.
These principles of our bereavement service reflect where we are
today. They have evolved from practice and theory and will change and
develop as we reflect on the services offered through review, evaluation and
research.
2.
The Model of Bereavement Care
One of the first objectives of our bereavement service has been to

establish a model for the development, delivery and evaluation of this service.
Colin Murray Parkes suggests that two thirds of people bereaved manage their
grief within their own natural support systems of family and community. Well
thats a great relief to a social worker - not everyone needs help! I believe our
challenge is to reach those who need or want support, which is not available or
not sufficient within their own natural support systems. Within our model
bereavement care is offered at a number of different levels (visually
represented by a pyramid, fig 1) and it incorporates both individual and group
approaches. It also reflects interdisciplinary collaboration caring for bereaved
78
individuals and families.
Bereavement Care
Pyramid
Individual,
family & group
counselling
Parent support days. Risk
assessment. Referral to
community or specialist services
Care of the dying and their families. Hospice
friendly approach within Beaumont. Helping families
meet the needs of bereaved children. The
Bereavement Support Programme -Coping After a
Death.
Bereavement out-reach. Bereavement information pack. When
Someone Close Dies. Adult & childrens remembrance services.
Awareness raising through various media. Links with community.
Bereavement skills training for health care workers. Study groups. Peer support
groups. Study days. Evaluation and research.
Fig. 1
3.
Bereavement Services Offered
There are four levels of direct service provision. The further you
ascend the pyramid, the more specialised the intervention and the smaller
number of people to whom it is offered.
The broadest level in our bereavement service is about reaching out to
the bereaved. Therefore the bereavement out-reach service is offered to all
next-of-kin following a death in Beaumont Hospital. At ten weeks following a
death a letter of condolences is sent by the bereavement co-ordinator and a
bereavement information pack is included. This pack contains information
about grief reactions, practical problems, support available if required and
encourages further contact with the hospital if necessary or wished for.
Annual adult and childrens remembrance services are offered to
all bereaved in Beaumont. The planning groups for these ceremonies are
interdisciplinary. Tony Walter (1999) suggests that memorial services
Siobhan ODriscoll
79
encourage the social existence of the dead person to be maintained beyond

the grave. In our experience one of the reasons why these ceremonies are
always very popular is that they give people the opportunity in a safe and
familiar way to remember and celebrate the life of the deceased person in a
communal setting.
Care of the dying and their families by multi-disciplinary teams is
now more influenced by a hospice friendly approach within Beaumont since a
multi-disciplinary palliative care team was established. Palliative care study
days held annually have provided a forum for discussion of bereavement
issues.
The Bereavement Support Programme Coping After a Death is
offered twice yearly and all those bereaved in Beaumont are invited to
participate. Participants (60 to 70) are between six and twelve months
bereaved. They attend four sessions over four consecutive weeks. Each session
begins with a talk on an aspect of bereavement and is followed by small
groups, which are facilitated by members of the social work team. Group
membership is closed and is based on relationship to the deceased. Each
programme has had participant evaluation and has had very positive feedback.
Two consistent themes have emerged from participants. Firstly the talk at the
beginning of each session has been identified as legitimising their grief
reactions. Comments such as the talk helped me understand that what Im
feeling is normal or I dont feel Im going mad now are common.
Secondly, as mentioned above, participants report that they felt really
understood in a group with others who had had similar losses and this helped
reduce feelings of isolation.
Bereaved parents and families are offered a range of services
including the annual remembrance service, day seminars with talks and group
work, and a quarterly newsletter.
Individual and family counselling is sought by a smaller number of
clients usually in response to the bereavement out-reach service and often
following traumatic deaths.
In our bereavement pyramid education, training and research are
represented as the foundation of the service. The bereavement co-ordinator is
available to develop and deliver packages of training for specific groups
within the hospital. Within the A/E department a training programme has been
established for staff on care of the bereaved at the time of a sudden death. The
co-ordinator is also involved in organising study days, study groups and in
giving presentations which focus on the needs of the bereaved and the services
available.
80
4.

The Journey Continues
The future development of the bereavement service will be influenced

by current budgetary constraints in the Irish health care system. Our next
challenge I believe is to direct our service to those who need it most. However
the question of need is an inherently difficult concept to apply in the area of
bereavement. We are considering the possibility of more formal risk
assessment at the time of bereavement to identify those who may have more
complex needs. Another possibility is to develop further proactive approaches
to certain groups, e.g. suicide or sudden death. A major question for further
evaluation is that of the timing of interventions. For example, when is the
optimal time to offer information and invite further contact with the
bereavement service? To answer some of these questions we are now planning
an external evaluation of the bereavement service in Beaumont Hospital.
References
Anderson, R. (1974). Notes of a survivor. In S. B. Troop & W. A. Green
(Eds.), The Patient, death and the family. New York: Scribner.
Klass, D., Silverman, P. & Nickman, S. (1996). Continuing Bonds New
Understandings of Grief. Taylor & Francis.
Saleebey, D. (1997) The Strengths Perspective in Social Work. Longman, New
York.
Walter, T. (1999). On Bereavement the Culture of Grief. Open University
Press: Buckingham/Philadelphia.
The Context and Contours of Bereavement Counselling:

A comparison of two counselling services, one community based
and one in a hospice and a comparison between those who chose
counselling and those that did not.
Jeremy Weinstein
Abstract: Bereavement counselling is a growing phenomenon, at least in the
English speaking world. It is an apparent response to the increased medicalisation of
death and the disappearance of previous support systems, such as the extended
family and organised religion.
This chapter starts by exploring some of the debates about bereavement
counselling, those that criticise it for policing grief and those that see the potential
of the stranger to offer support and comfort. The chapter then looks at the existing
evidence base and focuses on two pieces of research undertaken by the author of
two London based counselling services. One a community based service where
clients self refer, the other in a hospice where counselling is offered. Both pieces of
research highlight very high levels of satisfaction and in the questionnaires and/or
individual interviews respondents reveal interesting perspectives on what worked
for them, how they engaged and how they did not. And the hospice based research
offers some unique insights into those who now regret not taking up the offer of
counselling.
The chapter hopes to increase understanding of bereavement counselling,
how its limitations can be addressed and strengths developed.
Key words: Bereavement, Counselling, Evidence base, Hospice, Community
services.
1.
Introduction
In the novel The World According to Garp the main character finds
Marriage Counsellors in the Yellow Pages while looking for Lumberyards. He is
surprised that there are more of the former than the latter. He is curious about those
who call themselves Christian counsellors, or cite their qualifications; Garp wonders
who had certified her?, or whether her Ph.D. is in marriage? Dr. O. Rothrock,
self-esteem workshop; bank cards accepted is clearly a charlatan while a simple
entry M. Neff, by appointment only, is serious; M. Neff had vision, Garp could
tell. 1
82
The Context and Contours of Bereavement Counselling
A vignette, but a telling one. It captures a moment in the eighties when

counselling was establishing itself in the marketplace and the popular imagination,
or at least the English speaking sections of the wider world so there is a cultural
specificity. And, to be even more specific, the white members of the English
speaking world for it took some time for the profession counselling to address the
dynamics and need for what has now become known as transcultural counselling.2
And there are the specialisms, the marriage counsellors of the opening quotation,
and then there are debt counsellors, genetic counsellors, student counsellors, post
traumatic stress counsellors. And a friend of mine told me of a shopping exhibition
in a big store that led to the offer of a carpet counsellor. And all the various schools
promise a degree of authority and legitimacy, thus bereavement counsellors, it can
be argued, help reflect and reinforce particular ideas about good grief, what a
proper mourning should consist of. And Garp captures also the ambivalence, the
tensions inherent in the process of an individual becoming a client, seeking out
counselling and making sense of it. And these are some of the questions I want to
explore in this paper, the context and contours of bereavement counselling, and to
do so by comparing two, London based, counselling services,. The first is a
community based service where clients self refer and the second, the second, a
hospice where counselling is offered as a matter of course.
Both pieces of research3,4 highlight very high levels of satisfaction
and, in questionnaires and/or 1-1 interviews, the respondents reveal some
interesting perspectives on what went on for them, how they engaged and how
they did not. And the hospice based research also offers some unique insights
in its exploration of the responses of those who, while offered counselling,
decided not to take up the offer and some of whom now regret that decision.
And there are gender issues here. So this paper focuses on what might be
called the good client, resistant clients and non-engaging clients. And we
need to be tentative in drawing any conclusions since both research exercises
were relatively small scale.
In the hospice research fifty individuals were approached, half of
whom had received counselling, half of whom had not. Of the 50% who
responded 10 had received counselling, 14 had not. Seven had follow-up
interviews.
In the community based research 280 ex clients were contacted. 89
(or 32%) responded and nine had follow-up interviews.
And we need to note one other limitation. Across both pieces of
research there was just one non-white respondent (an Asian man) and so there
is an unanswered question. Do those from within the black and ethnic
minorities have such support from their families, communities and cultures
that they have no need for counsellors or is counselling required and the
Jeremy Weinstein
83
existing services fail to reach out beyond the standard service user: white,
articulate, middle class?
2.
The Debates About Bereavement Counselling
So this leads us into the need, before exploring the research in more
detail, to explore outline the contested nature of bereavement counselling.
As already argued, bereavement counselling is a growing phenomenon, at least
in the English speaking world where an estimated one third of all major
bereavements are taken to professionals.5 It is suggested that the bereaved turn
to counsellors because the systems that once offered comfort have largely
disappeared, whether this is religion or the family.6 Society is also confused by
death with open acceptance of mortality forbidden7 as increasing numbers of
people die not in the community but in hospitals in a medicalised, technocratic
process.
And some are wary of this growing reliance on counsellors who,
Walter8 argues, police grief, sustaining unhelpful models of grieving when
they echo Freudian concepts that encourage the bereaved to break the bonds
with the deceased and experience and express the pain of loss. Walters
biographical model stresses instead the need for an enduring sense of the
dead, building a shared and increasing picture of the deceased through
conversations with others who knew him or her, which would normally
preclude a counsellor.
Parkes research and clinical experience values the role of counselling
and cautions that it can be misapplied with already vulnerable individuals. He
warns against blandness, against an emphasis on catharsis, lest it engenders in
already emotional and distressed individuals increased feelings of insecurity
and fosters a dependent attachment to the counsellor. Further, too cognitive a
response can prove collusive to those clients who need help to be put in touch
with their emotions. In a powerful phrase he warns that, like any drug,
counselling can be most poisonous if used in the wrong dose.9
There are also persistent problems in defining counselling. Leick and
Davidsen-Nielsen10 has a continuum from grief help, through grief therapy
to crisis intervention, the latter demanding active, professional measures in
the initial period of loss.
Parkes11 distinguishes between the counselling offered by (a) the
professional services of trained doctors, nurses, social workers and
psychologists, (b) voluntary services in which selected and trained volunteers
are supported by professionals and (c) self-help groups in which bereaved
84
people offer support to other bereaved people without the involvement of

professionals).
Edwards researched the support offered to the bereaved in seven
hospices, a palliative care team and a local branch of CRUSE and found
enormous variety. Some services are clear about differentiating between the
basic support of nurses or befrienders using counselling skills, more formal
services offered by trained counsellors and then psychotherapy offered by
more specialist and/or experienced workers. Other hospices make less
distinction about the complexity of cases.12
So in the midst of all this how can counselling be justified in terms of
its evidence base?
Cameron and Parkes (1983, cited in Stroebe and Stroebe13) compares
two groups of relatives of patients who had died on different wards of the
same hospital. On one ward nurses run an informal counselling programme
(ranging from reassurance and active listening through to referral to more
specialist help) and one year on these relatives had better health ratings,
measured in terms of physical symptoms and use of psychotropic medication,
than the relatives on the other ward who also expressed far more persistent
irritability and anger. This may have been a consequence of the better
counselling provision and/or of the generally better service on the ward as
regards adequate pain relief and anticipation of the death.
Danbury researched two sets of clients and counsellors, one attached
to a local Cruse group and the other based at a hospice, found that 53% of
respondents were entirely satisfied.14
And Parkes, for all his previous caution, concludes that while:
We should not assume that every bereaved person will need
counselling, but those who do need it seem to benefit from
opportunities to express grief, reassurances about the normality of
the psychological accompaniment of grief, and the chance to take
stock of their present life situation and to start discovering new
directions.15
Marris writes how a stranger, who understands grief in general, and
stands in an acknowledged therapeutic role, can probably give more support to
the working out of grief.16
Zinker writes of the unbearable pain of death and the crucial role of
the therapist who can stay with the process and listen, not push for outcomes,
show respect for what is there, see the usefulness and even the beauty of the
Jeremy Weinstein
85
way others express their mourning and sense of loss and allow oneself to be
the firm ground on which the other stands.17
3.
The Research On Which This Paper Draws
Returning to my own research there was a very positive response

from both projects. In the hospice all the respondents were positive, rating
most highly the qualities of being taken seriously and shown respect, being
provided with a safe atmosphere, and being helped to express their feelings
about the bereavement (all agreed by 9 of the ten). Seven agreed that
counselling had allowed them to come to a fuller and more enduring sense of
the person who died and eight agreed that they had made progress, 5, a
lot, 2 a little and 1 some progress. Two were not sure.
In the community based service 93% agreed that counselling had
been useful, focusing on the same areas of growth. The main concern was with
the length of time that it had taken to be seen with individuals reporting very
high levels of distress while waiting. Some reported how they had decided to
stop counselling because they were aware of how busy the service was rather
than because they felt fully ready.
Although counsellors are generally seen as non advice giving in the
community based project some respondents recall and value a more directive
approach. After forgetting several sessions one young woman is urged to go out
and get a diary. Another grieving daughter is advised to watch a video in which
her mother appears or to go out for a walk when pressures build up.
There is appreciation of the counsellor who seems to go that extra mile
to help, like being visited in their own homes, which makes it feel less clinical,
or recall the times when the normal hour session is stretched because the client
feels especially stressed. One client comments several times on the fact that her
counsellor is working on a voluntary basis. It is as if clients know that that their
counsellor is not a friend and values the moments when strict professional
boundaries seem pushed, but not broken.
Frank, a hospice respondent who initially thought counselling a lot
of balls shifts to an eager anticipation of the counsellors visits. He
appreciates her style, she knew exactly when to be nice with me and when to
tell me off, personal disclosure of her own family pressures and her written
reviews of their work together. Sophie found her counsellor absolutely
amazing, she came to her home, she was was straightforward, no talking
down or clichs, she gave me things back. She was also flexible, with
sessions shifting from weekly to longer stretches between meetings and
emergency sessions if there was a hiccup.
86
A. What influences individuals when considering counselling

In the community based project GPs and hospital/medical services
were the biggest source of referrals (80%) and it is interesting that several
identified the prescription of pills as the incentive to turn to counselling, I
didnt take them because Im not one for pills. I thought, no, Ive got to get
through this.
Gender: In the community based project 84% of the respondents were
women. In the hospice, where people did not have to seek out counselling, the
figures are quite different. Of the 10 male respondents and 14 women, the
majority of men, six, received counselling and a minority of the women, just 5.
And what emerges is a strong theme of self support amongst the men
as contrasted with the number of women who found support from family and
friends.
Some of the men wrote in additional explanations, for example:
Mums death was a natural event. I felt somehow I should cope on my own
I didnt know enough about counselling

I didnt want to talk to strangers
I was getting support from my family
I was getting support from friends
I was getting support from my religious beliefs
and/or religious community
The counsellor contacted me at the wrong time
Male
Female
1
1
1
1
3
6
1
1
B. Types of responses: resistant clients, regretful non-clients and those who

struggle to engage.
Interviews for the hospice research throw up some interesting
examples of respondents who now reflect back on the considerable benefits of
counselling, life changing or life saving by their accounts, but were initially
very resistant.
Stuart was urged to go by his partner, he was, possibly acting
weird. Sophie was recommended by her doctor but she was clear that I dont
like counsellors, I never have. Frank literally shouts at me: I did not believe
in it (counselling) To me, maybe Im one of the old school but counselling is
a lot of balls. Both had been put off by previous experiences of hospital
Jeremy Weinstein
87
counsellors, seen by Sophie as awful, by Frank as patronising. In the

hospice counsellor, Frank found a shoulder to support me, not a shoulder to
cry on. It also helped that the counsellor rung to offer her services just three
days after the funeral when he was in a daze and that she was coming from
the hospice about which he had such positive feelings.
There was also an interesting group of regretful non-clients. Thus 5
(1 man and 4 women) of the 13 hospice respondents who did not accept the
offer of counselling now wish that that they had. A widow comments that she
just could not face up to people because all I could do was cry and I felt
ashamed of crying because I had had such a good long married life. A son
comments that as a family we withdrew into ourselves. Bereavement
counselling was offered but we declined help. In hindsight this was a mistake.
Annes ignoring the letters offering her bereavement counselling
arose from her being defensive. At the time she felt she had managed the
death quite well, the good support from friends, both during the illness and
afterwards left her feeling she could get on with life, And this reflects her
normal pattern of coping with difficulties. I just clamp down and try to get
on.
Tania ignored several calls from the Bereavement Service: I just
wasnt ready to talk it was all too raw for me. She also cites some
wonderful friends as a reason for not needing counselling. And now she now
wishes that she had gone to a counsellor, someone who is a stranger,
somebody who wasnt involved, who wasnt just going to tell me the things I
wanted to hear. She thinks that counselling might have helped her with her
continuing feelings of bitterness and anger And maybe it wouldnt have made
any difference Im just using that as an excuse even if I had had
counselling Id still (pause) You dont know.
Malcolm refused counselling from a family sense, derived from his
mother, that this would be seen as slightly self indulgent. That it was a
weakness to need help for something that wasnt a physical injury. There was
also the thought that his mothers death was a part of the natural order of
things and I have to get used to it. The fact that the offer of counselling came
from the hospice reinforced this feeling, I wanted to get away from there and
the whole episode. And he now regards this as a mistake and believes that
counselling would have helped him think over and so be less pointlessly angry
still about various events linked to the death, such as incidents in the hospital
and the funeral. But the things I was really angry about were simply to do
with life and you couldnt, and I think I did need to say it to somebody. His
mothers death has also put him in touch with the fact that his own life is
much more fragile I dont go round frightened but its a very sobering
88
thought and suddenly I seem closer to it than I ever did before. Yet he feels
silenced with all of this sometimes continuing upset, unable to talk to his
brother, who he feels would become intensely uneasy with such disclosures
or even his wife who is more openbut again theres this slight feeling that,
after a certain point, that its self indulgent.
A third group consists of those who started the counselling process but
failed to engage fully. The following quotations come from the community based
research.
The bereavement was straightforward of a very elderly and
infirm father I felt I was wasting the counsellors time (a daughter)
I felt the atmosphere morbid talking about Death and such I
was not sure what was expected of me (a 60+ son).
I would have liked some feedback, left feeling why did I have
counselling. Needed someone to talk, not just listen. (43 year old widower).
I told the counsellor I was much better and that he did not need to
come any more. I know how busy the service is as I had to wait a while
before seeing anybody (46 year old widow).
My doctor recommended counselling but I only had a couple of
sessions. My husband was such a private person it just didnt feel right
talking about him like that, felt like a betrayal (widow).
I only had two sessions I feel that the woman could not
understand
my problems and could not answer my questions (16 year
old sister).
The counsellor was a very pleasant young lady although she
encouraged me to talk she was unable to understand how I felt This lady
could have no idea of the grief and emptiness and the coldness I felt to be
a counsellor to the bereaved one must have lost somebody they dearly love
(67 year old widow).
4.
Some Conclusions
In this paper I sought first to set the wider context, to understand what
bereavement counselling offers and to appreciate the concerns and caution of
some important commentators and researchers who regard it as a mixed
blessing. And I then turned to the respondents of two different bereavement
counselling projects. Through the words the bereaved I have sought to get
their sense of the grieving process, where and how counselling has helped,
when the bereaved seek out counselling, or refuse its offer and for some their
regrets at not having it. Its a rich and complex picture and one which we need
to understand better. If bereavement counselling is gaining ground in our
Jeremy Weinstein
89
societies it needs to be better understood. We need to address its limitations,

especially in terms of the impact of gender and ethnicity in the patterns of
uptake, and appreciate and develop its strengths so that those who do draw on
its services can experience it as a safe place and a shoulder to support me,
not a shoulder to cry on.
Notes
1. Irving, 1986, 230/231.
2. DArdenne & Mahtani, 1989.
3. Weinstein, 1997.
4. Weinstein, 2002.
5. Raphael, 1983.
6. Worden, 1991.
7. Aries, 1974.
8. Walter, 1999.
9. Parkes, 2000, 19.
10. Leick & Davidsen-Nielsen, 1991, 5.
11. Parkes, 1980.
12. Edwards, 2002, 16.
13. Stroebe & Stroebe, 1987, 230/1.
14. Danbury, 1996.
15. Parkes, 1980, 25.
16. Marris, 1974, 153.
17. Zinker, 1994, 262.
References
Aries, P. (1981), The Hour of Our Death. London: Allen Lane.
Danbury, H. (1996), Bereavement Counselling Effectiveness. Aldershot:
Avebury.
dArdenne, P. and Mahtani, A. (1989), Transcultural Counselling in Action.
London: Sage Press.
Edwards, K. (2002), Bereavement Counselling in the hospice movement,
Counselling and Psychotherapy Journal vol. 8, no. 7.
Irving, J. (1986), The World According to Garp. London: Black Swan.
Leick, N. and Davidsen-Nielsen, M. (1991), Healing Pain, Attachment, Loss
90
and Grief Therapy. London: Routledge.

Marris, P. (1974), Loss and Change. London: RKP.
Parkes, C.M. (1975), Determinants of outcomes following bereavement.
Omega, 6:303-23.
Parkes C.M. (1980), Bereavement counselling; does it work? British
Medical Journal 281:3-6
Parkes, C.M. (2000) Counselling bereaved people help or harm?
Bereavement Care Vol. 19. No. 2.
Stroebe, W. and Stroebe, M. S. (1987), Bereavement and health: The
psychological and physical consequences of partner loss. Cambridge:
Cambridge University Press.
Walter, T. (1999), On Bereavement, The Culture of Grief., Buckingham: OUP.
Weinstein, J. (1997), My Safe Place, A Report on the Work of the Havering
and Brentwood Bereavement Counselling Service. London: South Bank
University.
Weinstein, J. (2002), A Shoulder To Support Me, Not A Shoulder To Cry On:
The indicators of recovery following bereavement, the role of the Hospice,
and especially the contribution of counselling to that process. A comparative
study of two groups of the bereaved, one which has received counselling and
one which has not. London: South Bank University.
Worden, J. W. (1991), Grief Counselling and Grief Therapy, a handbook for
mental health practitioners. London: Routledge.
Zinker, J. (1994) In Search of Good Form, San Francisco: Josey Bass.
Part VI
Survivors and Protagonists
Avoid this Crowd like the Plague: Historical Responses to

Epidemic Diseases
Jennifer Hart
Abstract: Since the discovery of the Yersinia pestis bacterium in 1894 by
Alexandre Yersin historians and scientists alike have been intractable in their
view that the disease of Modern Asia and Medieval and Early Modern Europe
was the same disease. Additionally, historians have been equally adamant in
their view that European physicians were helpless to defend against the
disease. However, comparisons of the signs and symptoms reported in the
Medieval and Early Modern European plague tracts to signs and symptoms of
other diseases suggests that the disease which struck Europe may not have
been Yersinia pestis. Moreover, in re-examining the remedies prescribed by
Don Alexis of Piedmont and Nicholas Culpeper and in highlighting their more
practical and healthful remedies a more complete picture of the Early Modern
practitioners emerges. Through re-evaluation of the idea that the disease in
Medieval and Early Modern Europe was the plague and that medical
practitioners were unable to treat the disease a more complete picture of
plague and the medical community emerges.
Key Words: Plague, Yersinia pestis, Nicholas Culpeper, Don Alexis of
Piedmont, Medieval Europe, Early Modern Europe, Alexandre Yersin.
Picture this: children crying in the streets, homeless and hungry

because their parents are dead; great estates with precious jewels strewn across
bureaus; kings hiding in their castles; priests refusing to give last rites to the
dying; doctors who are afraid to administer to the sick and unable to provide
relief if they do go; bodies piling up in the streets like firewood and a stench so
strong that women and children weep because of it. The disease ran rampant
for over three hundred years and the population stood defenceless against its
assault. History has provided us with this image of the plague in medieval and
early modern Europe. Closer inspection of this plague illustrates that the
medical community was not helpless and prescribed valuable remedies for
diseases that afflicted their patients.
The identity of the plague in medieval and early modern Europe
remained a mystery until a similar disease struck Asia at the end of the
nineteenth century. It was during this epidemic that Alexandre Yersin
discovered that the illness was caused by a bacterium, later named Yersinia
94
Avoid This Crowd Like the Plague
pestis. Yersin found the bacterium by examining plague victims.1 He

determined that a rodent infected with a particular bacterium caused the
plague. Healthy fleas fed off these infected animals, and the fleas became
infected. In the fleas, the infection would block the esophagus causing the flea
to keep feeding, but disgorging the blood and the bacterium back into its host.
The host would then become infected with the disease. The host would die
from the disease and the flea would move on to another victim.2 Comparing
the signs and symptoms from the plague of the Middle Ages with the signs and
symptoms of the plague that he was studying, Yersin claimed that he had
found the source of the disease that had wreaked havoc in the Middle Ages.
Since the discovery of the bacterium by Yersin, historians have
become intractable in their belief that the two epidemics were the same
disease. Their dedication to the idea that the disease in the medieval and early
modern period was Yersinia pestis, has caused them to ignore or dismiss the
many inconsistencies between the illness of the fourteenth and fifteenth
centuries and Yersinia pestis. There are two exceptions to this obstinancy.
Both Samuel Cohn (in his controversial work The Black Death Transformed
2003) and David Herlihy (in The Black Death and the Transformation of the
West 1997), have re-examined the evidence of these two epidemics,
concluding that the there is not adequate evidence to definitively claim that
plague of the medieval Europe and modern Asia was the same disease.
Cohn and Herlihy point to several inconsistencies as the basis for
their scepticism. For example, Yersin insisted that the plague of the fourteenth
century was Yersinia pestis based upon his findings in Hong Kong. The plague
in 1894 had a noticeable increase in numbers of dying rats. According to
Francis Gasquet, one of the first historians to write about the plague in
medieval Europe, the Indians claimed when the rats began to die the people
would soon follow3. There is no comparable observation of the rat population
dying in the medieval literature.4 This inconsistency either was ignored by
most historians or dismissed saying that there was not a sufficiently noticeable
change in the rat population to warrant discussion by the chroniclers of the
time.5 This assumes that the rat population was always high. David Davis,
used bone remains to demonstrate that the rat population in England and on
the continent were not at sufficient levels to sustain the plague and that the
plague rat was not indigenous to England or Europe. 6
Still clinging to the paradigm the plague is Yersinia pestis, historians
claim that because the pneumonic form of the plague can be transferred person
to person that the rat is not as necessary as the flea. They added to this fleas
could live with the bacterium in their system for fifty to eighty days.7 The
above argument can be refuted by the fleas anatomy. The female flea is not
Jennifer Hart
95
able lay her eggs unless she has a blood meal. The Yersinia pestis bacterium
prevents the flea from digesting a blood meal. This evidence suggests that
infected female fleas would be unable to reproduce. Since Yersinia pestis was
dependant on a high rat and flea population for transmission the absence of the
black rat and the fleas anatomy would indicate that this could not be Yersinia
pestis.
Yersin also relied on signs and symptoms when identifying the
plague of medieval Europe. When looking at the plague tracts of medieval
Europe, most historians focus on those signs and symptoms which coincided
with the plague in modern Asia. In 1894, the most common and consistent
bubonic sign was the appearance of the plague buboes on the victims bodies.8
The majority of the Asian victims had these swellings in their groin, armpits,
and the neck region. Pulmonary signs included the coughing and spitting of
blood. Plague tracts in Europe, on the other hand, reported signs of the plague
which were more diverse than the plague episodes of the nineteenth century.
The physical manifestations included carbuncles, boils, and buboes that
appeared not only on the lymph nodes, as they had in Asia, but also all over
the body. The lesions varied in size with some as large as a hens egg and
some just small black dots on the skin. In addition to the skin lesions, the
plague tracts discussed other disorders including high fever and an inability eat
and drink which were not noted in the Asian cases. 9
Stephen Bradwell, a physician in the seventeen century enumerated
these signs and symptoms in his treatise, Physick for the Sicknesse Called the
Plague, published in 1638. 10 In addition to the symptoms listed above, he
noted, headache and prickling pains there, vomiting and loathing the
stomach, bleeding at the nose, lethargy or extreme drowsiness, convulsions
and cramps, dry cough, and spitting of blood.11 Bradwell also described the
plague sores, or Gods Tokens, as the most faithful sign of the plague. He
wrote that the tumours, some againe are flat broad and spreading even over
halfe the Thorax.12 According to Bradwell, the tumour could lie deep in the
flesh and the physician could only discover it by feeling for it. Some tumours
could be as big as a Nutmeg or Walnut, yea even to the size of a mans fist or
penny-loaf.13 According to this account, he had seen tumours which were
smaller and varying in shape. Twentieth century physicians usually describe
Yersinia pestis buboes as single tumours located solely on the lymph nodes
and not as multiple swellings that vary in size and location.14
At first glance, some of these symptoms seem to mirror the signs and
symptoms reported in Asia. However, the pustules in the groin, armpit and
neck, the spitting and coughing of blood, lethargy and drowsiness, are not
unique to Yersinia pestis. Diseases which present similarly to the plague
96
include cholera, typhus, trench and typhoid fevers, as well as anthrax. Each
one of these illnesses presents with skin lesions, high fever, and delirium and
have pulmonary components.15
Historians have been equally as intractable when examining the
physicians response to the plague. They have highlighted the most ineffectual
remedies such as the letting of blood, purging the intestines, wearing of
amulets, and fragrant sachets. In addition, historians have tended to focus on
the more fantastic causes posited for the plague: poisonous vapours in the air,
the movements of the stars, and punishment of a wrathful God. 16 Closer
inspection of the medical community, based on their own writings, illustrates
that there were practitioners prescribing remedies which could alleviate
against many of the symptoms of the plague or other diseases.
The university medical schools in medieval and early modern Europe
taught an amalgamation of Hippocrates, Galen, and other ancient writers.
Hippocrates writings advocated the importance of the reputation of the
physician and the ability to inspire confidence in the patient and his family.
Roger French called this process, the good story.17 To his, universities added
Galens philosophies of the body and diseases. According to Galen, an
imbalance in the humours of the body caused diseases. The strict regulation of
these humours would prevent or cure all illnesses. To alleviate a build up of
the humours, Galen advocated purifying the body by methods designed to
regulate its fluids, usually by removing excess quantities of the offending
liquid.
These philosophies taught by the universities seemed successful until
the Black Death. The plague dismantled the relationship of trust between the
physician and patient because the Galenic remedies did not work and
endangered the good story. Historians have highlighted those physicians who
admitted defeat in the face of the plague claiming that it was the work of a
wrathful God or the result of the misalignment of the stars.
When studying medical practitioners historians have focused
primarily on the trained physicians at the expense of a greater understanding of
the practice of medicine in early modern Europe. Besides the university
trained physician there were wise women, apothecaries, and barber/surgeons.
These practitioners practiced on the fringes of the medical community and/or
administered to patients who could not afford conventional medicine. By
examining these healers more closely a complete picture emerges of the
medical community in Medieval and Early Modern Europe.
Many medical professionals did not feel defenceless and published
tracts in hopes of providing their communities or all of Europe with relief from
the plague. In 1522, an anonymous author in Montpellier wrote a pamphlet he
Jennifer Hart
97
claimed was for the good of the public health.18 He began his remedies by
declaring he would root up the vines of mistrust and deceit to make room for
the growth of his ideas and his cures, which went against conventional
wisdom.19 His advice to patients afflicted with was plague was practical. For
example, he told them to break the plague sores and sear the wounds,20 which
can slow the course of the disease. His attitude was atypical because he
believed that the plague was not the work of a divine agent punishing a sinful
world nor was it caused by planetary influences. 21 Therefore, the plague had
an earthly cause and regardless of where a person lived, they were susceptible
to it.
Still grounded in the philosophies of the ancient masters, there were
physicians who freely integrated a variety of methods into their practices. Don
Alexis of Piedmont, for example, incorporated the use of medicinal herbs. A
nobleman, who in his travels learned many of the recipes published in his four
books of Secrets. He wrote in the first books introduction that he chose to
publish the recipes because he refused to help a man and who then died and
the guilt compelled him to seek new solutions.22 His first publication sold out
in a year; it went into a second printing in 1557 in almost every European
language.23 Following his book of Secrets, many other authors published
similar books.24
Don Alexis discussion of recipes designed to regulate the humours in
the body constituted only a few pages in the beginning of his text. The
majority of his recipes did not come from the extensive body of university
training but from the careful study of the countries in which he travelled. 25
They included procedures to alleviate, prevent, and cure a wide variety of
aliments, from baldness, infertility, and to the ever-present plague. One
modern historian who has examined Don Alexis work chose to highlight his
reliance on exotic ingredients which were not easily found in Europe and his
unpleasant recommendations, such as placing a plucked hen' bottom on a
plague wound, at the expense of those herbs that have properties that were
effective against the symptoms of the plague.26
Don Alexis did recommend common ingredients as plague cures,
including figs, walnuts, and garden rue. He claimed that if a person took a
concoction of those foods every morning they would be safe27 One hundred
years later, the College of Physicians in London, prescribed these same
ingredients in their remedies for the plague.28 Don Alexis and the College
prescribed not only the mixture of walnuts, figs, and rue but also garlic, St
Johns Wort, juniper berries, salt, honey, wine and vinegar.29 Modern
pharmacology has established that many of these foods can be effective in
treating the symptoms of diseases such as typhus, cholera, or anthrax.
98
Another medical practitioner who published information on herbal

remedies was Nicholas Culpeper, a seventeenth century apothecary. Like Don
Alexis, he provided recipes in his Complete Herbal Book. In addition, he
provided detailed descriptions or drawings of the plants, including what
symptoms or ailments that the herbs could relieve. Culpeper began his training
to be a physician but dropped out before he had completed it. His father
apprenticed him to an apothecary where he learned his trade. Much to the
chagrin of the medical community he researched and prescribed herbs which
grew in England calling them by their English, rather than Latin, names.30 His
books were widely popular and his book The English Physician alone went
into forty-nine printings.31 He gained a reputation as an effectual healer and
attracted thousands of patients, which suggests that these remedies worked.
In studying the properties of the fig, rue and garlic, modern herbalists
have noted that they have the same curative properties that the practitioners
recorded in the medieval and early modern remedy tracts. Today figs are
prescribed as a purgative. However, Culpeper and Don Alexis and others were
prescribing figs for both the cutaneous and pulmonary symptoms of the
plague. According to Culpeper, the juice from the fig will close and dry ulcer
wounds, such as the buboes. 32 The fig also has properties which can relieve
coughs and the other forms of pulmonary distresses, such as those presented
by the plague, typhus, and cholera. In short, medieval medical practitioners
knew the curative nature of the fig for the two main symptoms they were
fighting coughing and skin lesions33
Culpeper and Don Alexis prescribed rue for coughs, hardness of
breathing and pains in the chest.34 Historian Johannes Nohl ignored the
medicinal properties of rue and states simply that rue was used in fragrant
sachets.35 According to botanists, rue purifies water, which can alleviate
cholera, and acts as a natural decongestant.36 It has been studied for its ability
to prevent the occurrence and growth of cancerous tumours. It is most often
used as an anti-inflammatory, which can ease the most common secondary
symptoms of the plague, including headache and fever. By highlighting the
medicinal properties of these herbs, instead of their more fanciful uses, it
demonstrates that these physicians were more aware of the diseases they were
fighting and were not defenceless against it.
The modern medical community has rediscovered garlic. Modern
research has shown garlic is effective in lowering cholesterol. Most
importantly, it is powerful antibiotic.37 The blood of people who consume
garlic can kill bacterium in their blood streams. Also, vapours from garlic can
kill bacteria within twenty centimetres.38 Studies have indicated that the
Jennifer Hart
99
bacillus anthracis or anthrax is especially sensitive to garlic. In addition to

anthrax, garlic has been used to combat typhoid fever and cholera.39
It is easy to see why historians made the assumption that the early
modern medical community was not able to provide cures for the disease that
wrecked havoc in Europe. It is also easy to see that they based their
assumption on another assumption, that the Black Death was only Yersina
pestis. By throwing out these assumptions, and stepping back to study all the
pieces, a more complete picture of the medical community emerges.
Practitioners such as Don Alexis and Nicholas Culpeper produced effective
remedies against diseases despite not knowing the scientific basis for their
success. In other words, do not judge a leopard by its spots or, in this case, its
carbuncles.
Notes
1
Samuel Cohn, The Black Death Transformed: Disease and Culture

in Early Renaissance Europe. (Great Britain: Arnold, 2003), 7-9.
2
Carol Benedict, Bubonic Plague in Modern China, Modern China, 14,

2(April, 1988):109; Samuel Cohn, The Black Death Transformed: Disease and Culture
in Early Renaissance Europe. (Great Britain: Arnold, 2003), 10; Christopher J
Duncan., and Susan Scott, Biology of the Plague, Evidence from Historical Population
(United Kingdom: Cambridge University Press, 2001.), 65; Francis Gasquet, The Black
Death of 1348 and 1349. 2d ed. (New York: AMS Press, 1977.),viii; David Herlihy,
The Black Death and the Transformation of the West. ed Samuel Cohn. (Cambridge,
M.A.: Harvard University Press, 1997), 21; Philip Zeigler, The Black Death (New
York: Harper and Row, 1969), 25-27. ,
3
Francis Gasquet, Black Death of 1348 and 1349. 2d ed. (New York:
AMS Press, 1977.), viii.
4
David Herlihy, The Black Death and the Transformation of the West. ed
Samuel Cohn. (Cambridge, M.A.: Harvard University Press, 1997), 26.
5
Samuel Cohn. (Cambridge, M.A.: Harvard University Press, 1997), 26.
6
David Davis, The Scarcity of Rats and the Black Death: Ecological
Study, Journal of Interdisciplinary History 16, no 3 (Winter, 1986):464.
7
Rosemary Horrax, The Black Death: Manchester Sources Series

(New York: Manchester University Press, 1994), 7.
8
Carol Benedict, Bubonic Plague in Modern China, Modern China, 14, 2

(April, 1988): :121
9
Norman Cantor, In the Wake of the Plague: The Black Death and
the World it Made. (New York: Free Press, 2001.), 12; Francis Gasquet, The
Black Death of 1348 and 1349. 2d ed. (New York: AMS Press, 1977.),8-10;
100
Samuel Cohn. (Cambridge, M.A.: Harvard University Press, 1997),22;
Jonhannes Nols, The Black Death: A Chronicle of the Plague, trans. C.H.
Clarke. (London: Unwin Books, 1961),8-9; Philip Zeigler, The Black Death
(New York: Harper and Row, 1969),18.
10
Stephen Bradwell, Physick for the Sickness Called the Plague [London,
1636) Amsterdam: Walter J. Johnson, 1977], 42-43.
11
Ibid., 43.
12
Ibid., 44.
13
Ibid.
Centers for Disease Control, (5 December 2003).
<http://www.cdc.gov/ncidod/dvbid/plague/diagnosis.htm>.
15
Centers for Disease Control, (5 December 2003).
<http://www.bt.cdc.gov/agent/anthrax/faq/signs.asp>;
<http://www.cdc.gov/travel/diseases/rickettsial_table.htm>;
<http://www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_g.htm>.
16
see for example: Norman Cantor, In the Wake of the Plague: The
Black Death and the World it Made. (New York: Free Press, 2001.),; Francis
Gasquet, The Black Death of 1348 and 1349. 2d ed. (New York: AMS Press,
1977.); Jonhannes Nols, The Black Death: A Chronicle of the Plague, trans.
C.H. Clarke. (London: Unwin Books, 1961); Colin Platt, King Death: The
Black Death and its aftermath in late-medieval England (Toronto: University
of Toronto Press, 1997); Philip Zeigler, The Black Death (New York: Harper
and Row, 1969).
17
Roger French. Medicine Before Science, The Rational and Learned
Doctor from the Middle Ages to the Enlightenment (United Kingdom:
Cambridge University Press, 2003),2.
18
Remede Tres Utile Contre La Peste, trans. Jennifer Hart
(Montpellier: Montier de Boys, 1522) 145, 2 med (3) microfilm.
19
Ibid.
20
Ibid.
21
Remede Tres, 145, 2 med (3) microfilm.
22
Alessio Pietmontese The Secret trans William Ward [(London,
1558) Amsterdam: Walter J. Johnson Inc 1975],
14
23
William Eamon. Science and the Secrets of Nature, Books of Secrets In

Medieval and Early Modern Cultural (New Jersey: Princeton University Press, 1994),
134.
24
Eamon,161.
25
Eamon, 143.
Jennifer Hart
26
101
Eamon, 144.
27
Alessio Pietmontese The Secret trans William Ward (London,

1558) Amsterdam: Walter J. Johnson Inc 1975), fol 38.
28
College of Physicians, Certain Directions for the Plague (London, 1636)

Amsterdam: Walter J. Johnson, 1979).
29
Alessio Pietmontese The Secret trans William Ward [(London,

1558) Amsterdam: Walter J. Johnson Inc 1975], and College of Physicians,
Certain Directions for the Plague [(London, 1636) Amsterdam: Walter J.
Johnson, 1979].
30
Barbara Grigg, Green Pharmacy, A History of Herbal Medicine
(New York: Viking Press, 1981), 94.
31
Grigg, 97.
32
Nicholas Culpeper, Culpepers Complete Herbal Consisting of A

Comprehensive Description of Nearly All Herbs with their Medicinal Properties and
Directions for Compounding the Medicines Extracted from them, (Great Britain: The
Bath Press), 142.
33
James Duke Medicinal Plants of the Bible (New York: TradoMedic Books), 68.
34
Culpeper, 304.
Jonhannes Nols, The Black Death: A Chronicle of the Plague, trans. C.H.
Clarke. (London: Unwin Books, 1961), 63-64.
35
36
Duke, 140.
Judith Summer, The Natural History of Medicinal Plants (Hong
Kong: Timber Press Inc, 2000), 172.
38
The Garlic Information Center
http://www.mistral.co.uk/garlic/antibiotic.htm (5 December 2003).
39
Duke, 16; Amazing Herbs, (5 December 2003).
<http://www.amazingherbs.com/meduseofgari.html>; Medicinal Herbs
Online, (5 December 2003) <http://www.egregore.com/herbs/garlic.html>.
37
References
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(April, 1988), 107-155.
Bradwell Stephen. Physick for the Sickness called the Plague, [(London, 1636)
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Campbell, Anna M. The Black Death and Men of Learning. New York: AMS
Press, 1966.
102
Cantor, Norman. In the Wake of the Plague: The Black Death and the World it
Made. New York: Free Press, 2001.
Centers for Disease Control
<http://www.cdc.gov/ncidod/divbid/plague/diagnosis.htm> (5 December
2003).
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<http://www.bt.cdc.gov/agent/anthrax/faq/signs.asp> (5 December 2003).
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Renaissance Europe. Great Britain: Arnold, 2003.
College of Physician, Certain Directions for the Plague (London, 1636)
Amsterdam: Walter J. Jonhnson, 1979).
Culpeper, Nicholas, Culpeper Completely Herbal Consisting of
Comprehensive Description of Nearly All Herbs with Medicinal Properties
and Directions for the Compounding the Medicines Extracted for them, (Great
Britain: The Bath Press).
Davis, David. The Scarcity of Rats and the Black Death: Ecological Study,
Journal of Interdisciplinary History 16, no 3 (Winter, 1986): 455-470.
Dols, Michael W. Black Death in the Middle East. Princeton, N.J.: Princeton
University Press, 1977.
Duncan, Christopher J., and Scott, Susan. Biology of the Plague, Evidence
from Historical Populations. United Kingdom: Cambridge University Press,
2001.
Eamon, William. Science and the Secrets of Nature, Books of Secrets In
Medieval and Early Modern Cultural. New Jersey: Princeton University Press,
1994.
Jennifer Hart
103
French, Roger. Medicine Before Science, The Rational and Learned Doctor
from the Middle Ages to the Enlightenment. United Kingdom: Cambridge
Gasquet, Francis. The Black Death of 1348 and 1349. 2d ed. New York: AMS
Press, 1977.
Getz, Faye. Medicine in the English Middle Ages .Princeton, N.J.: Princeton
Griggs, Barbara, Green Pharamacy, A History of Herbal Medicine. New York:
Viking Press, 1981.
Herlihy, David. The Black Death and the Transformation of the West. ed
Samuel Cohn. Cambridge, MA: Harvard University Press, 1997.
Horrax, Rosemary. The Black Death: Manchester Sources Series. New York:
Manchester University Press, 1994.
Nols, Jonhannes. The Black Death: A Chronicle of the Plague, trans. C.H.
Clarke. London: Unwin Books, 1961.
Pelling, Margaret. The Common Lot, Sickness, Medical Occupation, and the
Urban Poor in Early Modern England. New York: Addison Wesley Longman,
1998.
Pietmontese, Alessio. Secrets. Trans. William Ward [(London, 1558)
Amsterdam: Walter J. Johnson Inc., 1975].
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Remede Tres Utlile Contre La Peste, trans Jennifer Hart. Montpellier: Montier
de Boys, 1522 145 2 med (3). Microfilm.
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Timber Press Inc., 2000.
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London: Cambridge University Press. 1979.
Ziegler, Philip. The Black Death. New York: Harper and Row, 1969.
When the Protagonist is Death: Confronting Narrative in

Trilogies of Auschwitz and Hiroshima
Karen Thornber
Abstract: Although survivors of atrocity often feel an overwhelming
responsibility to translate into words the horrors to which they were
subjected, many also recognize the propensity of language to tame atrocity
and death beyond recognition. Thus, in addition to giving graphic
depictions of the horrors they encountered, writers of atrocity often call
attention to the severe limitations and deceptiveness of the written word.
This paper explores the confrontation with the literary enterprise
in Hiroshima survivor Hara Tamiki's 1949 Natsu no hana (Summer
Flowers) and Auschwitz survivor Charlotte Delbo's 1970 Auschwitz et
apres (Auschwitz and After). I examine how Hara and Delbo struggle to
prevent the literary text from becoming a means of reifying atrocity,
discussing their challenge to prior writings of trauma, their creation of
texts that cannot be assigned to a single genre, and their refusal to present
a past that survives only in memory, to confine atrocity to a particular,
single set of moments in time. Because Delbo's is a far more blatant
challenge to literature, juxtaposing Summer Flowers and Auschwitz and
After can give us a greater understanding of and a broader perspective on
the implications of translating death into words.
Keywords: discourse on atrocity, genre, Hiroshima, Holocaust, literature
of atrocity, memory, narrative, translating death
Although survivors of atrocity often feel an overwhelming

responsibility to translate into words the horrors to which they were
subjected, many also recognize the dangers inherent in such a translation;
the same language that can help make human slaughter at least somewhat
intelligible both to themselves and to their readers also has a penchant for
taming it beyond recognition. Thus, many writers of atrocity do not adhere
to conventional literary forms, and compose conspicuously uneven texts.
In addition to describing the horrors, they often call attention to the severe
limitations of the written word, not only critiquing their literary
predecessors, but also attempting to redefine literature's role in conveying
the indescribable.
This paper explores the confrontation with the literary enterprise
in two very different trilogies of atrocity: Hiroshima survivor Hara
Tamiki's (1905-1951) Natsu no hana [Summer Flowers, 1949], composed
of "Natsu no hana" [Summer Flowers], "Haikyo kara" [From the Ruins],
and "Hametsu no jokyoku" [Prelude to Annihilation], and Auschwitz
106 Confronting Narrative in Trilogies of Auschwitz and Hiroshima

survivor Charlotte Delbo's (1913-1985) Auschwitz et aprs [Auschwitz and
After, 1970], composed of "Aucun de nous ne reviendra" [None of Us Will
Return], "Une connaissance inutile" [Useless Knowledge], and "Mesure de
nos jours" [Measure of Our Days].
The narrators of both Summer Flowers and Auschwitz and After
underline the difficulties of their task, and explicitly refer both to the
absolute necessity of bearing witness, and to the challenges facing the
writer of atrocity. Literature is not only a means of exposing violence,
brutality, and death, but also, paradoxically, can be a strikingly effective
shield against the very horrors it reveals. Thus, while inundating the reader
with graphic portrayals of brutality and destruction, Hara and Delbo also
struggle to prevent the literary text from becoming a means of reifying
atrocity, from giving the illusion that destruction of human life can be
understood.
They challenge prior writings, or attempted writings of trauma,
including their own, and demonstrate in their trilogies how insufficient, if
not deceptive, translations of atrocity and death can be. This is manifested
in their creation of texts that do not fit comfortably into a single genre,
texts that cannot be classified as diary, documentary, drama, essay, fiction,
history, journal, memoir, novel, or short story, or even as prose or poetry.
It also is manifested in their refusal to present a past that has "passed," and
a present and future where the past survives in the form of memory. The
former, by fitting the text of atrocity into the mold of a "familiar" genre,
would suggest that customary shapes are capable of harnessing the
horrors. The latter gives the horrors a more definite "beginning" and
"end," allowing the reader to be physically carried beyond the tragedy
simply by completing the text. Because Delbo goes much farther than
Hara in her open challenges to literature, juxtaposing Summer Flowers and
Auschwitz and After can give us a greater understanding of and a broader
perspective on the implications of translating death into words.
We begin with the challenges to literary predecessors. Hara
confronts both pre-war allusions to trauma and his own prior writing on
the atomic aftermath, while Delbo defies earlier French literature of
atrocity, including her own publications on the Holocaust.
In Summer Flowers, Hara reveals a growing disillusionment with
some of the literary texts with which he previously had related quite
strongly. At times his disenchantment can be inferred. As a young adult he
had been particularly fascinated by Rainer Maria Rilke's 1910
Aufzeichnungen des Malte Laurids Brigge [The Notebooks of Malte
Laurids Brigge]. At one point in this semi-autobiography, the narrator, a
lonely and depressed Danish exchange student in Paris, attempts to
describe the oppressive silence by which he is surrounded. He states he
imagines that a similar silence occurs at the moment before a high wall,
under attack by a great conflagration, collapses in a terrifying crash. In
Summer Flowers, the instant of silence has long since disappeared, the
Karen Thornber
107
walls have collapsed, and fire is raging through the city. Prior literature,
prior emotions, prior concerns, particularly the incessant concern with the
self, all have been stripped of relevance.
The rejection of past literature at times is more explicit. Early in
Summer Flowers the narrator comments that the childhood garden that
once had given him such a sense of peace now seems cold and heartless;
he states that the phrase "The Fall of the House of Usher" suddenly echoes
in his mind. Edgar Allan Poe's "The Fall of the House of Usher" (1839)
begins with the narrator looking at the melancholy House of Usher and
commenting that he is infected with a sense of insufferable gloom,
insufferable because poetic sentiment, usually serving as a filter for
images of the desolate or terrible, has lost its effectiveness. But while
Poe's narrator has the luxury of contemplating the house of Usher and
speculating as to the origins of his unnerving, Hara's narrator has no
choice but to leave the ruins of his home and escape the engulfing fires.
The melancholy of Poe's narrator has been rendered superficial, his
laments as to the powerlessness of art, here and elsewhere in "The Fall of
the House of Usher," appear foolish at best.
Summer Flowers also can be read as a rewriting, if not criticism
of Hara's own earlier accounts of the atomic aftermath, particularly his
"Genbaku hisaiji no noto" [Notes From the Atomic Destruction, 1945],
composed only days after the bombing. The notes are terse, orderly, and
concise, and as such offer a much more straightforward, easily read
account of the immediate atomic aftermath than that presented in Summer
Flowers. In the latter text, the narrator emphasizes the terrible confusion
and sense of unreality that characterized the days following the dropping
of the bomb; he features a number of individuals attempting to determine
what has befallen their city, suggesting that the "reality" of Hiroshima was
far more complex than the portrait painted in "Notes from the Atomic
Destruction."
In Auschwitz and After Delbo also reveals a growing
disillusionment with some of the literary texts with which she had
previously related quite strongly, both her own and those of others. At
times the criticism is implicit. Auschwitz and After, completed twenty-five
years after the conclusion of World War II, is in many ways a response to
earlier literature of the Holocaust, particularly that written in France in the
late 1950s and early 1960s. Echoes of Andr Schwarz-Bart's Le dernier
des justes [The Last of the Just, 1959], Piotr Rawicz's Le sang du ciel
[Blood From the Sky, 1961], and Jorge Semprun's Le grand voyage [The
Long Journey, 1963] can be found throughout Auschwitz and After, but
always with a twist, one that underscores the latter's struggle with the
aestheticism of the former. For instance, at one point in The Last of the
Just, M. Krmer is said to feel as though an octopus has settled upon his
class and is devouring them all without discrimination. In "None of Us
Will Return," the single devouring octopus has become a group of lethal

octopi not content simply to consume; these octopi are described as coiling
themselves around their victims, crushing vertebrae until they break,
squeezing the trachea, oesophagus, larynx, and pharynx to the breaking
point. Moreover, in The Last of the Just, M. Krmer is allowed to look
outside the window and somehow find hope in the first signs of spring.
The narrator of "None of Us Will Return" discovers, however, that it is not
an imaginary octopus that threatens to strangle her, but the all too physical
mud, which almost swallows her and her companions alive. Whatever
signs or chances at life once existed, long since have been engulfed.
At times the rejection of past literature is explicit. In her
"Spectres, mes compagnons" [Ghosts, My Companions], Delbo speaks of
being accompanied, on the trip to Auschwitz, by the characters of French
literature, her only remaining companions: Ondine, Phdre, Julien Sorel,
and, most importantly, Alceste, from Molire's Le misanthrope. One by
one they vanish, all but Alceste. But when the gates of Auschwitz draw
near, he too jumps off the train and disappears. Molire's misanthrope
might be disgusted by his society, but the hypocrisy he decries has not
prepared him for the reality of the death camps. Stripped of meaning,
prior art is reduced to a series of words that the prisoners can memorize.
The narrator tells us that she trades her bread ration for a copy of Le
misanthrope; memorizing this text, far from allowing her to seek refuge in
a fictional world, will prevent the complete decay of her memory,
necessary if she is later to transcribe even a fraction of what she has
witnessed.
Auschwitz and After is also Delbo's response to her own earlier
writing on atrocity. For instance, in her 1965 work Le convoi du 24 janvier
[The Convoy of January 24] she gives a relatively "objective" and
"straightforward" rendering of events; this text opens on the morning of
January 24, 1943, and concludes with liberation. What a sharp contrast
with the extreme labyrinth that is Auschwitz and After, which goes to great
lengths to deny the closure imposed on The Convoy of January 24.
Moreover, Auschwitz and After often elaborates upon the brief sketches of
events found in the earlier narrative, giving a fuller picture of the horrors
to which the narrator and her companions were subjected. For instance,
both narratives offer descriptions of "races" through camp. In The Convoy
of January 24, Delbo speaks of the race rather objectively, opening her
discussion with the time and the temperature, and then providing the
reader with an outline of what transpired. But what is glossed in this text both the absurdity of the race and the horrors of its aftermath - become the
focus of the discussions in "None of Us Will Return."
While critiquing their predecessors, Hara and Delbo also attempt
to overturn more fundamental aspects of the literary enterprise: the notion
that there is a language, and a genre for every subject, and that the past has
passed, regardless of how strongly it impacts the present. Both responses
to their creators' more "historical" accounts of atrocity and death, Summer
Karen Thornber
109
Flowers and Auschwitz and After resist classification in a particular genre;

they are intriguing mixtures of "fact" and "fiction," of diary, essay,
memoir, and novel, of prose and poetry. Intermingling various genres,
particularly poetry and prose, is a very effective way of calling attention to
the ambivalent position of the written word when confronted with mass
slaughter and death.
The narrator of Summer Flowers, although having created a text
written almost entirely in prose, underlines the impotency of both poetry
and prose when faced with destruction of such magnitude. Auschwitz and
After, however, is a swirling mixture of poetry and prose, one that refuses
to be identified as either.
The narrator of Summer Flowers includes two poems, the first of
which demonstrates the impossibility of employing poetry to translate
destruction, and the second of which undermines his "prose" project. The
trilogy opens with a poem reminiscent of Hara's pre-war compositions,
one that calls on his loved ones to frolic like the deer in the mountains.
However, the narrator moves quickly from a nostalgic bucolic dreamworld
to the memory of his dead wife, remarking in the first line of the narrative
proper that he went out to buy flowers for his wife's grave. The fragrant
mountain flowers of the opening verse, pure and reminiscent of childhood,
have become memorial flowers, the smells of which are overpowered by
incense for the dead. The narrator comments that the incense clings to his
pocket that day, and the next; it was on the third day, he says, that the
atomic bomb fell. Poetry, abandoned after a single verse, cannot describe
the visit to the grave, much less the destruction of Hiroshima. Prose,
however, fares no better.
Early in his trilogy, in the middle of a discussion the narrator is
speaking of overturned streetcars, uprooted trees, scattered gravestones,
and the stench of death that permeates the road, when he suddenly states
that katakana, an alphabet used in Japanese for the transcription of loan
words, would allow him to better capture his impressions. Yet not only
does he switch to katakana, emphasizing the "foreign" nature of the events
discussed, he also switches to poetry. In his prose he had likened the
disaster to art, stating that the jumble of wires and limbs was a spastic
design, and that seeing the charred streetcars and horses with swollen
bellies made him think of a surrealist painting. Yet in his poem he asks
whether what he writes is really what there is: human corpses burned red,
smouldering electric wires. The prose that allowed him to tie images
together into a "painting" or "design" falls apart. But poetry hardly
provides him with the needed remedy. After this brief poem the narrator
returns to prose, where he will remain until the conclusion of the text. In
turning to poetry at a time of crisis, Hara follows in the footsteps of
countless pre-modern Japanese writers, whose prose texts are filled with
poetry, written most often at periods of heightened emotion, to articulate
what they believe cannot be expressed adequately in prose. But while

poetry served these writers well, it clearly does not offer Hara's narrator
much consolation.
While Hara suggests that poetry and prose are both ineffectual,
Summer Flowers is clearly a prose text, albeit one that incorporates
numerous genres. Delbo, however, takes the mixing of genres, particularly
poetry and prose, to an extreme. Auschwitz and After begins with prose
poetry, concludes with poetry, and is composed of an intriguing mixture of
prose and poetry. The narrator plays with our notions of genre from the
very beginning of the text. The first section, "Arrivals, Departures," with
its reliance on repetition and broken lines, reads something like a prose
poem. It is followed by two poems, the second of which relies on similar
repetition. These poems are followed by three more of a very different
nature. And these are followed in turn by a section entitled simply
"Dialogue," which reads something like a script for a performance on
stage. Delbo's poems often read like sentences chopped into lines, and her
prose often reads with the rhythm usually associated with poetry.
Auschwitz and After goes out of its way to reject its own classification, in
order that it also might reject the classification of the tragedy that is the
reason for its existence.
Even more striking is the way in which Summer Flowers, and
particularly Auschwitz and After, refuse to let the literary text articulate a
past that has "passed," alluding at once to the tenacious grip the past holds
on survivors of trauma, and the very real possibility that there will be
another, perhaps even more horrific, time in our future. "Summer
Flowers" covers 4 August to September 1945, "From the Ruins" from 8
August to December 1945, and "Prelude to Annihilation" from early in the
year to 4 August 1945.
"From the Ruins" thus retraces much of the territory explored in
"Summer Flowers." Moreover, returning to the days before the bombing in
the final section of the trilogy, bringing Summer Flowers to a close on the
same day it opens (two days before the bombing of Hiroshima), Hara
strips the disaster of a definite "beginning" and "end." The narrator
concludes "From the Ruins" with stories of continued searches for friends
and relatives. The opening scene of the following section features a
nameless traveller on a snowy bridge, whose relished memories of the
distant past suddenly are interrupted by a vision of the world coming to a
terrible end. Having just been taken through the days, weeks, and months
after the bombing, the reader assumes this man on the bridge to be haunted
by memories of Hiroshima; the rain of the concluding paragraphs of
"From the Ruins" would seem to have congealed into the snow of "Prelude
to Annihilation," as fall turns to winter. But we soon learn that the
traveller actually is foreseeing the dropping of the atomic bomb, as will
many other characters in this, the final section of the trilogy.
Concluding his text with the comment that more than forty hours remain
before the dropping of the atomic bomb, Hara underlines the cyclical
Karen Thornber
111
patterns of history. Thus, although memories play a very important role in

this text: memories of childhood and other relatively "innocent" times, in
addition to memories of the immediate atomic aftermath, the structure of
the text prevents the past from living solely in memory.
Delbo goes even further in her rejections of a narrative that would
see time as a linear progression from past, to present, to future. Her text
moves back and forth, from year to year, and between decades, with
remarkable alacrity. No dates are given in the first part of the trilogy,
where deportation and arrival are referred to repeatedly. The first date can
be found in "A Useless Knowledge," with a reference to "the summer of
1942," followed immediately by a newspaper clipping dated August 4,
1960. Although most of the experiences described in "The Measure of
Our Days" take place in the years following liberation, together they form
yet another labyrinth. We are taken from liberation to the present, back to
liberation, only to return to the present, again and again. In one sense,
Auschwitz and After does move chronologically, taking the reader from a
love destined to be destroyed (that between Delbo and her husband), to
imprisonment, to arrival, to liberation from Auschwitz, to final liberation
from the camps and beyond. It begins with a discussion of the railroad
station, contains flashbacks to life before the death camps, and concludes
with the narrator's warning for the future. But the twists and turns both
within and between sections call into question the notion of temporal
progression that forms the basis of most narrative.
The whirlpools of time in Auschwitz and After are greater in
number than those in Summer Flowers, swirling ferociously in paragraph
after paragraph, in subsection after subsection. Yet both texts struggle
against the temptation to confine atrocity to a particular, single set of
moments in time. Not only does the circular motion of these narratives
allude to the inextricable grip the past maintains on victims of trauma, who
are forced to relive it constantly in their memories and dreams, but also
serves as a powerful admonition to those who would convince themselves
that there will be no repetition of atrocity, that the greatest horrors are in
the past, not in the future.
Discourse on atrocity and death places unparalleled demands on
the reader. But often it also can provide us with a sense of security. After
all, do we not turn to such texts - presenting as they do death held between
the covers of a book, presented in a familiar form, written in language we
understand, and thus in a certain sense under control - just as much to
learn about what "happened" as to attain some grasp over what we have
heard has "happened?" Narratives of atrocity and death confirm that the
previously unimaginable can and does happen, at the same time that they
can suggest, by their very confirmation of extremes, that human
consciousness can harness the unimaginable. Summer Flowers concludes
with evocations of a warm sun and tranquil sky hanging over crape myrtle,
the narrator telling us that over forty hours separate us from the dropping

of the atomic bomb; Auschwitz and After concludes with evocations of
dawn, albeit one stained with blood. The imagination need not leap far to
stop the clock under that warm and tranquil sun, or see in the reddened sky
only a beautiful sunrise, although one of a slightly different hue than that
to which it has become accustomed. It has done so, many times before.
But bringing to us the freshness, the wetness of the blood, forever making
it new, the narrators of Summer Flowers and Auschwitz and After attempt
to deny us this transformation and the relative comfort that can ensue.
Literature, and the reader can never, must never be the same. As Delbo
would stress throughout her life: "Il faut donner voir," they must be
made to see, to see not only evil, violence, and death, but also all that
would prevent them from seeing the horror of these unfinished times.
Part VII
Palliative Care and Hospice Organization
A Rose By Any Other Name - The Palliative

Care/Euthanasia Continuum
Kay Mitchell, PhD
Abstract: Interpretative repertoires are employed in end of life care that
addresses the suffering of terminally ill patients. Hospice care,
palliative care, double effect or terminal sedation are terms which
have come to be associated with particular ways of dying in a culture that
is philosophically opposed to physician-assisted death. The principle of
double effect has long been recognised in medicine as a defence when
death is the outcome of actions taken to address pain and suffering so long
as the intent was not to cause the death. However foreseeing death as a
consequence of such actions may produce cognitive dissonance.
When a person engages in an activity that produces an
inconsistency between action taken and a belief system (in this case a
commitment to saving life and engaging in activities that hasten death),
the resulting dissonance can become so unpleasant that steps may be taken
to achieve consonance. It is argued that certain accepted repertoires of
meaning associated with end of life care have been made available to
practitioners. By employing these they may represent some medical
decisions that hasten death, even when death is the intended outcome, in a
way that renders them acceptable practice and different from
physician-assisted death or euthanasia. This preserves consonance
between a belief in a duty to save life and action taken that ends life.
Keywords: interpretative repertoires, cognitive dissonance, palliative care,
euthanasia, hospice, physician-assisted suicide.
1.
Interpretative Repertoires of Meaning in End of Life Care
The role of language in constructing the worlds within which we

live has long been recognised among critical commentators - see for
instance the work of Derrida and social constructionism. Potter and
Wetherall1 proposed the concept of the interpretative repertoire:
Interpretative repertoires are recurrently used systems
of terms used for characterizing and evaluating actions,
events and other phenomena. A repertoire is
constituted through a limited range of terms used in
particular stylistic and grammatical constructions. Often
a repertoire will be organized around specific
metaphors and figures of speech (tropes).2
116
The Palliative Care/Euthanasia Continuum
Such repertoires may be adopted or even authored by specific

social groups (such as hospice or palliative care workers) but are not
exclusive to any social group.3 Thus the repertoires are available to be
widely used when accounts are being constructed related to any situation
or by any person. Interpretative repertoires are represented as a "tool-kit of
resources for people to use for their own purposes."4 Inherent in this is the
concept of those who use these repertoires constructing an account that
warrants a version of events that is both socially and personally
acceptable. 5
Specific terms are used to signify certain actions that are
undertaken in the care of the dying patient. "Palliative care" is an umbrella
term to cover many treatment options/actions that are aimed to provide
comfort but not cure, to the patient. Inherent but unspoken within these
terms is the understanding that some actions may hasten death. Within
palliative care, "hospice care" is understood to relate to the care of the
dying, and the delivery of palliative care. Such care may include specific
actions such as removing a feeding tube from a comatose patient, and
inherent in this is the understanding that the patient will die by
dehydration. Similarly, "terminal sedation" refers to the sedation of the
patient until they die in response to intractable suffering. Inherent within
this term is the understanding that food and fluids will not be provided to
the patient. Such actions are defended under the principal of "double
effect", a term referring to actions taken with the primary intention of
preventing harm (addressing suffering), with a secondary effect of harm
(death of the patient). Medicine has long used the term "double effect" in
defence of actions taken that may hasten the death of the patient. Thus the
field of terminal care has available a repertoire of terms to cover, in every
sense of that word, actions that may hasten or even cause death, whether
or not that is the primary intention.
Moral distinctions between end of life care practices that hasten
death intentionally or unintentionally "are critical to some but relatively
inconsequential to others"6 and are informed by the cultural and social
context within which such distinctions are made. Terms that relate to the
intentional ending of a patient's life are "physician-assisted suicide" and
"euthanasia." There are international differences in the qualification of
these terms. In Oregon "physician-assisted suicide" has been legalised
under specific guidelines, and inherent in the term is the understanding
that the physicians may supply drugs and information to end life, but not
involve themselves physically in the administration of the drugs.7 In the
Netherlands, where euthanasia has been legalised, "physician-assisted
suicide" and "euthanasia" are both regarded as "euthanasia"
(administration of a lethal drug by a physician) for procedural and legal
purposes.8,9
Thus there are available in end of life care, a wide variety of
terms signifying "palliative" actions that address suffering but may hasten
Kay Mitchell, Ph.D.
117
or cause death. Similarly, there are terms signifying actions specifically

taken to cause the death of the patient as a response to intractable
suffering.
2.
Dissonance Theory
Festinger, who first proposed the theory of cognitive dissonance

suggests that "reduction of dissonance is a basic process in humans (and) it
is not surprising that its manifestations may be observed in a wide
variety of contexts."10 The theory proposes that cognitive dissonance
occurs when a person engages in an activity that produces an
inconsistency among the elements involved in that activity - what
Festinger calls the "nonfitting relations among cognitions" - these
elements consisting of beliefs, attitudes or feelings.11 The resulting
dissonance can become so unpleasant that it provides a motivation to
engage in dissonance reduction activities to achieve consonance. The
motivation to reduce dissonance will be a function of the magnitude of the
dissonance. The greater the magnitude of the dissonance, the greater the
motivation to address this. Moreover, Festinger proposes that the
magnitude of the dissonance between elements will be a function of the
importance of the elements. The element most resistant to change is the
point where most of the cognitive work is done. The magnitude of the
element most resistant to change12 increases as dissonant cognitions are
increased. Conversely, the magnitude of the element most resistant to
change decreases as the number of consonant cognitions increases.13
The magnitude and foreseeability of harm from actions was
implicated in dissonance arousal. When harm occurring was perceived as
large (and hastening the death of a patient could be thus perceived) and
foreseen (stopping food and fluids can have only one foreseeable
outcome), then dissonance increases.14,15 There are three categories into
which we can divide the consequences of our actions; foreseen,
foreseeable and unforeseen consequences and evidence suggests that
dissonance occurs when consequences are harmful from both foreseen and
foreseeable acts.16 Thus a doctor may invoke the principle of double effect
as an authority when a hastening death decision is considered, but the very
fact that the hastened death is a foreseeable outcome may be sufficient to
produce feelings of dissonance in some doctors.
Wide research in dissonance theory produced evidence of a link
between dissonance phenomena and moral reasoning17 or self-perception where subjects made rational inferences from the data available to explain
why they acted the way they did.18,19 However Sabini concludes when
considering the debate between self-perception and dissonance theorists
that the evidence suggests that: (1) the circumstances that produce
dissonance do produce some drive state (arousal), and (2) this drive state
118
doesn't directly produce the attitude change involved in dissonance; rather,

it serves as a cue Apparently finding ourselves aroused is a hint that we
have done something wrong. This cue, combined with a knowledge of our
own behaviour and a knowledge of our own initial attitudes (perhaps
known by generalization as Bem suggests), is enough to lead us to distort
our views. On the whole then, this evidence supports the dissonance view
rather than Bem's self-perception interpretation.20
Sabini suggests that a partition has occurred between the
conflicting theories of self-perception and dissonance.
The conflict between dissonance theory and selfperception theory has given way to a truce, in which
the domain of attitude change has been partitioned
into the territory of dissonance theory, when
behaviour flies in the face of attitudes, and the
territory of self-perception theory, when attitudes and
behaviour are in closer approximation.21
3.
Dissonance and Dying Decisions
When a physician is faced with suffering for which there seems

to be no relief, and a request for euthanasia is considered, the elements
producing dissonance could include the desire or perceived duty to reduce
suffering and the desire or perceived duty to protect the sanctity of life.
These are both important elements, and when one can only apparently be
achieved by sacrificing the other, the cognitive work to be done to achieve
consonance would place this decision-making in the territory of
dissonance theory, using Sabinis analogy. If the only perceived way of
reducing suffering was to agree to perform euthanasia (action), this would
run counter to the important element of protecting the sanctity of life
(belief). In order to reduce the resultant dissonance and achieve
consonance, one of the elements would have to be changed in some way to
bring it into line with the other. Either the euthanasia (action) will not be
performed which will achieve consonance with the belief in the sanctity of
life, or euthanasia will be performed but the belief in the sanctity of life
will be changed. In this context the belief could be reformatted to question
whether sanctity of life refers to "life" reduced to vitalism, or whether
"life" in this context might refer to say, an existence of value to the
patient. If the life is of no value to the patient and the patient has requested
for it to be ended, then the sanctity of life ethic (belief) as applied to that
particular life may be altered (other elements added to it) so that it
becomes less compelling. Thus consonance is achieved by altering one of
the elements to bring this into line with the action proposed.
Kay Mitchell, Ph.D.
119
The compassionate first-hand account of a doctor from Oregon

who had assisted the suicide of one of his patients indicates such a
psychological process. 22 He indicated he had voted against the adoption of
Oregons Death with Dignity Act. Several times in the account the author
states that he lost his composure as he and the patient negotiated the
suicide process over time. Months after the experience he reported that he
was now more settled and comfortable with (his) role in her suicide" and
more confident that he had made the correct decision for her.23 He wrote
that he had redefined intolerable suffering, his patient had the right to
choose and the emotional turmoil he recalled at the time of the suicide
was due to his unfamiliarity with such an action.24 Finally he invoked the
disruption to (his) emotional stability that this experience precipitated as
a marker of the extreme decision and an indication of the difficulty for
physicians who struggle with the solutions to active roles in aiding
patients in accomplishing their deaths.25
Some doctors question whether hastening death actions that are
sanctioned under palliative care are in fact different from euthanasia. They
questioned why it is ethically or morally correct to engage in some actions
to reduce the suffering of patients, knowing that those actions will bring
about the death of the patient, and yet not others.26 Others invoke the
principle of double effect and strongly argue that palliative actions that
hasten/cause death and "euthanasia" are not the same.27 And yet there can
be only one outcome from withdrawing hydration from a patient, and the
resulting death is just as foreseeable as death from a lethal infusion.
Physicians who do not subscribe to the principle of double effect as a
warranting agent may see little moral difference between hastening the
death of the patient through terminal sedation, removing food and fluids or
euthanasia. Similarly as has been argued, a doctor may invoke the
principle of double effect as an authority when a hastening death decision
is considered but the very fact that the hastened death is a foreseeable
outcome may be sufficient to produce feelings of dissonance.
Festinger proposed that "if a cognitive element that is responsive
to reality is to be changed without changing the corresponding reality,
some means of ignoring or counteracting the real situation must be
used."28 In this case, the "cognitive element responsive to reality"
(foreseeing death and death being hastened) may be altered by
"counteracting the real situation" (portraying the action as something other
than euthanasia/killing the patient). There is a strong motivating factor
present; to reduce the suffering of the patient. Equally there is strong
motivation to preserve the sanctity of life. In order to be able to address
the suffering by a death hastening action the action may be signified by
one of the metaphors in the interpretative repertoire available under the
palliative care umbrella and a philosophical principle, double effect,
invoked as the legitimising agent for the death hastening action.
120
4.

Dissonance as an Agent for Social Change
Festinger expands his theory to include a wider group becoming

involved in a process that serves to install and maintain the dissonance
reducing mechanism in society. Those who use such actions to address the
suffering of the patient can invoke the warrant of palliative care (as has
been discussed previously) because the hospice movement has embraced
the concept of double effect as part of the way they may address the
suffering of the dying patient. Thus there are a large group of like-minded
individuals under the auspices of the hospice movement who provide
authorisation for some hastening death actions over others.
Usually for this* to occur the person would have to be
able to find others who would agree with and support
this new opinion. In general, establishing a social
reality by gaining the agreement and support of other
people is one of the major ways in which a cognition
can be changed when the pressures to change it are
present. It can readily be seen that where such social
support is necessary, the presence of dissonance and the
consequent pressures to change some cognitive element
will lead to a variety of social processes.29
*change a cognitive element although the reality
remains the same
The ability of modern medicine to keep people alive for longer,
thus increasing the incidence of cancer and other painful diseases in the
elderly has lead to prolonged and often painful dying experiences. The
need to address the suffering of this population was, in part, what drove
the formation of the modern hospice movement and the development of
the relatively new discipline of palliative care. Included in this was the
adoption of certain philosophical principles, such as the principle of
double effect, which enabled practitioners to meet their goals of reducing
suffering, even at the expense of hastening the death of the patient.
Identical dissonance in a large number of people may
be created when an event occurs which is so
compelling as to produce a uniform reaction in
everyone. For example, an event may occur which
unequivocally invalidates some widely held belief.30
In this case, the perceived suffering of dying patients was
universally agreed to be inhumane and unacceptable. The "widely held
belief" in the sanctity of life came under threat when the only way of
addressing suffering seemed to be by increasing drugs to the point where
Kay Mitchell, Ph.D.
121
the death of the patient was hastened. The principle of double effect has
long been invoked in medicine and is recognised as an acceptable ethical
principle.31 However, it could also be recognised as a psychological
mechanism employed as a way of addressing the resultant dissonance
between engaging in death hastening actions and a prohibition on killing
the patient,32 an action that hospice philosophy has traditionally eschewed.
Thus the "real situation" (hastened death) was "counteracted" as Festinger
proposes, by representing this as a secondary consequence to the primary
intent of reducing pain. The inception of a "movement" that addressed
suffering in this way incorporated those who subscribed to this
philosophical principle and provided "social support" for this approach to
the problem of terminal suffering.
The existence of dissonance will lead to seeking out
others who already agree with a cognition that one
wants to establish or maintain and will also lead to the
initiation of communication and influence processes
in an effort to obtain more social support In
situations where many persons who associate with
one another all suffer from the identical dissonance,
dissonance reduction by obtaining social support is
very easy to accomplish33.
Long before the modern hospice movement was developed, and
the discipline of palliative care was refined to its present level, the
Netherlands used euthanasia as a way of addressing the suffering of dying
patients. In the same way that New Zealand and other countries may
arguably have addressed and rationalised treatment that hastens death as a
way of addressing the suffering of some dying patients by invoking the
principle of double effect, the Dutch may have rationalised their adoption
of euthanasia policies. The dissonance experienced between seeing
intractable suffering and feeling helpless to control this in any way other
than killing the patient, was resolved by invoking the defence of
"overmacht"34 as a warrant for an action that elsewhere would be called
murder. In this way "overmacht" may have been adopted by the Dutch as
part of the interpretative repertoire surrounding their particular end of life
care practices.
The important psychological variables are not personal attributes
as such but the limitations on individuals' systems for making sense of
themselves and their environment: the limitations, in other words, inherent
in the ideologies to which people have access.35
122
5.

Conclusion
Cognitive dissonance theory provides one possible perspective on

the adoption of hastening death practices by doctors who are committed to
the sanctity of life ethic, both professionally and personally. Authoring
and adopting interpretative repertoires around end of life care may be one
way that those who subscribe to hospice as a philosophy in terminal care
have "initiated communication" and influenced "processes" to obtain
social support, as Festinger proposes. A perceived need to reduce the
suffering of dying patients may operate in tension with a requirement to
preserve and maintain life, when the only available means of reducing
suffering is by hastening the death of the patient. In order to achieve a
psychologically acceptable outcome for the physician, the hastening death
action must be represented in a way that is consonant with the physician's
belief system. This allows the physician to proceed to address the
suffering of the patient in the best way known, even if this is only
achieved by hastening the death of the patient.
Palliative care, initially under the auspices of the hospice
movement, has provided a compassionate alternative to the care of the
dying patient by using the principle of "double effect" to justify medical
actions that may hasten, or cause the death of the patient, in response to
suffering. Those who do not believe it is in society's best interests to
legalise euthanasia or physician-assisted suicide are likely to endorse this
compassionate alternative. In fact it has been argued that such "clinicians
need a rule of double effect."36 Thus hospice both informs society by
offering alternatives to the legalisation of euthanasia and is strengthened
by those thus informed who join the ranks of those who oppose euthanasia
as unnecessary given the palliative alternatives.37 It is suggested that "the
most interesting discourses are those which are implicated in some way
with the structure of institutions."38
Notes
1. Potter & Wetherell, 1987
2. Ibid, p. 149.
3. Burr, 1995
4. Ibid, p. 119.
5. Ibid
6. Quill et al., 2000, p. 488
7. Oregon Health Division
8. Griffiths et al. 1998
9. Wherever physician assisted death has been legalised, this is
only available on patient request.
10. Festinger, 1957, p. 4.
Kay Mitchell, Ph.D.
123
11. Ibid, p. 3.
12. A later emphasis on commitment as a prerequisite to change
was argued to be "encompassed by the idea of resistance to
change". Wicklund & Brehm, 1976, p. 315.
13. Festinger, 1957
14. Nel, Helmreich, & Aronson, 1969;
15. Scher & Cooper, 1989
16. Goethals, Cooper, & Naficy, 1979
17. Cooper & Fazio, 1984, p. 261
18. Bem, 1967
19. Aronson, 1969, p. 27.
20. Sabini, 1995, p. 549.
21. Sabini, 1995, p. 553.
22. Kade, 2000
23. Ibid, p. 506.
24. Ibid, p. 506.
25. Ibid, p. 506.
26. Billings & Block, 1996
27. Mount, 1996
28. Festinger, 1957, p. 21.
29. Ibid, p. 21.
30. Ibid, p. 262.
31. Sulmasy, 1999
32. Loewy, 2001
33. Festinger, 1957, p. 265.
34. Under Dutch law this is a defence for euthanasia - (the result
of a force it is reasonable not to resist) Griffiths et al., 1998, p. 99.
35. Wetherell et al., 1987, p. 69
36. Sulmasy, 1999, p. 549.
37. Ibid.
38. Parker, 1992, p. 17.
References
Aronson, E. (Ed.). (1969). The theory of cognitive dissonance: A current
perspective (1st ed. Vol. 4). New York: Academic Press.
Bem, D. J. (1967). Self-perception: an alternative interpretation of
cognitive dissonance phenomena. Psychological Review, 74, 183-200.
Billings, J. A., & Block, S. D. (1996). Slow euthanasia. Journal of
Palliative Care, 12(4), 21-30.
Burr, V. (1995). An introduction to social constructionism. London:
Routledge.
124
Cooper, J., & Fazio, R. H. (1984). A new look at dissonance theory.

Advances in experimental social psychology, 17, 229-266.
Festinger, L. (1957). A theory of cognitive dissonance. Evanston, Ill: Row
Peterson.
Goethals, G. R., Cooper, J., & Naficy, A. (1979). Role of foreseen,
foreseeable and unforeseeable behavioral consequences in the arousal of
cognitive dissonance. Journal of Personality and Social Psychology, 37,
1179-1185.
Griffiths, J., Bood, A., & Weyers, H. (1998). Euthanasia & Law in the
Netherlands. Amsterdam: Amsterdam University Press.
Kade, W. J. (2000). Death with dignity: A case study. Annals of Internal
Medicine, 132(6), 504-506.
Loewy, E. H. (2001). Terminal sedation, self-starvation, and orchestrating
the end of life. Archives of Internal Medicine, 161, 329-332.
Mount, B. (1996). Morphine drips, terminal sedation, and slow euthanasia:
definitions and facts, not anecdotes. Journal of Palliative Care, 12(4), 3137.
Nel, E., Helmreich, R., & Aronson, R. (1969). Opinion change in the
advocate as a function of the persuasibility of his audience: A clarification
of the meaning of dissonance. Journal of Personality and Social
Psychology, 12, 117-124.
Oregon Health Division. (1997). Oregon's death with dignity act.
Retrieved
12
February,
2001,
available
from
<http://www.ohd.hr.state.or.us/chs/pas/pas.htm>.
Parker, I. (1992). Discourse dynamics: Critical analysis for social and
individual psychology. London & New York: Routledge.
Potter, J., & Wetherell, M. (1987). Discourse and social psychology:
Beyond attitudes and behaviour. London: Sage Publications.
Quill, T. E., Lee, B. C., & Nunn, S. (2000). Palliative treatments of last
resort: Choosing the least harmful alternative. Annals of Internal
Medicine, 132, 488-493.
Sabini, J. (1995). Social psychology (2nd ed.). New York: W W Norton &
Company Inc.
Kay Mitchell, Ph.D.
125
Scher, S. J., & Cooper, J. (1989). Motivational basis of dissonance: The

singular role of behavioral consequences. Journal of Personality and
Social Psychology, 56, 899-906.
Sulmasy, D. (1999). The rule of double effect. Archives of Internal
Medicine, 159, 545-549.
Wetherell, M., Stiven, H., & Potter, J. (1987). Unequal egalitarianism: A
preliminary study of discourses concerning gender and employment
opportunities. British Journal of Social Psychology, 26, 59-71.
Wicklund, R. A., & Brehm, J. W. (1976). Perspectives on cognitive
dissonance. New Jersey: Lawrence Erlbaum Associates.
Cultural Interpretations of Delirium Symptoms in the

Terminally Ill: A Barrier to Psychiatric Evaluation and
Management
Antonio C. Sison, MD
Abstract: Delirium is often one of the disruptive complications seen in the
terminally ill. Symptoms of Delirium include disruption in the sleeping
patterns, disruptive and combative behaviours and the presence of visual and
auditory hallucinations. In the private hospital setting, the presence of delirium
indicates psychiatric evaluation for the control of the symptoms. Consent from
the family members is necessary prior to any referral. Oncologists report that
when the patients report seeing dead relatives or would hear long dead family
members calling for the patients, the family members interpret this
phenomenon as the long deceased relatives coming to get the patientin other
words this signals the impending or near death experience. The family
members do not feel the need for psychiatric evaluation. This is often the case
when the patient has predominant visual and auditory hallucinations with
minimal disruptive behaviors. Consent for psychiatric evaluation is given for
severe delirium symptoms.
Key words: Delirium, Terminal Illness, Psychiatric Evaluation
Delirium is often one of the disruptive complications seen in

terminally ill hospitalised cancer patients. Delirium includes a wide range of
symptoms including disruption in the sleeping patterns, disruptive and
combative behaviours and the presence of visual and auditory hallucinations.
Additionally, the symptoms of delirium may occur episodically anytime. The
severity of delirium may range from mild delirium symptoms, which do not
cause any major disruption to the patients family and hospital staff, to severe
delirium symptoms, which may result in serious injuries to the patient and staff.
In the private hospital setting, the detection of delirium symptoms by
the primary physician would often recommend psychiatric evaluation for the
evaluation and control of delirium symptoms. Consent from the family
members is necessary prior to any referral.
Oncologists report that when the patients delirium symptoms consist
of visual and/or auditory hallucinations of long deceased loved ones (especially
the mother) the family members interpret this phenomenon as the long
deceased relatives coming to get the patient - in other words this signals the
impending or near death experience. This is consistent with the cultural beliefs
that when a person is near death, the deceased loved ones will be coming to
fetch the person and bring him or her to heaven.
128
Cultural Interpretations of Delirium Symptoms
In this cultural context the family members interpret the mild delirium
symptoms of auditory and visual hallucinations as signals that the dead
relatives are gathering around the patient who may be near death. This
interpretation cues the family members that the patients medical condition is
crucial and is near death. One oncologist had noted that when the patient is
young, the family members often tell the patient not to join the deceased
relatives, while if the patient is aged, they would tell the patients to accept to
join the deceased loved ones. With this cultural interpretation of mild delirium
symptoms and minimal disruptive episodes, family members do not recognize
the need for psychiatric referral.
One possible function of the cultural interpretation of mild delirium
symptoms, is the facilitation of the family members acceptance of the
possibility of death of the patient.
PATIENT
FAMILY
PHYSICIAN
PSYCHIATRIST
Mild
Normal
Does not detect
Symptoms_____ Cultural_______ Delirium_______ No referral
|
Interpretation
|
|
|
|
|
|
|
Refuse _______ Detect ________ No referral
|
Psychiatric
Delirium
|
|
Referral
|
|
|
|
|
|
|
|
|
|
Severe
Psychiatric
Detect
Referral
Symptoms_____ Interpretation___Delirium_______Psychiatry
Figure 1: Schema of Cultural Interpretation of Delirium Symptoms and
Psychiatric Referral
The clinical picture changes when the patients delirium mild
symptoms progress to severe delirium symptoms. The patient now
manifests behavior similar to a crazy person and the agitation and
potentially harmful behaviors are interpreted as a threat to the safety to the
patient and family members. In this context, the family members of the
patient accept psychiatric referral.
Although the cultural interpretation of mild delirium symptoms
may provide coping strategies for the family to accept the possibility of
death of the patient, the persistence of any delirium symptoms does not
facilitate the patients coping with death and dying since the patients
mental functioning is impaired by the delirium symptoms. The terminally
ill patient will have to cope with a multitude of issues and hence would
need mental clarity, not the mental clouding caused by delirium symptoms
-whether mild or severe.
Part VIII
HIV and Grief
Comparison Between Dickenss London in the 1850s and

South Africa Today in the Face of the HIV/AIDS Pandemic
Quite apart from my work at hospice, over the past few years I
have been doing studies in Victorian Literature through the University of
South Africa (Unisa), focusing on some of the novels of the midnineteenth century, and Charles Dickenss Bleak House in particular.
As I looked at works like Hard Times, Sybil and Bleak House I
began to be aware of the similarities between London during the 1840s
and 50s and South Africa today, as we struggle to cope with the impact of
HIV/AIDS. It is these similarities that I would like to explore in the first
part of this paper.
Let me take a few moments to focus on the scale of the disease in
South Africa. Each day, we have 1900 new HIV infections and
approximately 600 people die of the disease. In the area where I live and
work, the infection rate is about 23% but in other areas, it could be as high
as 40%. I recently did some work in the local prison where the infection
rate is between 60 and 65%. Since 1987, when we saw our first AIDS
patient at hospice, the numbers have grown to the extent that more than
half our patients are now AIDS patients and it is significant that new
developments in the field of palliative care, both for adults and children,
focus largely on HIV/AIDS treatment and care.
Anti-retrovirals are still only available to those who are able to
pay for them or who are part of overseas-funded programmes which
makes them available, on a limited scale, in certain areas where health
policies are a little more progressive. This means that most people who
need them, are not able to access them. Nevirapine for pregnant HIV+
women has recently become available at most state clinics and hospitals
but many rural women live too far from these facilities and deliver their
babies at home, assisted by traditional birth attendants. The impact on
family life and the increasing number of orphans are major areas of
concern.
In 1851 the Great Exhibition was held at the Crystal Palace in
London to showcase a wealth of new inventions and achievements the
fruits of industrialization. Dickens paid his shilling, visited the exhibition
and spoke of his bewilderment at being surrounded by such a profusion of
exhibits. In an article published in the same year, 1851, he countered the
tone of self-confidence and self-congratulation by suggesting that there
should be a parallel exhibition to highlight unemployment, poverty,
disease and death the negative side effects of industrialization, which
represent loss rather than gain. In Bleak House he presents a picture of a
country bogged down in political disorder, archaic inefficiency,
132 Comparisons Between Dickens London and South Africa Today

irresponsibility and pseudo-philanthropy where social and political change
has not kept pace with economic progress.
In South Africa, we have major trade, technology and tourism
exhibitions as well as huge AIDS conferences where many of the issues
surrounding the disease are debated ad nauseum. The problem is that some
conferences can leave participants with a feeling of bewilderment similar
to Dickenss and a great sense of frustration. As one South African woman
said at a recent AIDS conference We say no to conferences and yes to
drugs. You talk, we die. Everyone at this conference is just talking and
talking.
Some of the basic needs that Dickens wanted highlighted in 1851,
for example unemployment, poverty and disease are key problem areas in
South Africa today.
It is significant that the sub-title of Disraelis novel Sybil,
published in 1845, is The Two Nations, emphasizing the gulf that
separated rich and poor. One could argue that the poor form an integral
part of any society but, in the new industrial towns of the time,
Manchester, Leeds and London itself, there was a greater concentration of
destitution than ever before. It became increasingly evident that the poor
were a by-product of rapid industrial transformation. Although Sybil
emphasized the gulf that separated rich and poor, stratified Victorian
society was based on far more than wealth alone. Society was firmly classbased and was characterized by groups with conflicting interests, values
and aspirations.
The parallel with South Africa is not hard to find. Industrial
development, particularly within the mining industry, drew hundreds of
thousands of migrant workers to the cities; apartheid policies meant that
race became the basis for discrimination and isolation. Although
legislation has now changed, the country still bears the consequences of its
history. Today on the outskirts of several of the large mines, informal
shack settlements of squatters have developed. Here people, many of them
illegal immigrants from neighbouring countries, have come searching for
work. Some of the miners establish second families and then leave women
and children behind when they return home to the rural areas, suffering
from AIDS and no longer able to work. Most live in appalling conditions,
with no proper housing or sanitation. Young children are left to look after
mothers who are dying. I know some of the retired nurses who are running
a home care programme in the area and when you hear of their
experiences, you would weep.
Sybil ends on an optimistic note with Disraeli writing that the
youth of a nation are the trustees of posterity. In September, at a youth
forum in Johannesburg, Nelson Mandela said that the youth in South
Africa should play a leading role in a social revolution against HIV/AIDS
similar to the one against apartheid.
133
The correspondence between some of Dickenss descriptions of

London and its people in the 1850s and our own situation is not difficult to
establish.
In Bleak House Dickens was particularly critical of the guardians
of English society. As he wrote:
My faith in the people governing is, on the whole,
infinitesimal law givers are nearly always the
obstructors of society instead of its helpers in the
extremely few cases where their measures have turned out
well, their success has been owing to the fact that,
contrary to their usual custom, they have implicitly
obeyed the spirit of their time, and have been as they
always should be the mere servants of the people.
To quote a report in one of our South African newspapers on 26
September this year, Few countries have as tangled a history with the
AIDS virus as South Africa does. This was written in the context of
President Mbekis recent statement that he does not know of anyone close
to him who has died of AIDS. For years the President refused to recognize
the link between HIV and AIDS and this had a negative effect on AIDS
education in the country. Recently the South African Minister of Defence
said that AIDS should not be a cause for concern for South Africa or its
military. This at a time when at least 4,7 million South Africans are
infected with HIV and where the official estimates are that about 22% of
defence force members are infected. In response an analyst from Janes
Defence Weekly was quoted as saying, If 23% of your military is going
to be dead because of AIDS in ten years time, the Minister of Defence
should be ringing alarm bells. Finally, our Sunday Argus of 21
September this year reported that the Minister of Health refused to be
drawn on details about the project to provide anti-retroviral drugs in state
hospitals and clinics, saying that she had no idea when the long-awaited
drive will begin. Dickenss comments, made in the 1850s could apply to
us today.
One of the central perceptions of Bleak House is that the lives of
the rich and poor and linked through the spread of disease, mainly typhoid
and cholera. In South Africa it is HIV/AIDS which is infecting and
affecting all parts of society. The prominent disease theory of the midnineteenth century, miasma theory, argued that diseases like cholera were
caused and spread by gases emanating from diseased and dead bodies. It is
ironic that in the twenty-first century, when our information about the
spread of infection has a more accurate, scientific basis, myths and fears
about the spread of HIV continue to abound.
How are the dead remembered? I would suggest that the
disruption, pain and sorrow that death and loss pose are mitigated to some

degree by representation. In the nineteenth century the permanent effect of
loss was mitigated by commemorating the dead through elaborate
mourning rituals and through the construction of funerary monuments.
The tomb served as a representative sign of loss and a means of preserving
the deceased in the memory of the living. There was also the curl of hair in
a brooch or a photograph in a locket. In South Africa today mourning
rituals and funerals play an important part in honouring the dead,
particularly within the Black cultures. We make AIDS badges, we light
candles and wear red ribbons at remembrance services and there are
quilting projects where each square in the quilt commemorates someone
who has died. We also have what we call memory box projects where
children decorate a box which contains items that a parent, a carer or the
child chooses as memories of the deceased and as a link to the childs
roots.
Finally, what I have found of particular interest is the way taboos
have changed. The Victorians seemed to have an almost obsessive interest
in death. It was viewed as an essential part of human experience, was
openly spoken about and was a favourite subject in Victorian fiction. In
contrast, sex was unmentionable. Today, it is sex which is openly spoken
about, written about and visually presented while death has become the
subject that gives rise to discomfort and embarrassment. Today it is
believed that intelligent and sensible men and women should be able to
keep their responses to loss and grief under control in the same way that
sexual impulses were denied in the nineteenth century.
Dying has become a lonely business, disconnected from living
and seen as a failure of medical technology and scientific ingenuity. As
long as death happens to other people, preferably those who are far away
and unknown to us, we can continue to pretend that it never happened, or
that it will never happen to us. Dickens used death to challenge his readers
to become involved in the alleviation of poverty, suffering and loss but
today death is often portrayed more for its entertainment value and we can
remain at a distance, unmoved and unaffected, able to make it disappear at
the flick of a switch.
I wonder whether the AIDS pandemic will make us re-evaluate
our own attitudes to death and whether we will return to a more
Victorian perspective on our own changes and losses within our own
bleak house.
1.
Distracted Grieving
Fortunately much has changed in London since the 1850s. One

of the most striking differences between my work in London and my
previous palliative nursing job in South Africa, is the number and variety
of resources in the UK that are available to both to those who are ill and to
those families left behind.
135
For many families in South Africa affected by the AIDS

pandemic there is little time and energy for grieving. In this part of the
paper I would like to explore how some of the social and economic
conditions have an impact on the grieving process. The harsh reality of life
and poverty leave little room for working through stages of loss. The two
groups that I would like to focus on particularly are orphaned children and
elderly grandmother, who are often left to care for them.
Grief is about emotions. I was reminded of Maslows hierarchy
of needs, and how the lower order needs must be satisfied before one can
really move on to the more emotional tasks. This was reinforced by a
study done in Zambia where the specific focus of the study was to have
been on the psycho-social needs of the children and guardians affected by
HIV/AIDS. However, it became evident that basic human needs were very
closely linked to psycho-social needs and that all efforts to address
psycho-social issues had to be interfaced with efforts to address basic
economic needs which included food, education, shelter and access to
health care. These are needs which many of us simply take for granted.
When working in London, after a patient has died I will follow up
the bereaved family and look at factors which may complicate the
bereavement. If I feel that the person, or family, are at risk I will refer
them for further counselling.
The factors that I consider are as follows:
The perceived nature of the illness and circumstances of

the death.
Relationship with the person who has died.
Previous losses or life crises.
Response of family or social network.
Other current stress situations.
For the orphans and elderly grandmothers in South Africa, most

of these risk factors apply:
1) The perceived nature of the illness and circumstances of the death
There is still much stigma associated with HIV/AIDS. Many of
those infected never tell their families. The families that do know will
often not tell the community and the death will be attributed to pneumonia
or tuberculosis.
Many of those left behind, cared for a parent or child when they
were dying. This care often took place in a one roomed dwelling, which
housed the entire family. This space would be used for sleeping, cooking
and looking after the sick person. The care might have included coping
with uncontrolled episodes of diarrhoea, sometimes as many as 16 times a
day, when the only tap can be as far as 2 miles away. A lack of electricity

often means that all water for cooking and cleaning needs to be heated on
a fire.
Antiretroviral treatment is still not available to the vast majority
of people, but in some cases access even to medication for symptom
control such as diarrhoea is limited, due to the distance from the clinic, the
cost involved in getting to a clinic and the fact that the clinic might not
having adequate stocks of medication.
These carers would have seen the person waste away to a mere
skeleton and these distressing images of the loved one often dominate the
memories they have.
2) Relationship with the person who has died
Parents losing children goes against the way we believe things
should be. One elderly grandmother caring for 10 grandchildren said, It
was not supposed to be like this. These childrens parents were supposed
to take care of me. Now they are dead and I am nursing the children.
Some children lose their parents at a very young age, before they
have a chance to form proper memories of them. Older children talk of the
loss of both economic and emotional stability when their parents died.
3) Previous losses or life crises
Many elderly women have lost their husbands and then go on to
loss all their adult children. One lady, whose daughters were looked after
by some of the South African hospice care givers, buried three daughters
in three years and is now responsible for their eight children. The effect of
multiple losses is sometimes overwhelming.
Children, too, have often watched parents and siblings suffer and
die. One girl said, Seeing my mother suffer through her illness made me
feel a lot of pain. I was with her all the time. I even stopped going to
school because I had to take care of her. I was the one to clean her
bedroom and check on her every morning.
4) Response of family or social network
Due to the stigma surrounding the disease, many children and
grandparents faced discrimination within their communities. HIV/AIDS is
still often seen as a form of punishment for wrongdoing and can be
associated with witchcraft and promiscuity. This can result in acute levels
of exclusion for older people and orphans. One elderly lady said, I am
facing a hard time. I am repelled from my family and the children keep on
telling me about the relentless comments they hear from their peers
because of their parents illness and death.
5) Other current stress situations
This is perhaps where most of the problems lie. The parents who
have died were usually the breadwinners in the family. Elderly
137
grandparents who are not working only have their state pension of R650
per month (equivalent to 56 or US$75) as the only family income, unless
the children drop out of school to do piece work. From this money they
have to pay rent, which can be as much as 2/3 of their pension, school
fees, uniforms and books, food and clothes. In South Africa there are
foster care and child care grants available but the up take of these has been
very low. One reason for this is that many elderly people are illiterate and
found accessing these grants very difficult, due to the complicated
administrative process and the need to provide the appropriate
documentation which has often not been left with them when the parents
have died.
At a South African conference on the role of the elderly, which
marked International Day of Older Persons, the Minister of Social
Development said that the selfless willingness of the elderly to share their
pensions had kept most of South Africas poorest children alive and
nourished over the past five years. Evelyn, aged 75, who is looking after
her grandchildren, says the same prayer every morning, Dear God, thank
you for sparing my old bones through another night so that these children
do not starve.
Elderly people often struggle with their own health issues. High
blood pressure and diabetes are very prevalent. These, plus decreasing
energy levels, can make it difficult for them to cope with the demands of
young children
Catherine, aged 15, the eldest of eight grandchildren being cared
for by 80-year-old Irene, says, Our grandmother is so wonderful, she
helps us in so many ways. She feeds us, dresses us and brings us up
properly. When we see her, we see our mother. If she were not here, we
would be scattered around other families and would not be treated in the
same way. We are so grateful that she is still with us.
Some children are not as lucky as this, as they are separated from
their siblings and sent to various family members or guardians. They have
to cope not only with the loss of their parents, but a new home, in a new
area which can be unfamiliar and frightening. Some children spoke of
staying with aunts and uncles who mistreated them and often gave them
less to eat and wear than their cousins. The most vulnerable group,
however, are the children who have no adult guardian and either become
responsible for child-headed households or take to living on the street,
where they often join gangs and are involved in crime in order to survive.
Some children as young as 11, were trying to earn a living to
support their siblings. They would try and earn money through piecework
such as washing for the more affluent, street vending or small scale trading
such as selling small amounts of charcoal.
One young girl, responsible for looking after ten children, said,
We suffer so much since my mother died. I do not manage to provide
sufficient food and clothing for my siblings as well as pay their school

fees. To earn money she was buying live chickens, killing and plucking
them, and packing pieces in small packs. She earned less than 1 US$ per
day.
For many of these children, both those being looked after by a
grandparent and those from child headed households, education was just
too expensive. Some children saw schooling as only a possibility if you
had parents who worked and could pay the fees. As one child said, I like
school but you can only go to school if you have parents. My mother died
when I was a baby. I dont know how old I was when my father died so it
is difficult for me to go to school. In one study, when asked how people
could assist orphans, the overwhelming response was to pay school fees.
This was linked to the desire to have a good job in order to be able to care
for themselves and their families. For many of them the hope of a better
future was linked to being able to go to school
One telling comment by a child heading a household was, Life
will become tougher for us orphans. We have no means of paying for our
education and also there are no jobs to give us hope of our lives becoming
better.
In the face of these overwhelming social problems, worrying
about where your next meal will come from becomes more important than
talking about how you feel. It is not that these people have not been deeply
hurt or do not carry the pain of loss, it is just that basic human needs can
hinder ones ability to work through many of these feelings. In the light of
this, is can be very hard to make sense of death and dying.
It is hard not to feel a sense of overwhelming despair but it is like
the man on the beach where hundreds of thousands of starfish have been
swept ashore by a sudden change in the currents. The man picks up the
starfish and throws them back into the sea. A passerby asks, Why are you
bothering. There are too many starfish for you to make any difference. As
he picks up a starfish and throws it back into the sea, he says, Well I
made a difference to that one.
It is the individual families and lives that we can touch that make
the difference in an otherwise overwhelming disease.
***
It is a street of perishing blind houses, with their eyes stoned out;

without a pane of glass, without so much as a window-frame, with the bare
blank shutters tumbling from their hinges and falling asunder; the iron
rails peeling away in flakes of rust; the chimneys sinking in, the stone
steps to every door (and every door might be Deaths Door) turning
139
stagnant green; the very crutches on which the ruins are propped,
decaying. (Chapter 8.96)
I was glad when we came to the brickmakers house; though it
was one of a cluster of wretched hovels in a brickfield, with pigsties close
to the broken windows, and miserable little gardens before the doors,
growing nothing but stagnant pools. Here and there an old tub was put to
catch the droppings of rain-water from a roof, or they were banked up with
mud into a little pond like a large dirt-pie. At the doors and windows,
some men and women lounged or prowled about and took little notice of
us. (Chapter 8.106)
Part IX
Diagnosis: The Receiving End

Abstract: Science is increasingly met with demands to increase both life
quantity and life quality. On the basis of its achievements thus far,
clinicians have, some argue, acquired a privileged status. This paper aims
to explore the position of medics, who are themselves facing a terminal
cancer diagnosis. How do clinicians manage the journey from healer to
patient? Using sociological and anthropological theory this paper
explores how the change in their self-identity is negotiated, focusing on
the shift from being an individual who holds power, to becoming one of
the vulnerable. Drawing on empirical evidence from interviews
conducted with clinicians who were dying, this paper examines their
position from two perspectives. First, it analyses how professional
knowledge can impact on private experiences. My respondents were
conversant with the confines of medical power: they were aware of its
limits and how those boundaries would impact. When they learned their
diagnosis, they understood their likely prognosis. Countering this,
however, they were able to use their medical knowledge to maximise
their remaining biological and social life. Second, this paper examines
interactions, which they reported to have occurred between them and their
professional colleagues. Once healthy they were perceived by colleagues
to be insiders', their diagnosis, however, changed their status to that of
outsider'. This paper explores how and why these shifts occurred.
The behaviour patterns of medics has been under close scrutiny

for some years now, however, whilst describing this behaviour and its
probable consequences does not appear to hold problems, accounting for it
would certainly appear to. In line with this, I do not merely want to
describe the behaviour of some clinicians who become ill, I am going to
suggest one theory which might explain it. It would be foolish to imply
that the behaviour I will be describing is universal, but research indicates
that it is common. I shall use only one specific theory - Douglass
classification theory - but all of the rest of the points I make have been
thoroughly researched and referenced.
I shall begin by introducing Louise - on whom the case study will
be based, then briefly describe something of medical cultures attitude to
clinicians who are ill, provide a thumbnail sketch of Douglass
classification theory, and conclude by applying Douglas to the case study
based on Louise.
It seems trite to observe that no one expects to be stricken with a
terminal illness. Perceptions of the future seldom allow for the prospect of
144
chronic or terminal illness. The present is most usually spent, not just
editing and reliving our past but also preparing for a future into which all
our hopes are projected.1, 2 It is this comfort zone that is threatened by the
prospect of a terminal diagnosis.3, 4, 5 One of the respondents I met whilst
doing my PhD, and whom I will refer to in more detail later, Louise, told
me how, when she was a medical undergraduate, a lecturer had informed
her class that demographically it was probable that in y number of years, x
number of them would be dead. She told me:
We laughed; we thought it was so funny. Quite a few
laughed, others shivered. I know at least one has died, in an
accident, two of us have cancer, various other things have
happened, nervous breakdowns, divorces and we have not
hit 40 yet. No one expects it at their doorstep and we all feel
immune from it. Your mortality has just been waved in front
of your face, it is not surprising really.
This paper draws substantially on my interviews with 36 year-old Louise,
who explained that she had been forced to retire from her career as
General Practitioner [GP], because of her breast cancer that, she had
recently been told, was not curable. Prior to my meeting with her, her
husband, a professor, had had a brain haemorrhage and, following an
enormous stroke, was left blind, unable to speak, epileptic and in a
wheelchair. As our longitudinal interviews developed over an 18-month
span, her four year-old daughter, Laura, was diagnosed with Leukaemia.
This paper examines how professional medical knowledge
impacts on how clinicians behave when they are ill. It also explores, in
more depth than I have previously, the interactions that occurred between
medics and the doctors who were responsible for their treatments.6
In the same way as cats are not supposed to bark or pigs to fly, so
medics are not supposed to become ill or die.7 Medical schools, like many
others, serve not only to teach the skills of their occupation but also
disseminate the various social rules and the ethos that will dominate. For
example, trainee clinicians learn to adhere to the regimented clock time
observed in hospitals and clinics.8 Leak quoted in Zerubavel points out
how the American Medical Association educate medical students of their
new temporal expectations and priorities by including, in the opening
chapter of their code of ethics, the following instruction. A physician
should be ever ready to obey the calls of the sick' 9, 10 Doctors and
consultants are, consequently, reasonably expected to be in contact at any
time to enquire about their patients progress and earn their respect by
having the facility to break through the frontiers of the night'.11 Roles
and scripts, such as the doctors seeming invulnerability and their almost
constant availability to patients are passed on to trainees, learned and
assimilated. Nurses, too, acquire the attitudes and mindsets that affect their
145
opinion of themselves and their behaviour towards others that are

established and become imbued during this education. This medical
culture, into which all clinicians are enrolled, promotes the idea that
somehow medics are a breed apart; highly competent experts not subject
to the ailments afflicting more ordinary mortals. Furthermore, medical
culture attempts to present itself as a dichotomy to those whom it treats, its
patients; there are patients and, then, there are medical staff.12
The sick clinician, however, challenges these ideas. The medic
who becomes ill is, at once, a clinician and a patient, a condition that
threatens the prevailing ideas of order - the medic as patient embodies a
risk that must be managed.13
Clinicians, who are themselves ill and dying, and therefore
should be in the role of patient, threaten the purity of the medical
discourse, acting as agents of pollution. In response to this danger, their
peers treat them as anomalous beings.
I am now going to refer to the body of theory previously
mentioned in my introduction. Although I will be referring to Douglass
analysis of Dirt, perhaps you might substitute sick medic.
In her seminal, anthropological work Purity and Danger, Mary
Douglas examined why and how the anxiety triggered by confrontations
with dubious elements is managed.14 She began her influential treatise by
considering the origins of dirt, observing that it was created by the
differentiating activity of the mind, it was a by-product of the creation of
order. So it started from a state of non-differentiation; all through the
process of differentiating its role was to threaten the distinctions made;15
The offending entity, dirt, or matter out of place as it was
labelled by Lord Chesterfield, must therefore have originated from within
a pure and unpolluted classification. In choosing to borrow Chesterfields
phrase, Douglas16 extends the concept to embrace entities from one
specific classification found situated within the province of another
category or, as more succinctly expressed by Ardener ...X in contrast to
non-X.17 Rendered conspicuous by their difference to the uniform
characteristics of the primary form, these encroachments create
disturbance, causing a tension, as their intrusion threatens the innocence of
the previously homogenous form. Thus, the offending entity, be it dirt or
sick medic, is perceived to be threatening or, in some way, menacing the
purity of the strain of classification and it is because of this danger that
these risky intrusions need to be treated differently. It is important though
to bear in mind that the exclusion of the offending entity is not a negative,
rather it is a positive act. The elimination of the pollutant functions to
maintain and enforce the chaste nature of the pure strain, thereby enabling
it to continue functioning as the ideal in its original and innocent form. It
is, however, important to note that this desire to preserve a fixed and
permanent form also threatens, as that which is static is not open to
progress and therefore may shrivel and die.
146
In the face of this cult of the indomitable medic, stands the

indisputable fact that doctors and nurses do, indeed, become ill. Just like
all other individuals, clinicians are subject to disease and death but, taking
the fact that the medical community promote a discourse that focuses on
medics who are healthy and uncomplaining, illness for a medic is worse
than for a member of the lay public.18 Douglass classification model
might help shed some light on how these doctors who are ill behave, and
are treated by their peers.
Louises identity clearly switched several times over the course of
her illness. At the time of finding her lump, she immediately adopted the
role of doctor and persuaded herself that it was probably nothing. She told
me:
I had a baby in July, was breast feeding in August and one
night felt a definite lump, you know when you feel your
heart fall and thought Oh my God! Dont worry about it
dear, you are breast-feeding. Now this is another
disadvantage of being a doctor, you can rationalise all these
things away if you can go up another diagnostic track...
Like many medics, Louise used delaying tactics when initially confronted
both with her own symptoms and later, those of her daughter, Laura.19 In
view of her medical background, how can this hesitation in presenting for
medical treatment be justified? Referring to the delays, instigated by her,
after finding a lump in her breast, she told me that she felt reluctant to
attend for consultation with a colleague as she felt: embarrassed to
turn up with anything other than cancer. I would have felt a bit of a
Charlie turning up with a lump that was not and I think that that was a
deciding fact in my not going to the Doctor.
Although even in lay thinking, the discovery of a lump might
suggest a potential link to cancer, Louises fear of embarrassment and
humiliation before her colleagues won over her natural fear. The need to
maintain her dignity and self-respect put her in a situation where she
gambled her life rather than risk appearing foolish before her peers.
Louises hesitation to report to her associates for consultation was
compounded by her decision to speak initially with a midwife, who
unwittingly further exacerbated the delay in treatment, when she, too,
dismissed the lump as probably being a blocked duct. Tragically, Louise
repeated this behaviour when her daughter became ill, when, although
clearly aware that her daughter was not functioning normally, she (relying
on her own medical training initially) sourced the problem
psychologically, rather than biologically.
Just as she had rationalised the lump in her breast and, as is
common amongst doctors who self diagnose, trivialised it by relating it to
breast-feeding, she also dismissed Lauras fatigue as being caused by
147
stress at beginning school.20, 21 As she told me she might have been at

the doctor, if I had not been one. However, she did tell me that when she
finally brought Laura to see her GP, she knew before I went to see
him what the most likely diagnosis was.
I have already observed how the prevailing medical culture
promotes a radical segregation between those who are ill and their
caretakers.22 Doctors, especially, do not enjoy any personal association
with illness and, when this does occur, they struggle to accept the role of
patient. 23, 24, 25 Disclosure of their frailties will, they fear, leave them
vulnerable in the face of their colleagues and that, in seeking help, they
will be confessing that vulnerability.26
Having discussed how Louises hesitation delayed critically the
management of both her own and her daughters potentially fatal illness, it
might be interesting now to explore how she experienced being treated by
her colleagues.
From her reports, it would seem that she felt poorly treated both
when being told of both her own cancer by her own consultant and also by
the GP who told her of her daughter, Lauras diagnosis.
At the time of her own diagnosis, however, in spite of struggling
to maintain her position of doctor, she ultimately acceded to that of
patient. When her consultant told her she had cancer, she told me that she:
grabbed the chart but maybe there were few cells... but the surgeon
said 99 per cent definite you have cancer here. I remember the sister told
me to sit down.
As a doctor, Louise was used to being objective and in control.
Her diagnosis, however, directly threatened her constraint; indeed so
stunned was she by the trauma it induced that she gravitated into physical
action. In spite of this shock, her medical training intervened and she
wanted to check her test results herself. This quotation is important also,
as it records the moment when she made the switch back from medical
mode to being a patient, as she heeded the command of the nurse, who
told her to sit down. In choosing to obey that directive, she was
effectively identifying herself as a patient; immediately abrogating her
more senior medic role to that of a patient. Her resistance to that role,
though, soon broke through. During one interview, she explained how she
had:
removed control from the doctors. Now, I love the
doctors who look after me but they do it too much. I didnt
go to them with my symptoms, I thought, once that is
mentioned, there will be a chain of events over which I have
no control. It is very hard to retain control in the hospital. I
told them I dont want to come back unless I need to. I told
them, I consult lots of people about my health and I do
consider you a cog in the wheel... I pulled out of the
148

hospital. They ask me if I have appointments and I say, I
dont know! I see them [her appointment cards] and tear
them up. I know them both [her principal doctors] very well,
and they are lovely. But they are both in a very medical
model and they feel they own the cancer. Sorry, that is not
the way I see it at all.
Louise was fighting to maintain her medical control as doctor in charge of

her own health. She agreed with the course of chemotherapy she had been
prescribed and went along with it but, ultimately, it brought about a crisis
that resulted in her emergency admission to hospital. At this time the
deterioration, directly caused by the chemotherapy, was such that she
almost died. She explained:
I have been in hospitals twice with the side effects of
chemo and I, basically, didnt give a damn about the
children. Someone put a drip up on me And I just really
left them all to it, I have been in bed unable to do
anything I have been on morphine, begging for it to be
given to me early, but dont tell the doctor. You just lie
there and it all happens around you. I hated that, couldnt do
anythingcouldnt sit up in the bed, could maybe sip some
water until I fell asleep again. It is terrible, because you
might as well be dead.
Louises reaction to the chemotherapy was such that any identity she had
when well, that of mother or doctor, had been superseded by her status of
patient. She had surrendered control of her physical body to others who
were now responsible for its maintenance. In this incompetent condition,
she was deemed and treated specifically as a patient, a role that did not
threaten her colleagues. What does the theory have to say about this? In
referring to common rubbish, Douglas argues that So long as identity is
absent, rubbish is not dangerous, it clearly belongs in defined places. In
the final stage of disintegration, dirt is undifferentiated...27
Louise could be managed when in a coma; she was in one welldefined role. However, when she was ultimately able to regain some form
of bodily control, it is interesting to note that her social instinct intervened
and, perceiving that her request for morphine might be construed as
weakness to the doctors who were treating her, she conditioned her plea to
her nurses with the request not to tell the doctor.
It might be interesting to explore further, how the relationships she
had with colleagues developed throughout the illnesses. I asked her if her
medical knowledge helped and she told me:
149
I think it makes it easier for the doctors in one way, because

they can talk in medical terms; doctors love that. But if
things go anyway other than perfectly, they hate it, because
if you start asking I can see that they do not know that
much at all they get a bit shadier. Start avoiding me. If
I ask about the side effects of a drug, they hate that, wish
you could turn into a non-doctor for the duration. To get
around it, they treat you as a doctor, as if We are all
discussing another case here. This patient, who just
happens to be me, but they forget that and get technical. An
interesting case, now lets go on our way.
A doctor herself, Louise was thoroughly versed in medical
behaviour. She recognised the strategies adopted by her colleagues and
this understanding shaped her response to her colleagues:
It is almost easy for me to fall into this, I sometimes
acquiesce and then, in the car, wish I had not been such a
doctor but more like a patient. Sometimes I feel as if we are
not discussing me or my child, [Laura who has leukaemia]
but a case of something else and I let them do that. They do
not like my knowledge. The conversation comes to a halt if
you show you are upset, it is Get her out! They dont want
you really involved. If you say, Right, abnormal liver
function, what is the most likely cause of that?they are
much happier with that factual exchange. [Louise then
parodied herself as being ignorant of her medical
knowledge] No, Im not concerned with her wee liver, it is
not that important is it?
As a clinician who was ill, Louise found herself being treated as a
classic anomalous entity - matter out of place. Whilst she was a doctor,
she was not behaving like one, in that she was sick. Whilst being a patient,
she was not behaving like one, in that she clearly had medical knowledge.
Her familiarity with the medical discourse and her background knowledge
of the social lives of the very doctors who were treating her raised her
status to one of them - the invulnerable. In spite of this privileged status,
however, by virtue of her diseased biological cells, she was now also a
patient, who it will be remembered, in terms of the medical discourse is
perceived as out of control, helpless and passive.28 The medics who were
managing Louises treatment found themselves in the difficult position of
not having a script which would work. The traditional boundaries, upon
which they relied, of patient and doctor, had suddenly been shifted. They
felt awkward and uncomfortable and, for the most part, attempted to veil
their discomfort with politeness. Louise had become an embarrassment -
150
matter out of place. More than that, her doctors were conscious that her
knowledge extended to an awareness of their limited capacity to cure. At
one stage, she actually felt in danger of being thrown out of a consultation
because, as she said, she can see that they do not know that much at all.
Her medical training afforded her knowledge of the realities of medical
limits and that truth threatened her doctors.
Louise realised that if, at least to her treating doctors, she could
distance herself from her self as patient or the maternal role and instead
become set in a medical persona, she would be better positioned to acquire
more knowledge of the case and that might act to her advantage. In this
way, while speaking with her own doctors and those of her daughter, she
attempted to present herself as medic rather than patient.
Louise rationalised her position and decided that the medical
team who were managing the illnesses, responded more comfortably to her
when she presented in one role - that of professional - rather than risk the
danger inherent in managing anomalous situations. So, when dealing with
her health professionals, she preferred to provisionally dispense with her
social persona as mother or patient and assume instead her professional
medical role. This cannot have been easy.
In deliberately presenting herself in her professional role, rather
than that of patient, or as the mother of a patients, she was attempting to
balance the inequity that exists in the doctor/patient/carer relationship - to
avert the anxiety which would have been created if they had assumed their
other roles - matter out of place.
In an endeavour to learn more about medics as patients, this
paper has explored the experience of a medical professional, who
encountered serious illness both personally as a mother. My research
supports especially that of Jaye and Wilson among others, who explore the
delaying tactics employed by doctors who are ill, in presenting before
colleagues for professional opinion.29 It also examined how doctors
behaviour is changed when they are treating colleagues who are ill. To
explain this behaviour, I have applied Douglass classification theory,
which suggests how entities that are anomalous create anxiety, which
needs to be managed.
Notes
1. Platt, J.R. (1966)
2. Bourdieu, P. (1990)
3. Del Vecchio, M.J., Good, M., Munakata, T., Kobayashi, Y.,
Mattingly, C. & Good, B.J. (1994)
4. Nekolaichuk, C. L. & Bruera, E. (1998)
5. Nowotny, H. (1994)
6. Armstrong-Coster 2004.
7. Ingstad, B. & Christie, V. (2001)
151
8. Frankenberg, R. (1988)
9. Leak, W.N. (1948)
10. Zerubavel, E. (1981)
11. Melbin, M. (1987)
12. Jaye, C. & Wilson, H. (2003)
13. Hahn, R. H. (1985)
14. Douglas, M. (1988)
15. Ibid. p. 161.
16. Douglas, M. (1988)
17. Ardener, S. (1981)
18. Ingstad, B. & Christie, V. (2001)
19. Hahn, R. H. (1985)
20. Ibid.
21. Jaye, C. & Wilson, H. (2003)
22. Hahn, R. H. (1985)
23. Ibid.
24. Jaye, C. & Wilson, H. (2003)
25. Chambers, R. 1993
26. Jaye, C. & Wilson, H. (2003)
27. Douglas, M. (1988), p. 161.
28. Hahn, R. H. (1985)
29. Jaye, C. & Wilson, H. (2003)
Bibliography
Ardener, S. (1981) Ground Rules and Social Maps for Women; An
Introduction (1981), Oxford, Berg.
Armstrong-Coster, A. ( 2004) Living and dying with cancer. Cambridge:
Cambridge University Press.
Bourdieu, P. (1990) Time Perspectives of the Kabyle in J. Hassard (ed.) The
Sociology of Time, London: The Macmillan Press Ltd.
Chambers, R. (1993) What should doctors do if they become sick. Family
Practice 10(44), 416-423.
Del Vecchio, M.J., Good, M., Munakata, T., Kobayashi, Y., Mattingly, C. &
Good, B.J. (1994) Oncology and Narrative Time: Social Science and
Medicine 38(6), 855-862.
Douglas, M. (1988) Purity and Danger: an analysis of concepts of pollution
and taboo, London: Ark Paperbacks.
152
Frankenberg, R. (1988) Your Time or Mine? An Anthropological

View of the Tragic Temporal Contradictions of biomedical practice in M.
Young & T. Schuller (eds.) The Rhythms of Society. London, Routledge.
Hahn, R. H. (1985) Between Two Worlds: Physicians as Patients, Medical
Anthropology Quarterly, August 16:4. 87-98
Ingstad, B. & Christie, V. (2001) Encounters with illness: The perspective
of the sick doctor, Anthropology and Medicine 8(2/3), 201-210.
Jaye, C. & Wilson, H. (2003) When GPs Become Patients: Health: An
Interdisciplinary, Journal for the Study of Health 7 (2), 201-225.
Leak, W.N. (1948) The care of the dying, The Practitioner 161, 80-87.
Melbin, M. (1987) Night as Frontier; Colonizing the World After Dark, New
York: McMillan Free.
Nekolaichuk, C. L. & Bruera, E. (1998) On the Nature of Hope in Palliative
Care: Journal of Palliative Care 14(1), 36-42.
Nowotny, H. (1994) Time: the modern and postmodern experience,
Cambridge: Polity Press.
Platt, J.R. (1966) The Step to Man, New York: Wiley.
Zerubavel, E. (1981) Hidden Rhythms: Schedules and Calendars in Social
Life, Chicago: University of Chicago.
Between Organizations, Family & Death: Caring

Creatively within the Hospice Organization
Elizabeth Gill, Ph.D.
Abstract: Based on qualitative data obtained from open-ended interviews and
participant observation, this paper examines how hospice volunteers
reflectively and creatively use and manipulate the medical structure to
achieve caring objectives that are often counter to the expressed goals of the
health care organization. More specifically, I will shed light on the ability of
active, reflective human agents, within the bureaucratic system of hierarchy and
complex division of labour, to, both formally and informally, reflectively carveout space within these organizations, space that allows them to shape the course
of events and enable them to substantively care for dying patients and their
caregivers. Employing Joas concept of situated creativity, I focus on the
unexpected and novel ways that volunteers may respond to a particular
situation by considering the physical possibilities, normative expectations and
institutional arrangements that structure the field in which the action takes
place. Thus, for the purposes of my analysis, creativity becomes a form of
action employed by volunteers in response to structural constraints. By
considering creativity as an activity, and by empirically specifying the
processes by which human agents carve-out communicative space within the
organizational context, I develop a modified Habermasian framework that
further clarifies Giddens position on the enabling and constraining possibilities
for human agents within large-scale organizations, thereby bridging the gap
between the pragmatist tradition and the Weberian heritage.
Key Words: Hospice Volunteers, Palliative Care, Creativity, Reflectivity,
Death, Dying, Organizations, Joas
This paper examines how hospice volunteers reflectively and
creatively use and manipulate the medical structure to achieve caring
objectives that are often counter to the expressed goals of the health care
organization. More specifically, I will shed light on the ability of active,
reflective human agents, within the bureaucratic system of hierarchy and
complex division of labour, to, both formally and informally, reflectively carveout space within these organizations, space that allows them to shape the course
of events and enabling them to substantively care for dying patients and their
caregivers. The hospice philosophy of care attempts to preserve the dying
individuals life-world from system control by carving out a niche for the dying
to achieve a decent and fulfilling human life until death. The two primary
sources of data for this project were a series of 40 in-depth interviews and
participant observation. In addition, I supplemented these materials with a set
154
Between Organizations, Family and Death
of 23 open-ended questionnaires. Data for the study were collected over a

ten-year period from 1992 to 2002.
1.
Webers Iron Cage and Habermas Escape
The modern image of a dying person connected by tubes and wires to

life-sustaining equipment is a logical derivative of Americas bureaucratic and
technological orientations.1 This image, reflective of an ever increasing
percentage of deaths within formal institutional settings, embodies the loss of
human dignity and autonomy associated with the powerful large-scale
bureaucratic organizations and Webers iron cage.2 Although Weber
considered the human actor to be central to much of his work, when it came to
his analysis of bureaucracy and bureaucratic organizations, he gave little or no
consideration to the human agent. Webers agent was destined to become
enmeshed in the bureaucratic constraints of the iron cage. His lack of
attention to the possibility of agency within bureaucratic organizations runs
counter to my findings about the hospice volunteers actions within large-scale
bureaucratic organizations.
The major response to Webers lack of attention to agency has
come from Jurgen Habermas. Habermas objective has been to confront
Webers fear of bureaucracy run amok and provide an escape from
Webers iron cage by relying on the pragmatist heritage.3 Despite his
acknowledgment of the duality of society comprised of both the system
and the life-world, Habermas analysis falls short of acknowledging the
interaction that occurs between the two spheres. Although the distinction
between the life-world and system proves to be invaluable when trying to
come to terms with the effects of organizations on human agency, it seems
that Habermas is overly optimistic about the integrity of the life-world
apart from the system.
My examination of hospice as an alternative to the systemic
management of death and illness illustrates the possibility of negotiation
between the system and the life-world that is not necessarily pathological in
nature. Contrary to what one might expect, if one accepted the Habermasian
frame of reference, my research indicates that one of the latent functions of
hospice is to mediate between the broader medical system and the individual
and family/caregivers. The volunteer role provides a bridge between the system
and the life-world. In a sense, the volunteer straddles the boundaries between
the two worlds, becoming the link between the long-term facility and/or
hospital (i.e., system) and the life-worlds of the dying individual and caregivers.
Without this link, hospice principles would not be viable within
bureaucratically structured medical settings. The volunteer, if he or she is to be
effective, often needs to act in the capacity of mediator or arbiter not only
between the family and the system but also between the hospice organization
and the health care system.
Elizabeth Gill
2.
155
Constraints and Creativity
Since most hospice patients, at some point in their illness while under
hospice care, will be placed in a medical facility, the volunteers must be able to
operate within an organizational environment that is not designed to
accommodate the inefficient, non-professional and unspecified nature of their
role. In order to explain social action within the health care setting, social
theorists must develop a conceptual framework that accounts for the complex
interaction between the human agent and the structure. For the purposes of my
research, I drew upon the recent work of Hans Joas, who, writing within a
symbolic interactionist, or pragmatist, orientation, emphasizes the creativity of
human agents. Joas concept of situated creativity calls upon us to focus on
the novel ways in which a human agent may respond to a particular situation,
acknowledging the physical possibilities, normative expectations, and
institutional arrangements that structure the field in which the action occurs.4
As I analyzed the data on hospice workers, I discovered that the
reshaping of organizational contexts may vary considerably from situation to
situation and from volunteer to volunteer. I have found that volunteers employ
structure creatively by 1) carving-out social space, 2) combining resources of
the organizations in creative ways by soliciting the help of other organizational
actors (i.e. sympathetic professionals), and 3) using selective elements of the
structure to achieve their objectives. Based on their image of the organization
and their position within it, the strategies employed by volunteers enabled them
to operate effectively within the structured medical environment by
circumventing certain systemic barriers and constraints.
A. Carving-Out Social Space
The volunteer has no clearly defined role within the health care
setting. Even within the hospice organization itself, volunteers are
considered to be gap-fillers when it comes to caring for a dying
individual and the family/caregivers. In my research, the hospice volunteer
role dramatizes the slippage between the agency and structurally defined
expectations. The volunteer role itself is unique in that it is not
characterized and defined by strict guidelines mandated by professional
affiliation. In fact, hospice training stresses the tenuousness of role
constraints. Each situation is evaluated on its own merit; thus, the
volunteer must adapt to a myriad of possibilities and constraints within a
given situation. Volunteer responses reflect how the fluidity of the
situation affected their role performance within the medical setting:
Case 1: I go slowly into each new situation. I try to be
very observant and I listen to assess what my role will
be. Now I realize that it will never be the same as any
156

other time. I help in whatever way I can and do what
must be done.
Case 2: My role is a reflection of the situation I am in.
Some patients are physically able to do more things than
others. Some family members need me and others
simply tolerate me. Some facilities are more flexible in
the kinds of things that I can do.
Despite the fact that there is a considerable amount of freedom

and flexibility involved in the volunteer role, there are still certain societal
and organizational restrictions that delimit the boundaries of agency. In
order to operate effectively within the health care setting volunteers must
use their knowledge about constraints to create a buffer, or a social
space, between those in power and those who seek the good death for
individuals struggling to find meaning within the bureaucratic setting.
Volunteers, aware of the constraints placed upon them and those in their
care by the health care organization, must actively acquire this space and
make it their own. More specifically, the volunteer must mediate between
actors with formalized roles as well as the broader organizational structure
in order to carve-out this sanctioned space. In the words of one
respondent, the difference between simply being a volunteer and being a
good volunteer is ones ability to make the facility work for, not against,
the patient and the family/caregivers.
B. Sympathetic Professionals
Another strategy utilized by the respondents involved working
within the complex division of labour which characterizes the medical
setting in order to further interest the staff of these facilities in the care of
their patient. Efforts were made by the volunteers to interest key
caregivers within these facilities by personalizing their patient/family and
elevating them above the business as usual or simply another terminal
case attitudes in the eyes of the staff. Toward this end, respondents stated
that they would seek out professionals within these health care facilities
who were sympathetic toward their cause. These sympathetic
professionals can best be characterized as health care professionals who
either have not been well socialized to system rules or who have chosen to
challenge these rules in the course of their duties. The volunteer
respondents indicated that they would cultivate these relationships by
employing such strategies as: 1) professional admiration and/or sympathy
for the health care staff and their occupations; 2) individualization and
personalization of the patient/family by telling their story: or 3) via
threats and innuendo about the quality of care that their patient was
receiving. The following cases illustrate how the use of sympathetic
Elizabeth Gill
157
professionals by the volunteers enabled them to carve-out the space

required for themselves and the patient/family.
One volunteer recalled a frantic mother's reaction to the
"atrocious" conditions of a nursing home in which her son had been
placed:
The woman clung to me like a life preserver. I
was a familiar face in a sea of strangers. She was almost
inconsolable: They dont care about my son. They are
all on deathwatch waiting for him to die. No one here
knew him before he was sick. They dont care if he is
clean or comfortable; all they want is for him to die. I
am terrified that he will die alone, with no one around
him that cares.
All I could do was promise her {the mother}
that I would sit with him while she rested and ate. I
assured her that I cared about her son, and that he would
not be alone when he died. I also talked to the nursing
home staff and persuaded them (i.e. through flattery and
empathy for their working conditions) to spend some
quality time with mother and son. Some of them were
very accommodating, and the mother noticed the
difference immediately.
This particular case is indicative of many of the respondents
experiences, particularly in long-term care facilities. Acting in this
capacity, the volunteer would attempt, not to change the system, but reach
a common middle ground between the system and hospice ideals. This
often mean extra effort on the part of the volunteer to fill in the gaps of
care delivered by the hospital or extended care facility, as well as efforts to
further interest the staff in the care of the dying individual:
In order to accommodate patient/family wishes,
I get to know one or two staff members who are helpful
and are willing to often go against nursing home policies
in order to fulfil certain patient needs. One case involved
taking a patient to a local mall. It was against home
policy to remove a patient without a family members
signature. His wife was the designated caregiver, but she
was in a mental institution at this time. With a lot of
wrangling (i.e., under the pretence of being his daughter
in conjunction with a couple of aides who were
especially fond of the patient), I was able to take this
man to the mall. It was his last outing.
158
These sympathetic professionals enabled the volunteers to

carve-out a space for themselves and the patient/family. The
aforementioned cases highlight, first, the acknowledgement of the system
by the volunteer; and secondly, the ability of the volunteer to engage those
representing the system on their own terms, with the volunteer ultimately
carving-out space within the organizational structure and shaping the
dying process.
C. Knowledge/Experience
Finally, an almost universal difficulty experienced by
respondents in the institutional setting was one of legitimacy. Several
respondents expressed frustration at their inability to command respect
within the formal health care environment.
One strategy utilized by the volunteers was to indicate to medical
personnel a certain degree of medical knowledge or experience beyond the
volunteer role. Several volunteers had been health care professionals and
utilized this experience to attain a certain amount of respect from medical
personnel and staff within medical settings:
This particular nursing home is probably one of
the worst in the area. The facility is filthy and the staff
treat the patients like animals. Volunteers are generally
treated as a nuisance and ignored. One day I walked in
and saw the aides throwing my patient around like a
sack of potatoes under the auspices of changing his bed.
That was the last straw. I informed them that I had been
a nurse and that I would report their activities to the
proper authorities. Suddenly, I was transformed from
nuisance to threat. After that, my patient received special
care and respect (at least as far as I knew) and so did I. I
have since used this strategy from the outset of my
relationship with a particular facility. It is nice to be
taken seriously.
Volunteers stressed the importance of not being "dumb" in
situations in which you are already at a disadvantage as far as professional
status. One volunteer learns as much about the illness of her patients as
she can in order to pass herself off as an "expert" and receive the respect
and power that goes along with it:
Case One: It makes no sense to walk into a situation
unprepared. Nurses and doctors already view volunteers
as sweet, well-meaning people who probably are unable
to do anything else with their lives. Why make the
Elizabeth Gill
159
situation worse by playing into that stereotype . . . I

always try to volunteer smart. I want to have as much
information as I can before I walk into a particular
setting to meet a particular patient/family and medical
personnel. I feel that this gives me an advantage with the
medical staff . . . I have already broken their
conceptualisation of the typical volunteer.
Case Two: I read everything I can about my patient's
illness...I have found that this not only helps me deal
with my patient, it also allows me to appear to be pretty
savvy to the nurses and doctors I have to deal with. I
think they are never really sure if I have had medical
training or not...I keep that kind of vague. They respect
my knowledge; I like that; it also gives me the
opportunity to oversee the care of my patient. In most
cases if I complain about the care of one of my patients,
I get results.
The aforementioned cases dramatize the importance of
knowledge, feigned or otherwise, in establishing legitimacy within the
health care environment. The hospice nurse as a bridge between the
volunteer, health care staff, and dying individual; the mimicking of status
as a family member or health care professional; and the use of the inferred
knowledge of a retired nurse are illustrative of the volunteers ability to
creatively manipulate the health care professionals and system.
On the basis of my empirical studies, I do not feel that the traditions
of pragmatism, symbolic interactionism, or the Habermasian Theory of
Communicative Rationality, have gone far enough in explaining the impact of
organizations on interaction. The volunteer experience cannot possibly be
explained simply in terms of process or negotiation, for oftentimes the
volunteer will simply act without negotiation. Moreover, the volunteers
interviewed were very much aware of the constraints they face within the
organizational context and where they stand in the pecking order of the
bureaucracy in terms of status and knowledge. Thus the volunteers, because of
their unique relationship and marginality to the system and the patient/family
life-worlds, were able to develop a reflective stance toward the constraints of
the health care setting and use this insight to carve-out communicative space
within the organization. This communicative space provides an opportunity for
the dying to live out their final days unencumbered by the iron cage.
3.
Implications and Conclusions
My attempt to articulate the relationship between agency and

structure expands upon symbolic interactionist and pragmatist efforts to
160
understand the relationship between the human agents and social

structures. Building upon Joas Theory of Creativity, I have sought to
bridge the gap between the pragmatist tradition and the Weberian heritage.
The result has been a modified Habermasian framework that recognizes
the constraining and creative possibilities for human agents within largescale organizations.
More specifically, I found the hospice volunteer to be more
proactive with respect to structure than Weber and the symbolic
interactionists have acknowledged; but, by the same token, the volunteer is
also more influenced by the constraining and creative possibilities of the
organization than the pragmatists and Habermas wish to concede.
Acknowledgment of the proactive agent, who is bound by the constraints
within the organizational context but capable of reflectively interpreting
and reinterpreting the rules, has provided the basis for my analysis of the
volunteer within the medical setting. And opened up the possibility of the
human agent capable of reflectively using and manipulating the social
structure.
My research data suggest that hospice stands as a buffer between the
family and civil society with hospice as a broker, mediating between the
family, and the civil society and broader system. The role of the volunteer
challenges some of Habermas basic principles concerning the relationship
between the system and the life-world. As indicated above, the volunteer role
often demands that the volunteer act in the capacity of mediator or arbiter not
only between the family and the medical system, but also between the hospice
organization and the medical system. In Habermasian terms, the volunteer
attempts to maintain and buttress up the boundaries of the life-world within a
system that threatens to pathologically intrude and destroy the life-worlds of
the patient and family/caregivers. Respondents often acted to alter either the
medical or hospice organization in a way that was more true to the original
hospice ideals. Joas (1998) concept of situated creativity enabled me to
address the shortcoming of Habermas system/life-world distinction by
examining the human agents creativity with respect to particular situations,
defined by the physical possibilities, normative expectations, and institutional
arrangements that structure the dying process.
In conclusion, my data indicate that refusal to acknowledge the
organizational context sells human agency short. In a sense we discredit
the agents ability to manipulate or challenge the structure based on his/her
reflective evaluation of the organizational context. By recognizing the
ability of human agents to reflectively evaluate the social constraints
placed upon them within the organizational context we open up the
possibility for creative activity and unencumbered discourse and the
achievement of caring objectives that provide the opportunity for the
dying to live out their finals days unencumbered by the iron cage.
Elizabeth Gill
161
Notes
1. David Moller, Confronting Death: Values, Institutions &
Human Mortality (New York, New York: Oxford University Press, 1996),
24.
2. Max Weber, From Max Weber, trans. and ed. by H. Gerth and
C. W. Mills (New York, New York: Oxford University Press, 1946).
3. Jurgen Habermas, The Theory of Communicative Action:
Lifeworld and System: A Critique of Functional Reason (Boston,
Massachusetts: Beacon Press, 1987).
4. Hans Joas, The Creativity of Action (Chicago, Illinois:
University of Chicago Press, 1996), 133.
5. Anthony Giddens, The Constitution of Society (Berkely,
California: University of California Press, 1984).
Part X
Voluntary Death and Suicide
For Fear of What the Neighbours Might Say: Social

Networks and Suicide in Early Modern Holland
Laura Cruz
Abstract: My paper centers on the question: Did the seventeenth-century
Dutch have an exceptionally modern (i.e. private and secular) view of
death, especially suicide. I argue that rather than a modern view of death,
they had a unique one.
The paper is based on the records of the municipal courts in the
Dutch town of Leiden, which include 400 cases of possible suicides.
While most studies of death in the early modern period link perceptions
and practices to religious culture, the argument presented is that in the
spread of Protestantism was of minor importance in explaining low levels
of suicide. I argue that suicide was an unpopular option because the cities
of Holland deliberately constructed strong, informal and semi-formal
social networks that were independent of the (non-state) Church. In most
other countries, much of the responsibility for order and control migrated
from the Church to the state, but not in the Netherlands because the central
state was too weak to take them over. Instead, those functions fell by
default on the existing intermediary institutions. In short, Dutch social
corporatism played a significant role in mitigating suicide levels during a
period of intense upheaval and rapid change.
Keywords: Suicide, Durkheim, Netherlands, Corporatism, Leiden, Death
In his 1897 work Suicide, Emile Durkheim argued that while

individual suicides may have psychological causes, suicides rates are
primarily a social phenomenon and, therefore, rightfully fall under the
purview of sociologists. He attributed variations in suicide rates to the
effect of social forces, or the collective tendencies of a given society
which produce external pressure or influence on individual decisions.1
These forces are intangible and unconscious; uncrystalised as Durkheim
calls them, and include such phenomenon as the great movements of
enthusiasm, indignation, and pity in a crowd.2 Similar to the proverbial
fickleness of crowds, social forces vary according to the historical
circumstances that constitute and consume them. In order to highlight the
potential explanatory power of social forces, Durkheims project
compared suicide rates across time and across national borders in
nineteenth century Europe. In these studies, he largely ignored the
Netherlands, as he deemed the number of reported cases too small. In
doing so, he glossed over a case of potentially great significance for the
understanding of suicide in the past. Since the sixteenth century, suicide
166
Social Networks and Suicide in Early Modern Holland
rates in the Netherlands appear to have been consistently below the

European norm, and they remain so today.3 As so much of the history of
this tiny northwestern corner of Europe has been exceptional, it is no
surprise that suicide rates should also be so. The interesting question,
however, is why? What unique social forces have shaped the collective
mindset of the Dutch people?
When the seven northern provinces of the Dutch Republic
claimed independence from Spain in 1579, they found themselves in a
precarious position. Their independence was not recognized by the King
of Spain, Philip II, who continued to pursue an aggressive war to retain his
possessions. The war would last eighty years and required the disparate
populations of the provinces to cooperate to a historically unprecedented
degree. It also left them without a central mechanism to facilitate that
cooperation and, especially after the assassination of William of Orange in
1581, without a clear leader. The document that became their constitution,
the Union of Utrecht, resembled an alliance agreement more than an actual
basis for a functioning government. After two disastrous experiments with
borrowed kings, the new state chose the default option, which was to
continue making the majority of their decisions at the local, or town level.
Under absentee rulers Charles V and Phillip II, the towns of the
Netherlands had gained an extraordinary independence of action,
especially fiscal action.4 They grew accustomed to controlling their own
finances and making their own decisions, a custom they continued through
the interregnum and independence. The States General and the Stadhouder
provided a thin veneer of central government, but for most of the life of
the Dutch republic, decisions were negotiated at the level of the town and
provincial governments, the direct opposite of the trend that characterized
the rest of ancien regime Europe.
This decentralization can be real thorn in the side of an historian,
for it results in wide divergences in practices among towns and provinces,
which makes it difficult to compile national statistics of nearly any sort
and certainly complicates the prospect of comparing the Netherlands to
other countries. Historians have calculated suicide rates for the southern
towns of Brussels and Ghent and the northern towns of Amsterdam and
Breda.5 Yet, they have overlooked the town of Leiden. Leiden was one of
the largest cities in the Netherlands in the seventeenth century and its
population grew exponentially with the flood of immigrants that found
work in Leidens thriving textile industry. The growth of the town
presented new challenges to its magistrates, who struggled to maintain
law, order, and balance amidst an ever-changing urban population.
During the Middle Ages, Leiden had been held under Rhineland
law, which was administered by the count of Holland or his representative.
The law was a mixture of old Friesian and old-Frankish principles, with
the experiences of past and present rulers thrown in the mix.6 By the midfifteenth century, control over Holland had passed into the hands of a
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167
series of Burgundian-Habsburg rulers, including Charles V, who were

generally content to reinforce the independent privileges of the northern
towns in return for large cash payments. In 1434, the Leiden municipal
court asserted its right to administer both higher and lower justice in the
town and its surroundings. Crimes against the prince or his regime were
still remaindered to the higher court at The Hague, but otherwise the legal
matters of Leidenaars were handled by a court of select citizens, which
satisfied the requirement of Rhineland law for a council of wellborn
men to administer justice.7 According to the same privilege, the schout,
or sheriff, was to lead the court and carry on his functions with a rod in
his hand in a symbol of knowledge. 8
From 1434 onwards, the legal system of the towns of Holland
moved further away from its origins in Germanic law. Though it
maintained some of its nomenclature and procedural etiquette, the old
forms were increasingly mixed with Roman law, precedent, and the
opinions of the schout and other members of the bench. This made for a
very specific body of law that related very closely to the environment from
which it sprang--the energetic industrial town of Leiden. According to the
old customs, suicide in Leiden fell under the jurisdiction of the criminal
court. Each case of suicide or possible suicide was subject to a postmortem evaluation by court experts, upon whose recommendations the
judges of the Schepenbank issued sentences. Between 1575 and 1646, the
court conducted 399 post-mortem examinations and ruled that thirty-eight
of them were suicides. After 1646, no more cases of post-mortem
investigation appear in the court records and it would appear that the
criminality of suicide had, at least in practice, been suspended. A similar
pattern occurred in Amsterdam, where juridical condemnation of suicide
ended in 1658.9
Leidens suicide rate seems low, even in comparison to other
European countries in the seventeenth century. Jeffrey Watt, in his
masterful study of suicide in Geneva, uncovered forty suicides during the
same period, though that citys population was less than half of Leidens.10
Arne Janssons study of suicide in Stockholm does not include sixteenth
century figures but does suggest that if suicide and what she calls suicidal
murders are counted, the rate was higher than Leidens and was rising
rapidly.11 In England, McDonald and Murphy shy away from a great deal
of statistical analysis, citing problems with the records, but still indicate
that suicides rates in English towns during this time were as high as 10 per
100,000 and rose rapidly in the latter half of the seventeenth century.12
Leidens apparent exceptionality may also be due, at least in part,
to problems with the records. Across Europe, there was a strong social
stigma against suicide and, therefore, great motivation to disguise it for the
sake of propriety. There were also more tangible disadvantages. The legal
sanctions against convicted suicides included public display and
condemnation, property confiscations, and dishonourable burial. While
168
these penalties could certainly be substantial, there is evidence that they

weighed more lightly in the Netherlands than they did elsewhere in
Europe.
Public ritual executions and draggings were common European
practice for suicides.13 In 1587, for example, the Leiden court ordered the
body of suicide Jacob Jacobs to be dragged over the threshold of his
former house and afterwards to be hung in the gallows field to serve as a
mirror to others, but such spectacles seem to have been increasingly rare
in seventeenth century Holland.14 The Leiden court recorded only three
other cases between 1560 and 1650, each with extenuating circumstances.
In 1627, Jan Jorisz. committed suicide while imprisoned for sheep
rustling. After hanging himself in his cell, the court ordered that his body
be displayed at the gallows field with sheep fleece glued to it.15 In 1638,
the body of Joris Ballieu suffered the indignation of being displayed at the
gallows field, but he was a foreigner, originally from England.16 Finally, in
1639, the court convicted Adriaetngen Frederiz. of infanticide after an
examination of the body of her child. They sentenced her to death and
ordered that her body by displayed at the gallows field with a wooden doll
in her arms.17 Pieter Spierenburg, the foremost scholar on Dutch crime and
punishment, suggests that the gradual disappearance of punishment as a
public spectacle was characteristic of much of the seventeenth century
Netherlands.18
The confiscation of property was also rarely prescribed. In
England, confiscated property reverted to the Crown under the crime of
felo de se (a felon to himself). Between 1485 and 1660, English courts
declared 95% of English suicides to be felo de se, as opposed to only 2%
found to be non compos mentis.19 Tudor reforms strengthened the crowns
ability to prosecute suicides and to receive the confiscations as a source of
revenue, likely some several hundred pounds each year. 20 In Leiden, on
the other hand, the court prescribed confiscation in only one case of
suicide, that of the Englishman Joris Ballieu in 1638, though it was
frequently invoked in cases of capital punishment for other crimes. Their
actions had precedence in Dutch law. In the Carolina, a 1532 edict
concerning crime including suicide, Charles V favoured using confiscation
only in cases in which it was clear that the suicide was not motivated by
disease, melancholy, or mental deficiency, and/or when the suicide
occurred in connection to other crimes.21
In most suicide cases, the Leiden court did set restrictions on
burial. In most cases, suicides had to be buried during prescribed hours,
usually at night, and often with the admonition that the ceremony be held
in full silence. In some cases, bodies had to buried in areas outside of the
regular churchyard, perhaps symbolic of their separation from the
community. In 1592, the court required that the body of suicide Annetgen
Dircxdr. be buried in the place normally reserved for criminals.22 In 1602,
Lijsbeth Bartolomeesdr. died in prison where she was serving a term for
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169
infanticide. It is not clear from the records whether or not she committed
suicide, but the court ordered that her body be donated to the University
for anatomical research.23 The court usually dictated that female suicides
be buried at the Vrouwenkerk, though in 1624 they indicated that the body
of a male suicide, Pieter Isaaxszn Bats, be buried there as well.24 Burial at
night was certainly not desirable, but it was preferable to the alternative of
public display in the gallows field. In 1633, the court explicitly stated that
it would not condemn one suicide to the gallows field because it appeared
that he was not mentally normally and instead sentenced him to a night
burial.25 In several instances, family intervention swayed the courts to
hand down the lighter sentence of night burial.
The Leiden court did not seem to be inclined to judge the crime
of suicide harshly, even as their punishments for other crimes, such as
theft, escalated. This suggests that underreporting of suicide may not have
been as prevalent as it was in other places. On the other hand, the Leiden
judges still faced the problem of detection. Of the eighteen cases which
reported the method of suicide, thirteen were death by hanging, two by
stabbing, two by drowning, and one by poison. The court usually called
upon surgeons to perform the post-mortem investigations, but their
methods were certainly not foolproof. For example, in 1625, the case of
the body of Dionijs Maertenszn. baffled the authorities.26 They could not
determine the method of death and the court noted that there was no
apparent use of poison or signs of disease. In the absence of proof, they
granted permission for her body to be properly buried.
Drownings were more problematic. The court performed the vast
majority of post-mortem investigations upon bodies that had been
recovered from one of Leidens many canals. Living in a community
surrounded by water made drowning an all-too-frequent occurrence. While
they could easily establish the cause of death, the judges were less able to
ascertain whether the drownings were intentional or accidental. In light of
this, several early laws required that drowning victims be left with their
feet in the water by their point of recovery and other laws emphasized the
importance of witnesses and extenuating circumstances. In the period from
1575 to 1646, the court investigated 130 cases of death by drowning.27
Forty-four of these were children under the age of eighteen and so were
unlikely to be suicides. Thirteen cases were noted as being clearly
accidental. The other seventy-three cases are all possible suicides, though
the high incidence of drowning in the winter months strongly suggests that
people frequently found themselves literally and figuratively skating on
thin ice. The court consistently bestowed the benefit of the doubt in these
cases and allowed full burial privileges.
Many of the patterns exhibited by the Leiden court will not be
surprising to those familiar with the history of early modern suicide. In
England and Geneva, the end of the seventeenth century marked the
beginning of a period of relative leniency towards the punishment of
170
suicides and an increasing concern with the state of mind of the

perpetrator, a trend which would culminate with the full medicalisation
of suicide in the eighteenth century and the end of criminal suicide
prosecutions.28 What is noteworthy is that these transformations seem to
have occurred earlier in Leiden then they did elsewhere. Why?
Durkheim found the strongest correlations between suicide rates and
religion, noting that Catholic societies had lower rates of suicide than Protestant
ones. Other scholars have suggested that Protestantism, with its emphasis on
individual conscience, led to increased anxiety or despair and, therefore, a
greater tendency towards suicide.29 Durkheim, on the other hand, argued that
the differences were not strictly attributable to theological differences, but
rather to sociological ones. Catholic societies provided stronger support
networks, both formal and informal, for their members than their Protestant
counterparts. According to Durkheim, Protestantism was simply less conducive
to social integration than Catholicism. Unfortunately, all of the detailed studies
of early modern suicide come from Protestant countries so no comparison with
Catholic counterparts is currently possible, though many studies of
contemporary societies have tended to reinforce his thesis, albeit with some
qualification.30
The towns of the Netherlands, with relatively low rates of
suicide, would seem to disprove this thesis. Certainly, Watts study
suggests that Durkheims thesis did not hold true for early modern
Geneva, an undeniably Protestant state.31 The situation in Leiden is not so
clear cut. The religious complexion of the Dutch Republic in general and
Leiden in particular is very difficult to gauge. The Republic has long been
associated with Calvinism, but the identification is a superficial one. In his
influential essay, Dutch Civilization in the Seventeenth Century, Johan
Huizinga passionately argued that the spirit of Dutch society was not
Calvinist. The Reformed Church never achieved the position of State
Church and few of the leading lights of the Dutch Golden Age-including
Grotius, Vondel, and Rembrandt-were openly confessed Calvinists.32 By
most counts, Calvinists constituted barely 10% of the population in 1580
and did not constitute a majority even by 1650.33
The more difficult question is: if they were not Calvinist, what
were they? The Republic tolerated many faiths, and there were substantial
Catholic, Jewish, and Anabaptist minorities living within its borders, but
the religious beliefs of the remaining population, a substantial majority,
remain unknown. Jonathan Israel has suggested that they were cryptoProtestants and A.H. van Deursen called them liefhebbers, sympathetic to
Protestant beliefs but unwilling to submit to the disciplinary regimen
required for full membership.34 Others have suggested that the religion of
the Netherlands owes much to the Devotio Moderna movement and one of
its leading students, Erasmus. The libertines emphasized the highly
personal nature of religious belief and practice and the importance of
balance and moderation in religious affairs.35 On one hand, then, it would
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171
be incorrect to throw Durkheims baby out with the bathwater, as the

Dutch republic could not properly be called a Protestant state. On the
other hand, the dogmatically pluriform and radically decentralized state
of Dutch religion does not appear to be conducive towards generating
increased social integration.36 Of the eight suicide cases who registered
their marriages in Leiden, all of them did so civilly, choosing neither the
Catholic nor the Reformed ceremonies.
On the other hand, by 1641, Leiden was home to 3,500 Catholics
(7% of the total population) and approximately 17,500 Calvinists (35%).37
The population of Leiden had been decimated by a siege in 1574, and the
town magistrates, themselves Calvinists, worked to attract new residents
through a series of legal and financial enticements. Their efforts were
highly successful and the population grew spectacularly throughout the
early seventeenth century, largely due to the influx of new immigrants
from the southern Netherlands.38 The majority of these immigrants left
their homes for religious reasons and tended (throughout the Republic) to
be the most vocal supporters of orthodox Calvinism. In the factional strife
between the States and Orangist parties, the town of Leiden consistently
supported the latter, due in no small part to the Princes championing of
Orthodox Calvinism. Popular demonstrations in favour of the Prince of
Orange occurred frequently. In short, while the Calvinists may not have
constituted a majority of the population of Leiden, they had a significant
impact on its government and social structure. According to Durkheims
thesis, the plurality of religious faiths and the strong influence of the
Reformed Church should both point to increasing rates of suicide, but in
the case of Leiden, they do not.
If the answer to our question does not lie in the religious
character of the young Republic, perhaps we should widen our search to
include more variables. Dutch historiography has long been plagued with
the precocious modernity thesis, i.e. the idea that the Republic exhibited
characteristics of modernity--such as religious tolerance, high literacy
rates, capitalist economic growth--long before the rest of the world. In the
last fifty years, historians have poked many holes in the thesis, and the
conventional wisdom has settled on the compromise position that although
the republic possessed many of the apparent characteristics of modernity,
it lacked the spirit or ideology of modernity. More precisely, the Dutch
adopted policies, such as freedom of speech or republicanism, that may
have appeared forward-thinking or modern, but they did so by default or
inability, not intention.39 Could it be that their treatment of suicide follows
a similar trend?
Dutch leniency towards prosecuting suicides and their relatively
early termination of juridical suicide might be a sign of modern
enlightened attitudes towards death and the causes of suicide. Until the
seventeenth century, popular opinion attributed suicidal tendencies to
diabolic or demonic possession, usually as the result of witchcraft.40 The
172
Netherlands were among the first places to discontinue witch hunts and
trials, and there is little evidence of a belief in possession stemming from
the court records.41 By mid-century, the Leiden judges displayed clear
sympathy towards those suicides whose friends and relations testified that
they suffered from melancholy or mental incompetence. It is also possible
that the judges took the principle of freedom of conscience, as espoused
most eloquently by William of Orange, seriously and saw that it applied to
the freedom to choose ones own death, as is the case with modern Dutch
laws governing euthanasia and assisted suicide.42
Unfortunately, there is little evidence to support the idea that
Leiden city officials had developed a noble, ideological defence of suicide.
The rulings on suicide were not mitigated when it came to cases that did
not involve mental distress. The question is not prominent in the writings
of Dutch scholars. Spinozas contributions to the subject, for example, are
brief and largely oppositional.43 On the other hand, the subject was
definitely not ignored by Reformed preachers who continued to expand on
the evils of suicide, which had been recurrent topics with Luther and
Calvin. Popular books of Dutch emblems and poems spoke about suicide
as an affront to God, and images of Biblical suicide were reproduced in
popular forms, including Delftware tiles. The lesson to be learned? Life
was precious and not to be squandered by suicide.44 In the Netherlands,
popular culture was replete with pressure not to commit suicide.
It is far more likely that they had to discontinue their
investigations of suicide because the court simply became too busy to
handle its caseload. From 1550 to 1599, the court handled 131 cases,
including violent crimes and post-mortem investigations, the latter of
which constituted approximately 16% of its casework. From 1600 to 1649
that number jumped to 556, nearly 30% of which were post-mortem
investigations. These cases could be complicated as they could involve
conferring with experts, witnesses, and family and friends of the deceased,
especially with the apparent increased attention paid to the state of mind at
the time of the act. With few severe penalties other than ritual execution,
an act that was widely falling into disfavour, it would make sense for the
court to spend its time more efficiently elsewhere, especially in the
prosecution of violent crimes.45
Durkheim argues that modern suicide rates vary inversely with
homicide rates and that as a society develops, the latter will fall while the
former rises. Historians have generally assumed that suicide rates were
low during the Middle Ages, though records are scarce, and that rates
began to rise first in England during the seventeenth century and in the rest
of Europe during the eighteenth. In eighteenth century Geneva, Watt
found that suicides did increase precipitously and though homicides
decreased, they did so less dramatically.46 In Stockholm, the trend was
similar, though suicides did not increase as rapidly, perhaps due to an
increase in suicidal murder.47 This pattern directly contradicts the
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173
precocious modernity thesis because it suggests that the suicide rate in the
Netherlands remained pre-modern in the seventeenth century, despite the
trappings of modernity. Because suicide statistics are not available for
eighteenth century Leiden, it is not known if its rates followed a similar
pattern, though the decline is evident in other Dutch towns, such as Breda,
where not a single suicide took place from 1700-1795.48 Violent crime,
including homicide, assault, and rape in Leiden did markedly decline, both
relatively and absolutely, starting from the middle of the century, as Figure
1.1 shows.
FIG 1.1: Rates of Suicide and Violent Crime in Leiden
155016001650170017501599
1649
1699
1749
1799
#Violent Crimes 110
390
44
77
21
# Suicides
9
26
N/A
N/A
N/A
Population
12,000
55,000
65,000
45,000
31,000
(Approximate)
* The figures in column 1 (1550-99) and column 3 (1650-1699)
are likely to be distorted, as population was rising rapidly in the first
period and falling rapidly in the second. The average population figures
used does not adequately take this into account.49
Durkheim believed that the transition from high rates of homicide
to high rates of suicide was attributable to the alienation brought on by
modern economic life, including an advanced division of labour and the
nature of urban, industrial work. If this is the case, we are again left with
an apparent paradox as Leiden was primarily an industrial city, with an
urban workforce geared towards the mass production of goods for export
markets. The primary output of the city was in textiles, and from 1580 to
1648 annual output exploded to over 130,000 pieces valued closed to 10
million guilders.50 Of the 399 cases of accidental death investigated by the
court, 202 were identified by profession and of those 92 worked in the
textile industry (46%). Of the 38 cases of suicide, fifteen were identified
by profession and of those, 8 (53%) worked in the textile industry. At its
height, the textile industry employed roughly half the urban work force in
Leiden, so these percentages suggest that their numbers were not overrepresented in the frequency of suicide.51
In his study of Geneva, Watt proposed an alternative to
Durkheims definition of modernity. Similar to their Leiden counterparts,
the judges in the Consistorial court made thorough examinations of the
state of mind of suicidal men and women. In his examination of these
proceedings, Watt found that an increasing number of suicides felt
compelled to take their lives for what can prosaically be called reasons of
the heart. With the exception of spikes in suicidal behaviour during
174
periods of extreme social and political disruption, an increasing number of

suicides came from those victimized by love, either through broken
engagements, bad marriages, loneliness or similar troubles.52 From this,
Watt concluded that increased suicide is an unfortunate by-product of the
transition from traditional marriage patterns to those based more on
conceptions of romantic love.53
In the case of Leiden, such enviable records are not available, but
some hypotheses can be drawn about the state of romantic love. In only
one case is there enough evidence to suggest that romantic love may have
been a cause. In December of 1637, Aron Loovoet, a widower, married
Christina van de Walle, a recent immigrant from the Southern
Netherlands. Only six months later, he took his life and she quickly
remarried.54 In the seventeenth century, Leiden was a city of immigrants.
J.C.A. Briels estimated that 2 out of every 3 Leidenaars were born
elsewhere (though this figure is now regarded by most scholars as too high
and the most likely ratio is 40%).55 Marriages between two people born in
completely different places were the norm and matches made through
family and other traditional ties were less common, especially among the
lower classes. Because the majority worked in industry, there was little or
no admonition to wait for marriage until land could be secured to support a
family. Even in the early sixteenth century, the average age at first
marriage in Leiden was lower than the European average. It would seem
that romantic love had arrived in Leiden, but higher suicide rates were not
forthcoming, at least not yet.
So, is Durkheim completely unhelpful in explaining the low
suicide rates in seventeenth century Leiden and, by extension, for the early
modern Netherlands in general? Not if his argument is examined more
closely. In a 1989 article, Bernice Pescosolido and Sharon Georgianna
argued that the essence of Durkheims argument was the role of social
cohesion and the function of churches as natural communities. He focused
on religion because that was the main determinant of social networks in
many nineteenth-century societies, but it appears not to have been in the
seventeenth century, at least in Protestant countries, nor is it necessarily
the case today. Social cohesion, if it is not too restrictive, provides
individuals with a sense of meaning and order in their lives and a large
support group to help them in times of trouble.56 Was there perhaps
another source of social cohesion in Leiden, one that was largely
independent of the church and the state?
In his classic work, The Civilizing Process, Norbert Elias
suggests that the harbinger of the modern state was the process of selfdiscipline, first adopted by European elites in an effort to distance
themselves from the lower ranks of society. This discipline focused on
control over arbitrary, impulsive, or instinctive behaviour, and included
such behaviour as the cultivation of table manners and the suppression of
violent activities, including sports.57 As these behaviours trickled down to
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the middle and eventually the lower classes, the result was a society with
much lower rates of violent crime, but also one that could more easily be
ruled by a central authority, which Elias linked to the acceptance of
totalitarian regimes in the 1930s.58 In looking at crime and capital
punishment in the Netherlands, Spierenburg has found ample evidence to
support the spread of the civilizing process, albeit in a slightly different
form than Elias original, and has linked it to not only the decline in
violent crime, but also to the end of exemplary punishment. 59
Michel Foucault has also looked at changes in crime and
punishment in the early modern period. In some sense, his conclusions are
similar to Elias in that discipline played a decisive role in changing
attitudes, but he puts the locus of discipline not on the individual but on
the state and state-sponsored bodies. Rather than trickling up, discipline
trickles down in Foucaults model, as states work to achieve and
institutionalise docile populations.60 Both theorists conclude that the
ultimate result of disciplinary regimes, be they personal or political, is
increased power for the centralized state. This conclusion is clearly
problematic for the Dutch republic, which lacked a central bureaucratic
apparatus sufficiently large to effect such changes or to take on such
powers, and it continued to lack these until well into the nineteenth
century.
Supporting the conclusions made earlier against Durkheims
religion thesis, John Bossy says that the period of the Reformation did not
produce many significant differences between Catholic and Protestant
societies. Protestantism and Counter-Reformation Catholicism, he argues,
were simply slightly different responses to the same underlying reality, the
transition to a radically new social structure.61 In both Protestant and
Catholic countries, the result was the same--the migration of the holy, as
he calls it, or the shift in the responsibility for order and control from the
Church to the State, in which sense he concurs with Elias and Foucault.
The problem is that in the early modern Netherlands, the holy had
nowhere to migratethe central state was simply too weak to perform
these functions. Instead, those functions fell by default on the new and
previously existing intermediary institutions---guilds, church, family, the
military, public funds, orphanages, etc. The strength of these institutions
explains why factors that would normally affect suicide rates-economic
and political upheaval, large amounts of immigration -result in very little
change in suicide rates in Leiden.
The court records support such a conclusion in several ways.
First, the few suicides that are found are drawn overwhelming from the
ranks of those not fully incorporated into these networks. Most of the
suicide victims had been born elsewhere and none of them appeared to
have obtained full citizenship in the town, even during the period when the
fees for this privilege had been greatly reduced. Only two of the Leiden
suicides have entries in the rolls of the local churches (both Protestant). At
176
least three had been prisoners. Finally, the suicide rates were higher for
those who lived and work outside of the city (i.e. in rural areas), a trend
that has reappeared in the twentieth century and has no known parallel
anywhere else.62 These suicides were men (and women) on the margins of
the social world.
One such intermediary body was guilds. Although the Dutch may
have possessed the first modern economy, they did not achieve this by
consciously applying the principles of classical economics. Their economy
was driven by workers who were firmly enmeshed in a moral economy
normally considered incompatible with modern capitalism or a modern
worldview in general. In Leiden, guilds were not primarily instruments of
self-regulation, but of social control. According to Robert DuPlessis and
Margaret Howell, the town magistrates supported and maintained the guild
system in order to keep the amount of work spread out among a number of
small enterprises, thus preventing the rise of larger conglomerations. Such
conglomerations could potentially threaten not only the livelihoods of a
large number of town residents, but also the power of the town to control
its own affairs.
Accordingly, in Leiden a large number of the suicides were
apprentices or temporary workers (about 20% of those reported), many of
them middle-aged or older, who were not subject to the full benefits of
guild membership. This may suggest poverty as a cause of suicide, but
wages in the Netherlands were higher than the rest of Europe and rose
throughout most of the seventeenth century. Certainly, fluctuations in the
fortunes of the textile industry (and others) produced structural
unemployment, but there is considerable evidence that temporary workers
floated from town to town throughout the republic, and possessed the
ability to move to where work could be found. Suicide was not limited to
the economically marginal, as it also took the life of the daughter of the
schout and several men who practiced highly-skilled trades that would
have been in heavy demand.
Another powerful social intermediary was the church. The
disciplinary tactics of the Reformed Church are well-known, especially as
practiced in the Calvins model godly community in Geneva. How do they
apply, though, in a state such as the Netherlands where church and state
were separate? In a 1993 article, Philip Gorski argues as follows:
Calvinismconsisted not only of a work ethic but an
ethic of self-discipline. In order to maintain selfdiscipline, the Calvinists employed a wide variety of
techniquesthese included regular devotional readings,
frequent prayer, and moral logbooks or journals. Yet why
would anyone voluntarily adhere to such a harsh creed?
Part of the answer no doubt lies in purely religious needs
and interests. But self-discipline also contained a status
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claim, that is, a claim to moral superiority. While this

claim likely exercised general attraction, it had a
particularly strong affinity to the interests of political
elites, for self-discipline could buttress or even replace
birth as a sign of fitness to rule. The Calvinist ethic was
therefore suited not only to justifying the economic
activities of a nascent economic class but also to
legitimating the domination of rising political elites.63
Calvinist discipline applied only to those 30% of the population
who belonged to them, including those who held public office, who were
required to be members of the Church. That 30% had to face formal and
informal disciplinary procedures, from regular home visits from clergy to
sentences passed by the courts, which included the crimes of bankruptcy,
drunkenness, or sleeping in church. Another 10% of the population fell
under the disciplinary sway of the smaller Anabaptist churches, who were
also noted for their strict disciplining of members. The Calvinists also
worked to extend their influence to the rest of the population by building a
host of charitable institutions, including workhouses, organized poor
relief, orphanages, and even prisons.64
There were other institutions that inspired strength of mind
outside of the guilds and the churches. Gorski cites the increased
discipline in the army as just one example. The reforms of Maurice of
Nassau led to an army that was more standardized, organized, and
supervised than the European norm. Elsewhere in Europe, soldiers had
exhibited high rates of suicide, but not one soldier in Leiden committed
suicide, though the court did examine the bodies of six soldiers who had
met untimely deaths in other ways.
Even families, Protestant and non-Protestant, became
increasingly important conduits for the transmission of behaviour norms as
the nuclear family emerged as perhaps the most important site of
associational identity in the Netherlands beginning in the sixteenth
century.65
The majority of the Leiden suicides were men, about two thirds,
which was the typical pattern in most of Europe. Watt posits the thesis that
marriage was more important to men and that they found bachelorhood
difficult. Women, on the other hand, often found the married state more
onerous. His conclusions are supported by the Leiden records, as eighteen
of the male suicides were bachelors, versus only three that had wives and
ten of the female suicides were married, versus only one that was not.
Marriage, especially for men, clearly had integrative functions. Children
had a special place in Dutch society and their parents treasured them
above all possessions, so the lack of children may have been a factor
leading to suicidal despair.66 Unfortunately, the court records do not
contain information about children, except when the victim itself is a
178
child. In five cases, the family of the suicide victim intervened on his or
her behalf, but it is not clear if this means children, parents, or extended
family members. There were changes made in the structure and curriculum
of schools during the period, in many ways designed to impart moral
messages and to instil in children the values of obedience and restraint.67
The fragmentary evidence available from the Leiden court
records suggests that the intermediate, corporate groups in Dutch society
acted as effective agents of social cohesion, knitting together the disparate
elements of the Dutch state, in a manner that was strengthened by the
absence of interference from a centralized state. Rather than instituting a
repressive regime, theirs was a grass roots movement, achieved not by any
central mechanism, but by the collective decisions of thousands of Dutch
people adapting to the circumstances in which they found themselves after
independence. The social forces of the Dutch towns produced a state and a
people much stronger, politically, economically, and morally, than either
historians or contemporaries have been willing to give them credit for.
Notes
1
Emile Durkheim, Suicide: A Study in Sociology. Trans. John A.

Spaulding and George Simpson. (New York: The Free Press, 1951), 309.
2
Emile Durkheim, The Rules of Sociological Method. (New
York: Free Press, 1964), 4.
3
S. Gargas, Suicide in the Netherlands. American Journal of
Sociology 37 (1932), 697-713.
4
For more details see James Tracy, A Financial Revolution in
Habsburg Holland. (Berkeley/Los Angeles: University of California Press,
1985).
5
For Brussels, see F. Vanhemelryck, De criminaliteit in de
ammanie van Brussel van de late middeleeuwen tot het einde van het
Ancient Regime (1404-1789). (Verhandelingen van de Koninklijke
Academie voor Wetenschappen, Letteren en Schone Kunsten van
BeligieKlasse der Letteren, 43, 97, 1981). For Ghent, see A. van
Werveke, Bijdragen tot de Geschiedenis en de Oudheidkunde van
Vlaanderen. (Ghent: Van Rysselberghe & Rombaut, 1927). For Breda, see
J. van Haastert, Beschouwing bij de criminele vonnissen van de
schepenbank van de stad Breda uit de jaren 1626 tot 1795, Jaarboek van
de Geschied- en Oudheidkundige Kring van Stad en Land van Breda De
Oranjeboom 29 (1976), 77-79.
6
P.J Blok, Geschiedenis eener Hollandsche Stad Vol. 2: Eene
Hollandsche Stad in de Middeleeuwen. (The Hague: Martinus Nijhoff,
1910), 223.
7
Blok, 223.
8
Blok, 228.
Laura Cruz
179
Pieter Spierenburg, The Broken Spell: A Cultural and

Anthropological History of Preindustrial Europe (New Brunswick, 1991),
177.
10
Jeffrey Watt, Choosing Death: Suicide and Calvinism in Early
Modern Geneva. (Kirksville, MO: Truman State University Press, 2001),
24.
11
Arne Jansson, From Swords to Sorrow: Homicide and Suicide
in Early Modern Stockholm. (Stockholm: Almqvist and Wiksell
International, 1998), 26 and 50.
12
Michael Zell, Suicide in Pre-Industrial England, Social
History xi (1986), 309-310.
13
Lieven Vanderkerckhove, Van Straffen Gesproken: De
bestraffing van zelfdooding in het oude Europa. (Tielt: Lannoo, 1985), 5372.
14
H.M van den Heuvel, De Criminele Vonnisboeken van Leiden
1533-1811. Leiden: Rijnland, Tijdschrift voor Sociale Genelogie en
Streekgeschiedenis voor Leiden en Omstreken 1977-8 n. 14 and 15, 43.
15
Van den Heuvel, 171.
16
17
18
Pieter Spierenburg, The Spectacle of Suffering: Executions and
the Evolution of Repression: From a Preindustrial Metropolis to the
European Experience. (Cambridge: Cambridge University Press, 1984).
19
Michael McDonald and Terence R. Murphy, Sleepless Souls:
Suicide in Early Modern England. (Oxford: Clarendon Press, 1990), 16.
20
McDonald and Murphy, 27.
21
Vandekerckhove, 87.
22
Van den Heuvel, 51.
23
Van den Heuvel, 72.
24
25
26
27
For a comparison, see Karla Oosterveen, "Deaths by Suicide,
Drowning, and Misadventure in Hawkshed, 1620-1700," Local Population
Studies 4 (1970): 17-20.
28
For a discussion of this, see Michael McDonald, "The
Medicalization of Suicide in England: Laymen, Physicians, and Cultural
Change, 1500-1870," in Framing Disease: Studies in Cultural History, ed.
Charles Rosenberg & Janet Golden (New Brunswick, 1992), 85-103.
29
See for example H.C. Erik van Midelfort, "Religious
Melancholy and Suicide: On the Reformation Origins of a Sociological
Stereotype," in Madness, Melancholy and the Limits of the Self, ed.
Andrew D. Weiner and Leonard V. Kaplan, 41-56 (Madison, 1996).
180
30
See for example K.D.Breault, Suicide in America: A Test of

Durkheims Theory of Religious and Family Integration, 1933-1980.
American Journal of Sociology 92 n. 3 (1986), 628-56.
31
Watt, 263.
32
J. Huizinga, Nederlands Beschaving in de Zeventiende Eeuw.
Haarlem: H.D. Tjeenk Willink and Son (1941), 98.
33
L.J. Rogier, Geschiedenis van het katholicisme in NoordNederland in de 16e en 17e Eeuw. Vol. 1. Amsterdam: (1945), 439
34
Jonathan Israel, The Dutch Republic: Its Rise, Greatness, and
Fall 1477-1806. Oxford: Clarendon Press (1995), 85. A.Th. van Deursen,
Plain Lives in a Golden Age: Popular Culture, Religion, and Society in
Seventeenth Century Holland. (Cambridge: Cambridge University Press,
1978), 262.
35
Ben Kaplan, Hubert Duifhuis and the Nature of Dutch
Libertinism Tijdschrift voor Geschiedenis 105 (1992), 1-19.
36
Source of quote: Israel, 85.
37
Israel, 390.
38
Dirk Jaap Noordam, Nieuwkomers in Leiden, 1574-1795. In
In de Nieuwe Stad: Nieuwkomers in Leiden 1200-2000 ed. Jaap Moes and
Ed van der Vlist, 39-85. (Leiden: Dirk van Eck, 1996), 41.
39
See for example S. Groenveld, The Mecca of Authors? States
Assemblies and Censorship in the Seventeenth-Century Dutch Republic.
In Too Might to be Free: Censorship and the Press in Britain and the
Netherlands ed. A.C. Duke and C.A. Tamse, 63-86. (Zutphen: De
Walburg Press, 1987).
40
For a general discussion of this shift, see Jeffrey Burton
Russell, Mephistopheles: The Devil in the Modern World. (Ithaca, NY:
Cornell University Press, 1986) and P. Spierenburgs The Broken Spell.
41
The last (known) death sentence for witchcraft in the
Netherlands was in Schoonhaven in 1597. (Source: Van Deursen, 252.
42
For a fuller discussion of the modern debate over morality and
euthanasia in the Netherlands, see David C. Thomasma et al, ed. Asking to
Die: Inside the Dutch Debate about Euthanasia. New York: Kluwer
(1998). The Dutch law allowing euthanasia and assisted suicide was
enacted on April 10, 2001.
43
Steven Barbone, "Spinoza and the Problem of Suicide,"
International Philosophical Quarterly 34(1994): 229-41.
44
Ron M. Brown, The Art of Suicide. London: Reaktion Books
(2001), 115.
45
Vandekerckhove develops a similar argument (and a few
others) about the end of confiscations and prosecutions in the last section
of her Van Straffen Gesproken, see pages 139-150.
46
Watt, 57.
47
Jansson, 16 and 26.
Laura Cruz
48
181
Van Haastert, 78.

Source for population figures: Noordam, Nieuwkomers in
Leiden, 39-85. Source for violent crime figures: Van den Heuvel,
Criminele Vonnisboeken. The content of this text has been partially
digitized and can be accessed at:
http://esf.niwi.knaw.nl/esf1998/projects/criminal/.
50
Jan de Vries and Ad van der Woude, The First Modern
Economy: Success, Failure, and Perseverance of the Dutch Economy,
1500-1815. (Cambridge: Cambridge University Press, 1997), 285-6.
51
For a fuller discussion of the role of the textile industry in
Leiden, see N.W. Posthumus classic multi-volume study, De
Geschiedenis van de Leidsche Lakenindustrie. (The Hague: Martinus
Nijhoff, 1939).
52
Watt, 223-229.
53
Watt, 251.
54
Doop-, Trouw-, en Begraafregisters Leiden, Huwelijken voor
Schepenen 1592-1795, available at Digitale Stamboom Leiden,
http://leiden.websilon.nl.
55
For the different views see Noordam, 45.
56
Bernice A. Pescosolido and Sharon Georgianna, Durkheim,
Suicide, and Religion: Toward a Network Theory of Suicide, The
American Sociological Review 54 (1989), 43.
57
Norbert Elias, The Civilizing Process, Vol. 1: The History of
Manners. (New York: Pantheon Books, 1982).
58
Norbert Elias, The Civilizing Process Vol. 2: Power & Civility.
(New York: Pantheon Books, 1982).
59
See Pieter Spierenburg, Elias and the History of Crime and
Criminal Justice: A Brief Evaluation. IAHCCJ Bulletin 20 9 (1995), 1730.
60
Michel Foucault, Discipline and Punish. The Birth of the
Prison. trans. Alan Sheridan and Allen Lane (Penguin: London, 1977).
61
John Bossy, Christianity in the West 1400-1700. (Oxford:
Oxford University Press, 1985).
62
See Austin L. Porterfield, Suicide and Crime in Folk and in
Secular Society. American Journal of Sociology 57 (1952), 331-338.
63
Philip Gorski, The Protestant Ethic Revisted: Disciplinary
Revolution and State Formation in Holland and Prussia. The American
Journal of Sociology. 99. No. 2 (1993), 273.
64
For prisons see Pieter Spierenburg, The Prison Experience.
(New Brunswick, NJ: Rutgers University Press, 1991). For orphanages
and poor relief, see Anne McCants, Civic Charity in a Golden Age:
Orphan Care in Early Modern Amsterdam. (Chicago/Springfield:
University of Illinois Press, 1997).
49
182
65
For studies on the family as a site for indoctrination and

discipline, see the following: R.A. Houlbrooke, The English family 14501700 (1984); J. Flandrin, Families in former times (1979) C. Hill, `The
spiritualization of the household' in Hill's Society and Puritanism (1964),
S. Amussen, An Ordered Society: Gender and Class in Early Modern
England (1985); and L. Roper, The Holy Household: Women and Morals
in Reformation Augsburg (1989). For a specific discussion of the role of
families in the Netherlands, see P. Spierenburg, The Broken Spell, chapter
8: Family Life: Bonds Between Men and Women, Parents and Children,
227-287.
66
Schama, chapter on Children.
67
Simon Schama, The Embarrassment of Riches: An
Interpretation of Dutch Culture in the Golden Age. (Berkeley/Los
Angeles: University of California Press, 1988).
Voluntary Death in Japanese History and Culture

Lawrence Fouraker, Ph.D.
Abstract: Stereotypes exaggerate the extent and bizarreness of voluntary
death in Japanese history, emphasizing widespread hara-kiri by
medieval warriors or the kamikaze pilots of World War II. Actually,
samurai who committed suicide were exceedingly rare, the deaths of
kamikaze pilots were far from voluntary, and the relatively few Japanese
who committed suicide did so in the same manner as in the West. Where
the culture of suicide in Japanese history is indeed strikingly different
from the West involves Japanese attitudes towards suicide. Japanese have
often tolerated or even admired those who took their own lives. To explain
this unique cultural attitude toward voluntary death we will review the
historical evolution of suicide and attitudes toward it in this distinctly nonWestern, non-Christian culture. One might expect traditional attitudes
toward those who take their own lives to become anachronistic as Japan
underwent rapid modernization (and Westernization) from the late 19th
Century. Yet public reactions to a series of suicides of novelists and
intellectuals throughout the 20th century demonstrate the persistence of
these traditional attitudes. The strong emotional resonance of traditional
attitudes toward voluntary death even today constitutes part of the core
cultural identity of the Japanese people.
Key Words: Mishima, suicide, Japan, Arishima, samurai, hara kiri,
seppuku
1.
Introduction: Voluntary Death as Japanese Culture
25 November, 1970. Japanese novelist Mishima Yukio strode

onto the balcony of the Self-Defence Force Headquarters at Ichigaya.
After haranguing the crowd below, reading them his Manifesto
lambasting Japans materialism and disrespect for traditional values
(designed to rouse the soldiers to action), he shouted out three times:
Long Live His Majesty the Emperor. Then, after retreating inside the
building, in the midst the jeers of the young Self-Defence Force volunteers
below, Mishima carried out a samurai-style seppuku suicide, slitting his
bare abdomen with a razor-sharp short sword, and then literally
disembowelling himself with a vertical cross stroke.1 Morita Masakatsu,
close follower of Mishima and member of his militaristic Shield Society,
tried to serve as Mishimas second by beheading the bleeding author
with a long sword, but failed. Another Society member Koga Hiroyasu
184
successfully completed that beheading, and then cut off Moritas head as
well after the latters botched attempt to follow Mishima in ritual suicide.
Mishimas suicide struck many Japanese observers as
anachronistic nonsense. Arguably just as reflective of popular Japanese
attitudes toward the self-destruction samurai-style emulated by Mishima is
the movie Seppuku (1962, directed by Kobayashi Masaki). This film
brutally emphasized the cruelty and barbarism of the seppuku custom, as a
desperate young samurai in the early 17th Century is forced to carry out the
ritual act with a bamboo sword, having pawned his real sword due to
poverty.
Westerners, and sometimes the Japanese themselves, tend to
exaggerate the tendency toward self-murder in Japanese culture.2 For
instance, Emile Durkheim remarked: The readiness of the Japanese to
disembowel themselves for the slightest reason is well known.3
Durkheims careless comment may indicate a different understanding of
suicide in Japanese culture and in the West. What he considers the
slightest reason was, after all, more important than even human life itself
to those who killed themselves in this manner.
Actually, though, the suicide rate of Japan in both premodern and
modern times may not be significantly higher than in the rest of the world.
Modern Japanese suicide rates are only slightly higher than the average of
other developed countries (and given the attitudes toward voluntary death
we consider here, there may be less reason for those who take their lives to
hide their suicide in Japan). Recent data show that impoverished former
Soviet countries like Lithuania and Belarus have higher rates of suicide
than Japan. But so do France and Austria.
Yet as Mishimas death confirms, at least some Japanese still
have a traditional tolerance, or even a respect and admiration for those
who take their own lives. How are we to explain the persistence of these
very traditional values in a postmodern context? The historical cultural
heritage of samurai seeking death before dishonour is surely pertinent.
Other cultural influences include non-Christian concepts of reincarnation
coming from the imported Indian religion of Buddhism, and a preference
for groupism over individualism, which may translate into less emphasis
on the sanctity of individual lives. As the method of Mishimas suicide
suggests, one key to understanding the culture of suicide in Japan lies in
the past, in the traditional values embedded in its long history.
2.
Samurai and Death
The Way of the Samurai is found in death.4 The opening line of

Yamamoto Tsunetomos Hagakure seems to confirm that the Way of the
Warrior (Bushid) is in fact a cult of death. Yet Yamamoto penned these
lines in 1616, a year after the last significant samurai battle for more than
Lawrence Fouraker, Ph. D.
185
two centuries. In other words, this classic of Bushid was a product of

an age of peace, not warfare.
Not only are some of the most-cited versions of the Way of the
Warrior (bushid) a later construct. Further complication emerges from a
study of the centuries of battle from which samurai practices of selfmurder actually emerged. For it turns out that voluntary death among
warring samurai was actually quite rare. Earlier versions of Bushid are
more aptly called the Way of the Bow and Arrow (kyusen no michi) or
the Way of the Bow and Horse. Even Tsunemotos famous opening lines
about the way of the samurai being death can be read not so much as an
endorsement of suicide as advise to be prepared to die and to not cling to
life. It is, in short, a call to bravery, not a celebration of suicide.
Certainly death itself was no stranger to the warring samurai of
medieval Japan. The 11th Century Konjaku Monogatari recounts some of
these early battles, which resulted in the display of the severed heads of
defeated enemies. But many other battles were individual confrontations
between two warriors, with much lower casualty rates. Mass slaughter on
Japanese battlefields came only with the arrival of Western muskets in the
late 16th Century.
Yet if many samurai even during ages of warfare died of old age,
the practice of ritual suicide by samurai warriors (seppuku) occupies a
prominent place in most considerations of suicide in Japan. The first
probable case of seppuku was by Minamoto Tametomo, scion of a warrior
family facing defeat by the Taira clan in 1170. Gradually the self-murder
by samurai sword became a ritual, with a second (kaishakunin) to lop
off the dying mans head, ideally after he has carried out the excruciating
second crosswise cut (jumonji; literally in the shape of [the Chinese
character for] ten) to fully disembowel himself. By the Tokugawa age
(1600-1868), seppuku had become a Shint-influenced ritual with
ceremonial cleansing and white cloth aplenty.
In addition to the original motive for seppuku, to prevent capture
by an enemy, there were other causes. Suicide for remonstration (kanshi)
was a way to subtly influence ones superior, who you would not dream of
directly criticizing. In 1553, for instance, Hirate Nakatsukasa Kiyohide
apparently took his life to encourage the young general Oda Nobunaga to
alter his behaviour. One can consider Mishima Yukios death to fit at least
loosely in this category as well, since he hoped to change the course of
Japanese history with his act. Another type of seppuku was to make
amends for ones own wrongdoing (sokotsu-shi). Not a particularly
common cause of death, it evinced a popular response in the premodern
media. One famous case was of the Warring States general Yamamoto
Haruyuku who launched a suicidal attack against the enemy to compensate
for his own actions which endangered his lord in 1561. Wounded, he
retreated from the fray to take his own life.
186
3.

Fact and Fiction: Gauging Medieval Attitudes
The fact that Yamamoto wrote his Hagakure in the Tokugawa

period is full of insight to that peculiar and yet formative age for
traditional Japanese culture and attitudes toward death. Following more
than a century of war, the Tokugawa shgun initiated policies designed to
keep the country at peace. These policies were so successful that some
samurai (and indeed, as we shall see, some non-samurai as well) looked
back longingly to a golden age when warriors actually lived by the
sword.
Most historical cases of seppuku were a product of the Warring
States period (1467-1600) preceding the pax Tokugawa, proving a
warriors loyalty and bravery in the face of death, as well as, on a practical
level, offering an alternative to the disgrace of capture by ones enemy.
During the two-and-a-half ensuing centuries of Tokugawa peace, instances
of seppuku were few and far between. But another type of suicide attracted
great attention during the Tokugawa erathe suicide of lovers. The
poignant emotional tragedy of lovers who saw no way other than to die
together also became the topic of popular puppet plays and Kabuki
dramas, often based on real-life incidents.
Chikamatsu Monzaemon (1653-1725) wrote two of the
undeniable masterpieces of Japanese drama dealing with the actual
suicides of ill-fated lovers: Love Suicides at Sonezaki (Sonezaki Shinj,
1703) and Love Suicides at Amijima (Shinj ten no Amijima, 1721)5
These poignant tear-jerkers, popular with theatre audiences from
Chikamatsus time on, are dramatic largely because of the irresolvable
dilemmas between duty and passion, chronicling the inevitable tragedy of
impoverished lovers who find no way to remain together other than death.
In a sense, the actual love suicides upon which Chikamatsus
plays were based, as well as the plays themselves, constituted texts that
represented a tacit protest against the overarching power of the state. The
Tokugawa bakufu repeatedly banned these plays because of their
potentially subversive message, even though they were always set in a
fictional ancient setting.
Yet another form of self-immolation in traditional Japan was
following ones lord in death (junshi). Generally this was a desperate act
by samurai whose lord had fallen in battle. Rather than become
masterless samurai (rnin), and in deference to their leader, they chose
to die.
Junshi was not a common cause of death. Most samurai preferred
to live on as rnin rather than die in this manner. But in the mid-17th
Century, as Japan became a country at peace, the incidence of junshi was
on the rise. Furthermore, these were cases of samurai who willingly died
after the death of their daimy from illness. Following a case in which
187
twenty-six followers of Nabeshima Katsushige in 1657, the Bakufu

formally prohibited junshi.6
4.
Traditional Death in Modern Times
After the Meiji Restoration of 1868 Japans leaders issued order

after order to destroy the immediate past and build Japan into a modern
nation. Yet old ideas and attitudes persisted. The 20th Century was only a
few years old when the Japanese public was shocked by a suicide. In 1903
a promising higher school student named Fujimura Misao had leapt to his
death from Kegon Falls. As a wave of copycat suicides took place, pundits
feared the social consequences of these anguished youth.
Many observers, at the time and since, attributed the suicide of
Fujimura and other anguished youth to their social isolation and
loneliness, portraying their anguish as the inevitable product of their
pursuit of individualism. In this view, by breaking with convention and
setting out to fulfil their individual potential, these young people
inevitably became anguished as they abandoned traditional values and
destroyed their relationship with their families and society. What actually
motivated Fujimura to take his young life is debatable. His cryptic suicide
note, carved on the tree above the falls where he plunged to his death,
makes no mention of loneliness or isolation, but rather refers to his
personal engagement with deep philosophical problems and the meaning
of life. Indeed, what was so shocking about Fujimuras case for many
Japanese was that he was dying not for the sake of country or emperor but
for his own individual reasons.
Fujimuras disenchantment with the power of ideas to explain
existence had led him to a personal dilemma. His attempt to escape this
intellectual dilemma through suicide terrified many Japanese, but inspired
many others. For those who scorned him, his willingness to die for what
they saw as trivial personal reasons suggested the need to inculcate
traditional values more thoroughly among an increasingly individualistic
younger generation. For those who admired him, Fujimura stood as a
rejection of the call for young people to dedicate their lives to making
themselves and the nation strong and rich. He was seeking deeper truths.
Founder of the Iwanami publishing house Iwanami Shigeo recalls that
many young people in those days were moved to tears by Fujimuras
anguish, which they saw not as the result of loneliness or isolation but as
proof of his commitment to the search for answers to the questions they
were all asking: Where did I come from? Where am I going?7 (Note that
both Fujimuras detractors and his supporters stressed the individual
motivation for his death, rather than the act of suicide itself, reflecting the
fairly tolerant attitude toward suicide in Japanese culture.)
Twenty years after Fujimuras death, we encounter the death of
an unusual intellectual and writer. Arishima Takeo (1878-1923) was a
188
popular Japanese novelist and a founding member of the White Birch

Society, an influential literary group advocating humanism and
individualism. The last few years of Arishimas life, and the manner in
which he died, has provoked as much interest and controversy as any of
his fictional works. The events leading up to his death seem to form a
tragic teleology. From around 1920 he produced few works of fiction,
suffering, literary critics argue, from an insoluble writers block. Then, in
1922, Arishima published One Declaration, an essay that predicts the
collapse of the bourgeoisie of which he was a member, and denies the
possibility of any productive involvement of people like himself in the
working-class movements that were about to transform Japanese society.
Many observers at the time and since have read this essay as a confession
of Arishimas social irrelevance due to his inability to participate in social
change. The dramatic denouement of Arishimas life came in 1922-1923,
when he gave away his inherited land in Hokkaido, and then committed
suicide with a married journalist.
Yet my own research convinces me that, far from the desperate
act of a tortured soul, Arishimas suicide was actually the culmination of
years of earnest pursuit of individual self-fulfillment. And the particular
character of Arishimas self-fulfillment through suicide reflects the
powerful influence of traditional Japanese culture on what was in most
respects a thoroughly modern man.
On 9 June 1923 Arishima and Hatano Akiko, a journalist for the
Fujin Kron, hung themselves in the Arishima family house in the resort
town of Karuizawa. The best explanation of their death is found in Love
the Plunderer, a 1920 essay that strongly endorses the view that even in
death Arishima was seeking to fulfil his project of self-realization. This
essay serves as an indispensable corrective to the view that Arishima died
to escape feelings of doubt and anguish.
The connection between Arishimas complex and unorthodox
view of love and his death with Hatano Akiko in Karuizawa emerges in
the following passage from Love the Plunderer, dealing with the
ultimate realization of love in the impulsive life:
Love takes as much as possible from the
outside world, leading to the growth and freedom of
ones individuality. Beginning close at hand, love
carries back its booty from every which way. The
stronger a persons individuality, the more striking is
loves action. If I take all of the person I love, and in
turn, all of me is also taken, at that time, we two
become one. Thereupon, nothing remains for me to
take, and nothing remains to be taken from me.
189
Therefore, at such a time, my loves death is

my death. Following ones lord to the grave or love
suicide in this way is extremely natural. Even if the
love between two people does not take from each other
completely, if my love can intensively do its work, my
individual growth will broaden more and more. In this
manner, a certain worlda world unbound by time and
spacewill be firmly formed within my individuality.
The ceaseless expansivity of this world will break my
hitherto existing habits, change my life, and finally,
destroy my weak and short-lived body. Thereby, my
body will explode.
In the final analysis, what does this sort of
self-destruction indicate for those who attack my
view? Simply the loss of ones physical body, and
nothing more? We are human. Eventually humans must
die. Eventually our bodies will decay. No matter what
we do, we cannot avoid this. But if I were to die on
behalf of love, these people would be wrong to think
that therefore the growth and freedom of my
individuality were lost as well. My physical loss is not
my individualitys loss. The ruination of my body goes
hand in hand with the expansion of the growth and
freedom of my individuality. (p. 345)
A serious reading of this passage in light of Arishimas steadfast
sincerity and lifelong pursuit of consistency between thought and action
makes it hard to see Arishimas suicide together with his lover was
nihilistic or the product of anguish and doubt.8 Indeed, in this essay
Arishima pities those who were so afraid of death that they dared not truly
love.
In a short poem published two months before his death in his own
magazine, Arishima explored the relationship between love and death. At
the burning peak of love, he wrote, an embrace is insufficient. Death is
what such a lover wants. So death arrives at the very moment life achieves
its fullest glow in love. What a contradiction! Arishima concluded.9 This
poem shows how Arishima privileged emotion above rationality. He was
well aware that in terms of rational thinking it was contradictory or even
foolish to seek to realize oneself in death, yet he believed that death was
the highest culmination of love in the emotional impulsive life.
Virtually every aspect of Arishima and Hatanos suicide conform
to the view of love suicide found in Love the Plunderer. And the letters
Arishima left behind in the Karuizawa house were also consistent with his
philosophy of love, what he told Asuke, and the letter of Akikos just
cited. In two of these letters, one to Akikos husband, and the other to
190
Arishimas mother and three sons, he provided little explanation for why
he was dying, but basically merely asks their forgiveness. He was
apparently aware that to explain his death to these people was an
impossible task. He told his mother and three sons that I know that to act
in this way is abnormal (ij).10 But, he continued, it cannot be helped.
His farewell letter to his family ended with the seemingly cold: Until it
came to this decision, how much I loved you! It seems that at the time of
his death, Arishimas love towards Hatano Akiko knew no bounds, even to
the extent of making the love he felt for his children and mother only
relative. In terms of the philosophy of Love the Plunderer, one would
have to conclude that Arishima died a satisfied man, even as he acted in a
manner sure to bring grief to his family.
In Arishimas final three letters he is more explicit about why he
and Hatano Akiko were taking their lives, probably thinking it more likely
that his siblings (who were fellow artists) and friends could understand his
decision to die than his mother and children. Writing at midnight on the
train to Karuizawa, he told his younger siblings that since he fell in love
with Akiko, he had realized my true fate for the first time in my life. He
emphatically stated that their death together had absolutely nothing to do
with any outside pressure. Rather, the two were full of freedom and joy as
they faced death. He reported that even as the train arrived at Karuizawa,
he and Akiko were laughing and chatting happily with each other. He
asked his siblings to consider he and Hatano apart from convention.
Likewise, in his brief note to Asuke Soichi, Arishima reported that they
had finally arrived at the dark Karuizawa villa, drenched from their long
walk in a heavy downpour, but that far from feeling gloomy, they were as
playful as two infants. Why? Until this moment, I had not realized that
death is nothing in the face of love. (He also asked Asuke to help take
care of Arishimas children, by providing them with the royalties from his
writings.) The note concluded with the frank remark that their bodies
would probably be rotten by the time they are discovered (indeed they
were). In Arishimas final letter, to Morimoto Kkichi, his close friend
since they were students together in Hokkaido, he requested that
Morimoto keep an eye on the communal farm, and once again insisted, for
the last time: We are dying together at the peak of our love. We are not
dying because someone is threatening us.
Further insight into Arishimas death emerges in his Masters
thesis, a review of the entire course of Japanese civilization from its
origins to the 19th century, written (in English) at Haverford College.11 In
the same way he had pondered what had motivated Fujimura Misao to kill
himself, in his thesis Arishima is fascinated by the highly emotional
motives that led characters in Tokugawa-era drama to commit love
suicide. He reveals the degree to which he treasures the emotional side of
life. He deplores how the feudal Tokugawa regime used the imported
philosophy of Confucianism to stifle the free expression of the Japanese
191
peoples native sensitivity and sentiment, which he saw as an excellent

cultural trait of the Japanese, and probably the only means they could
make some important contribution to the general progress of the world.
(pp. 231-232) In the context of a Tokugawa clampdown on the free
expression of feelings, the Japanese had to find some outlet for their innate
emotional expressiveness. Thus, Japanese commoners (and indeed, many
samurai as well) became great fans of the urban performing arts. Arishima
saw this drama to have reached its peak in Chikamatsu Monzaemon, who
he praised as Japans Shakespeare, and a powerful defender of the true
Japanese sentiment and character. (pp. 243-244)
Yet another famous Japanese intellectual took his own life only a
few years after Arishima and Hatano. But the death of Akutagawa
Ryonusuke in 1927 was a drastically different case. As he stated in his
suicide letter, A Note to a Certain Old Friend, Akutagawa was dying
because he was prompted by a vague sense of anxiety. Explicitly
reporting that he did not feel suicide to be a sin as Westerners do,
Akutagawa further expanded upon his reasons:
We humans, being human animals, do have an
animal fear of death. The so-called vitality is but
another name for animal strength. I myself am one of
these human animals. And this animal strength, it
seems, has gradually drained out of my system, judging
by the fact that I am left with little appetite for food and
women. The world I am now in is one of diseased
nerves, lucid as ice. Such voluntary death must give us
peace, if not happiness.
The contrast between Arishima and Akutagawa is striking.
Akutagawa died for the sorts of reasons many thought Arishima suffered
from. Both Arishima and Akutagawa are products of a society that
continued to tolerate and respect suicide at least in part because of its
traditional culture; otherwise, their cases could hardly be more different.
5.
Todays World: Terrorism and Culture Redux
During World War II, Japanese units suffered casualty rates

higher than fighting men in any other conflict. The defence of reinforced
Pacific islands such as Iwo Jima could be called a form of voluntary
death, as virtually the entire Japanese population of the island was
eliminated rather than surrendering. Likewise, the one-way pilots of
suicide torpedoes, bombs, and the notorious Kamikaze pilots also seem to
be in the tradition of suicidal behaviour. But I consider these to be a
separate case, since the coercion of fascist Japan during the Fifteen Year
War from 1931 to 1945 made these decisions far from voluntary.
192
(Sometimes this was literally true; one survivor of the supposedly allvolunteer Kamikaze corps reported that he was ordered to volunteer.)
Instead of that gruesome history, let us conclude with two more recent
stories, horrible enough in their own right.
In January 1985 a 33-year-old Japanese housewife walked into
the waves off Santa Monica, California. She took her 4-year-old son and
infant daughter with her. Pulled from the water by two passing college
students, Mrs. Kimura Fumiko survived to stand trial for the murder of her
children, who drowned. She insisted that she had not intended to live, but
was seeking to die and by taking them with her, to save her children from
the horrors of life without a mother.
For most Americans, regardless of any extenuating factors,
Kimura was clearly a murderer. Yet in Japan, it is a common defence that
such cases are not simply murder, but parent-child suicide (oya-ko
shinj). This form of suicide is illegal in Japan, but is generally
punished more lightly than murder. Kimuras attorney did not stress this
cultural explanation for her behaviour at the trial, but rather argued that his
client was temporarily insane. But the 20,000 signatures from Los Angeles
Japanese Americans on a petition for leniency may well have swayed the
judges sentence. The petition argued that in such cases, the mothers
intent is to save the child from a life of suffering without her. Indeed,
Kimura herself claimed that her children were extensions of her.12 For
this Japanese mother, her death was really the same thing as the death of
her children; she did not grant them an individual existence. Mrs. Kimura
seems to confirm an ongoing distrust of individualism and borderline
admiration for suicide among todays Japanese.
The response to Kimuras case also suggests that the emotional
resonance that Arishima Takeo had for love suicide in the plays of
Chikamatsu persists in the attitudes of many Japanese (and Japanese
Americans). As a penultimate example of this, consider one of the leading
members of a small Japanese terrorist group, the Red Army. Three
members of this group carried out a gruesome attack in the arrivals
terminal of Tel Avivs Lod Airport in May 1972. These Japanese terrorists
murdered 26 travellers (mostly Puerto Rican nuns) and wounded 76 other
bystanders.13 One of the three apparently threw himself onto his own hand
grenade after he ran out of machine gun ammunition. The only surviving
member of the terrorists was Okamoto Kozo, who had also tried to kill
himself by throwing grenades at a plane on the runway. Only when the
plane did not explode did Okamoto try to escape.
Only after the Israeli officer interrogating Okamoto, Major
General Rehavam Zeevi, promised the Japanese terrorist a gun and a
single bullet to commit suicide did Okamoto begin to talk.14 Interviewed
in jail, Okamoto spoke of his admiration for Japanese traditions of suicide
old and new: Even though Mishima and other Japanese suicide heroes
believed in anti-revolutionary or reactionary ideologies, their emotions
193
were the same as those of revolutionaries.15 Denied his wish death,

Okamoto was freed in a prisoner exchange in 1985 with the Palestinians,
and welcomed as a hero by Qaddafi in Libya. Okamoto clearly displays
both a flawed revolutionary consciousness and an ongoing grudging
respect for traditional forms of voluntary death. Similar sentiments linger
in the innermost emotional attitudes of many Japanese to this day.
Notes
1
The Chinese characters for seppuku may also be read (in reverse
order) as hara-kiri, literally belly-cutting.
2
For the use of the term voluntary death, see Maurice Pinguet.
Voluntary Death in Japan (Polity Press, 1993).
3
Emile Durkheim, Suicide: A Study in Sociology. The Free Press,
1951, 222.
4
Yamamoto Tsunetomo, Hagakure: The Book of the Samurai,
trans. William S. Wilson (NY: Kodansha International, Ltd., 1979), 17.
5
Steven Heine. Tragedy and Salvation in the Floating World:
Chikamatsus Double Suicide Drama as Millenarian Discourse. The
Journal of Asian Studies 53, no. 2 (May 1994): 367-393.
6
Ikegami Eiko, The Taming of the Samurai: Honorific
Individualism and the Making of Modern Japan (Cambridge,
Massachusetts and London, England: Harvard University Press, 1995),
219.
7
Sumiya Mikio,Dai Nihon Teikoku no shiren, 196.
8
In several emotional diary entries and letters Arishima confesses
feelings of despair. In a few cases he vaguely refers to being unable to
write, facing a deadlock or a terrible crisis. But he never explicitly links
these personal problems with his voluntary death. Rather, all of his
references to suicide are positive and strongly-worded. Furthermore,
Arishima attributes most of his difficulties in writing and the frustrations
in his life to the ongoing burden of his private property and how it
interferes with his creativity.
9
Arishima Takeo, Shi e no itsudatsu, Arishima Takeo zensh,
Vol. 9, 157-158.
10
The letters discussed here are found in Arishima Takeo zensh,
Vol. 14, 666-669.
11
Arishima Takeo, Development of Japanese Civilization From
the Mythical Age to the Times of Decline of Shogunal Power. Masters
Thesis, Haverford College, 1904. Thanks to Ms. D.F. Peterson of the
Haverford Library staff for arranging access to the thesis. (I later found
that it is also reprinted, albeit without Arishimas excellent penmanship, in
Arishima Takeo zensh, Vol. 1, along with a complete Japanese
translation.)
194
12
Japanese Mom who drowned children given probation,

Houston Chronicle, November 22, 1985, 2.
13
Ian Black, Israels Secret Wars: A History of Israels
Intelligence Services (1992), 269.
14
William R. Farrell, Blood and Rage: The Story of the Japanese
Red Army (Lexington, Massachusetts and Toronto: D.C. Heath and
Company, 1990), 139. Despite making his promise in writing, Zeevi did
not in fact offer Okamoto a gun.
15
Robin Morgan, The Demon Lover: The Roots of Terrorism
(2001), 172.
References
Arishima Takeo. Arishima Takeo Zensh. 14 Vols. Tokyo: Chikuma
Shob, 1980-1985.
Bryant, Tamie. Oya-ko Shinju: Death at the Center of the Heart. Pacific
Basin Law Journal, 8 (1).
Farrell, William R. Blood and Rage: The Story of the Japanese Red Army.
Lexington, Massachusetts and Toronto: D.C. Heath and Company, 1990.
Headley, Lee A., ed.. Suicide in Asia and the Near East. Berkeley:
University of California Press, 1983.
Heine, Steven. Tragedy and Salvation in the Floating World:
Chikamatsus Double Suicide Drama as Millenarian Discourse. The
Journal of Asian Studies 53, no. 2 (May 1994): 367-393.
Ikegami Eiko. The Taming of the Samurai: Honorific Individualism and
the Making of Modern Japan. Cambridge, Massachusetts and London,
England: Harvard University Press, 1995.
Lifton, Robert Jay, Kat Shuichi, and Reich, Michael R. Six Lives/Six
Deaths: Portraits from Modern Japan. New Haven and London: Yale
Minamoto Ryen. Giri to ninj. [Duty and Passion] Tokyo: Ch
kronsha, 1969.
Morgan, Robin. The Demon Lover: The Roots of Terrorism. 2001.
Morris, Ivan. The Nobility of Failure: Tragic Heroes in the History of Japan.
New York: Holt, Rinehart and Winston, 1975.
195
Pinguet, Maurice. Voluntary Death in Japan. Polity Press, 1993.

Sansom, G.B. Japan: A Short Cultural History. New York: AppletonCentury-Crofts, 1952.
Seward, Jack. Hara-Kiri: Ritual Japanese Suicide. Rutland, Vt., and
Tokyo: Charles E. Tuttle, 1968.
Suwa, Haruo. Shinj: Sono shi to shinjitsu. [Double Suicide: Its History and
Reality] Tokyo: Mainichi shinbunsha, 1977.
Yamamoto Tsunetomo. Hagakure: The Book of the Samurai. Translated
by William S. Wilson. NY: Kodansha International, Ltd., 1979.
Gender, Youth, and Suicide: Life and the Meanings of Death

in the Jazz Age
Kathleen W. Jones
Suicide is the third leading cause of death among adolescents and
young adults in the United States.1 In making sense of suicide, we focus on
the psychological the feelings of depression, hopelessness, and loss of
control that appear to lead some young people to see suicide as an alternative
to an unrewarding emotional life. Suicide narratives, told in suicide notes or
the stories of survivors, capture this private torment. But suicide also has a
public meaning. As the anthropologists and sociologists have argued, the
numbers and the stories of suicide are windows onto the soul of a culture as
well as the psyche of the individual.2 When the voluntary deaths are those of
young women, making sense of the suicides brings us to the nexus of a
societys beliefs about gender and generations.
This paper is a historical study of suicidal behavior of 113 adolescent
girls and young women as reported in the New York Times during the 1920s,
a decade well-known for both gender and generational tensions. According to
the headlines: Girl, 17, Commits Suicide; Girl, 17, Dies by Gas; Girl,
17, Tries Suicide; Girl Dies in 20-Story Leap; Girl Drinks Iodine in Pew;
Girl in Love Takes Poison; Girl Kills Herself by Gas; Girl Kills Herself
Calling on Friend; Girl Jumps to Death Off Ferryboat after Gay Night
Touring the Cabarets; Girl Lays Suicide to Broken Heart; and Girl Leaps
under Train. Publication in the press signified that the death was
extraordinary, unnatural, and deserving of public notice, but the stories
themselves were formulaic, factual and usually brief, consisting of an
identification of the victim, the location, the method, who found her; what
happened once she was discovered; and if possible, the motive.
These stories have nothing to tell us about changes in the numbers of
suicides or the suicide rate during the 1920s. Nor can they tell us why these
girls chose to die; newspaper accounts do not provide evidence for a
psychology of adolescent suicide. It is the ordinary, banal quality of the news
items, however, that makes these suicide narratives such excellent data for
exploring the cultural meaning of youth suicide in the 1920s.3 They can be
used by historians of death and dying to uncover folk beliefs, the
commonsense and immediate explanations of youth suicide. These folk
beliefs are important, not because of their distance from or nearness to the
interpretations created by psychiatrists, sociologists, and statisticians during
Life and the Meanings of Death in the Jazz Age
198
the 1920s, but because they embedded the victim and her act in a social
framework that provided for both public and private reconciliation to an
untimely and violent death.4
That framework in the 1920s was constructed out of the gender and
generational tensions of modernity. No figure captured the essence of
"modern" better than the flapper, the hedonistic young woman whose lifestyle
challenged a femininity that was submissive, domestic, matronly, and asexual.
5
As witnesses and reporters (and occasionally the girls themselves) recounted
the suicide stories, they did so in light of the behavior, the manners, and the
morals the cultural script of modern young womanhood.6
1.
Who
The suicide announcements began by constructing the victims

identity. Her social pedigree, personality, and appearance were as important to
the story as were her name and address. With these markers journalists
positioned suicide as part of the contest between traditional femininity and
modern views of independent young womanhood.
Her familys social status, her family relationships, and her race
established the young suicide victims membership in the broad community of
newspaper readers and writers. Racial identity contributed to social pedigree in
the 1920s and suicide appeared in the New York Times as a behavior of girls
privileged by their whiteness. In contrast, the suicidal behavior of girls from
all economic strata was newsworthy. These stories, however, were framed
less by class identity than by gender and age, a meaning evident in efforts to
situate each young woman within a family configuration. They were daughters
and sisters (and in a few cases wives). Even if the suicide victim lived alone,
in death her primary identity referred to family, facts in the story that
reaffirmed her dependent status as both a young person and a female.
Dependency and passivity, however, complicated the journalists task of
explaining the extreme individualism of the suicide.
By locating the suicides in the community as well as the family, the
stories made a space for suicidal behavior in the lives of the young. These
victims, despite family connections, were often represented as women on their
own. They were college students, or independent working girls in search of
wages or knowledge if not necessarily in pursuit of careers. During the 1920s
the independent female -- the flapper -- symbolized all that was exciting,
fashionable, and modern. Suicide stories in contrast pointed to one of the costs
young women might have to pay for their independence.
Kathleen Jones
199
The concept of despondency gave reporters an emotional link

connecting independence and suicide. In the press accounts despondency was
a personality quirk, not an innate quality of a young womans character, and in
the suicide discourse of the 1920s despondency was always situational. The
suicide victim became despondent because of some concrete experience loss
of a job, loss of a beau, loss of her health, loss of access to educational
opportunity. These were the shadows that marred a flappers freedom and
independence and supposedly led some to choose suicide.
When the press portrayed the girls as despondent, the stories
highlighted their relative powerlessness in protecting their independence. And
yet, in finding despondency at the emotional core of suicide, the press
accounts also held these young women accountable for their actions.
Despondency did not create a victim, in the sense that we, today, describe the
suicidal individual as a victim of psychological pain and trauma. Suicide in
the press of the 1920s was a choice, not an illness, if often represented as a
reckless or foolish one.
Like personality, a young womans appearance also helped to
construct identity and give meaning to her suicide. When the press reports
described the girls and young women as "pretty" or "beautiful," the news
accounts set these features in life against the death that was to follow. A
flawed body image might explain suicide (scars, a leg deformity) but beauty
made a womans suicide incomprehensible.7 Appearance, like family, was at
the core of female identity in the 1920s. But sometimes it was not so much
beauty as style that shaped the reporters efforts to convey the identities of
the victims, and here, the tensions surrounding modern young womanhood
were explicitly framed as a question of hair. If any one metaphor in these
stories spoke to the gender and generational conflicts of modernity it was
bobbed hair.8 The short boyish haircut represented the vanguard of 1920s
female fashion and in the context of the suicide stories, reporters described it
as a statement some girls literally did not want to live without. The
consequences of being fashionable, however, were not always what the
bobbers expected ; the press also reported on two incidents in which young
women attributed their suicidal acts to regret over the loss of their long hair.9
The news items in the local press used the subjects identity to situate
her in the community, enabling the reading public to frame a sympathetic
response to her unnatural death. But even as they generated sympathy, the
discussions of identity also conveyed the message that the independence
modern young women craved was not without risks.
200
2.

Where and How
When these young women chose to die, they also chose the setting
and in describing the physical context of each act reporters did more than add
sensation to their stories. Press images of the bedroom suicide and the public
suicide memorialized and moralized about the expectations of young women
in modern society.
When a young woman was found lying on her bed, with a picture of
her lost love on the pillow, or lying on her bed with a book open to a poignant
passage, or lying on her bed with love letters strewn about,10 witnesses and
reporters interpreted their poses as evidence of the failure of modern romance.
The easy companionship between young men and women that seemed a
benefit of 1920s youth culture showed up in suicide stories as potentially
disastrous for the girls. The flappers boyfriend, according to these dramas,
was a fickle fellow, his promises not to be trusted.11 Other young women
chose public spaces and audiences of strangers for their suicide performances.
In these instances, the news reports often told stories of thwarted romance
similar to those of the bedroom suicides, Whats the trouble love affair? a
police officer asked Gloria [Seeho] Seijo, on her way to the hospital after
jumping in front of a subway train. Youve struck it, the eighteen-year-old
reportedly replied.12 But the tale of the public suicide conveyed other
messages as well. The public places ranged from high school corridors to
ferry boats to subway platforms, from standing in front of a police station to
standing in front of a church, to standing in front of a Chinese restaurant, from
Morningside Park in the morning when mothers were walking their babies to
the corner of Broadway and 49th at 1:00 AM with a city patrolman nearby.
According to these stories, the modern young women could be found nearly
anywhere, doing nearly anything, including expiring, in public.
News reports allowed readers to stare at both the bedroom scenes and
the public spectacles of youth suicide, but the death notices offered more
protection from lurid reporting to those who died in their beds. Based on these
reports readers might assume that those who died at home did so decorously,
with poison, gas, or the occasional gunshot wound. Their actions suggested
elements of true womanhood; their deaths fit more closely the sentimental
death scenes of nineteenth-century Victorian drama. And their suicides could
be contained within well-understood hierarchies of age and gender. In
contrast, those who chose to act in public often did so before strangers and the
accounts given by witnesses suggest that these strangers saw in the acts the
kind of flair associated with the new-style young woman of the 1920s. The
public settings for these stories pointed to the opportunities young women
Kathleen Jones
201
found in the modern city; the suicides cautioned that when young women
attempted to take advantage of these opportunities, their actions might well
culminate in an unnatural death.
Suicide settings outside the home also gave reporters license to
describe the consequences in gruesome detail. Contrast the description of
pretty Betsy Tevis, found in her room, her gown now stained red with blood,
with that of Dorothy Wilson, the pretty well-dressed girl whose leap in front
of a train left her wedged between the engine and the platform, being slowly
crushed to death13 or the even more gruesome description of the
dismemberment of another subway jumper, her head and leg falling to the
platform below.14 Descriptions of appearance after suicide made clear that
despite their modernity, girls still faced special risks in public, even when the
ultimate aim was self-destruction.
In news accounts the location of the body, like the identity, positioned
suicide as an emotional consequence of unsettled gender and generational
relationships.
3.
Why
Beyond who and where and how, the reporters wanted to write about
why and the stories from the 1920s ascribed the young female suicide to one
of four reasons: unrequited love, poverty, illness or school problems.
In her recent work on gender myths in suicide research the
psychologist Silvia Canetto argues that, by projecting female suicidal behavior
as primarily a response to problems in personal relationships, the current social
science literature is merely reflecting popular assumptions about female
dependence and passivity.15 Current literature, Canetto might have added, is
built on a long tradition of assigning to love the explanation for a womans
suicidal behavior.
The suicide stories from the 1920s certainly did a great deal to
substantiate beliefs that women turned to suicide when prevented from being
with a particular suitor. The press was captivated by stories of the suicides of
young women who had been jilted and reporters and editors also liked the
melodrama of a couple kept apart by unreasonable circumstances, the Romeo
and Juliet scenario.
The references to love as a motive for the female suicides of
the1920s might be read as popular belief in female dependence, as Canetto
argues, because the stories certainly contained a message about the importance
modern young women attached to marriage. 16 But Id like to suggest that in a
decade rife with stories about companionate marriages and other forms of
202
sexual freedom, dying for love stories can be read as more than commentary
on female foolishness or female dependency. Suicide also warned young men
that their behavior, their relationships with women were not inconsequential.
Dying for glory (to use Canettos phrase for achievementmotivated suicides) may not be a part of the current social science mythology
of female suicidal behavior, but it was certainly a component of folk beliefs
about the young female suicide as represented in press accounts from the
1920s. For younger girls, school provided a context for accomplishment;
academic failure or a teachers reprimand could explain the suicidal behavior
of adolescents. For young adults, it was sometimes college, but more often the
world of work shaped their ambitions and framed accounts of their suicides.
News reporters deemed the failure to get or keep a job an understandable
motive for suicidal behavior. But reporters, quoting witnesses and victims,
also observed that leisure was as great a necessity for young women as was
employment or school. Or, as Lillian Feinstein, put it in a letter to her mother,
all my life is work and there is no time for pleasure . . . I do not care to live17
The expectations of her work as a maid kept Lillian from pleasure.
More often, however, restriction on leisure time or social activities came from
parents. This motive situated suicide in conflicts between mothers and
daughters over appropriate female behavior.
The new forms of public amusement available to the young were
central to these conflicts, and in press accounts both mothers and daughters
saw suicidal behavior as a reaction to the limits mothers imposed on when and
where daughters could go, and the punishment mothers imposed for going
out without permission. Seventeen-year-old Estelle Corrigans suicide, for
example, took place after her mother chastised her for going out so much in
the evenings.18
If marriage was the goal to which young women aspired, they also
expected getting there to be fun. The suicide stories reminded parents of the
limits on their ability to constrain the social activities of their modern
daughters much as the stories of thwarted love cautioned men about the
serious consequences of toying with modern romance.19 Amusement and
romance, freedom and marriage, public and private, the young women of the
1920s were individualists intent on tradition and traditionalists intent on
breaking boundaries. Similar explanations for female suicide can be found in
other eras but how those explanations made sense of suicide in the 1920s was
specific to the way young women were positioned and positioned themselves
in the decades realigning of gender and generational relationships.
Kathleen Jones
4.
203
Conclusion
The meaning of suicide was written on two levels in the news stories
of the 1920s. On the one hand, the stories offer up the shared beliefs used by
the press and the public to explain the individual untimely death. On the other,
the stories reveal a deeper cultural meaning, one in which accounts of suicide
served as a conduit for messages about gender, youth, and modernity.
In looking for motive, the press and the public defined suicide as a
conscious choice in light of a specific situation. Such a characterization, I
would argue, made the suicide death easier to absorb than the current
characterization of suicide as illness signified by hopelessness, depression,
and despair. And it may help to explain why suicide, tho the subject of so
many stories in the press of the 1920s was not yet perceived to be a public
health problem of any import.
Beyond accounting for an unnatural and untimely death, the suicide
stories of the 1920s appeared in the press as cautionary tales not only for
young women, but also for young men, and their elders. In the descriptions of
the victims, the accounts of the death scenes, and the interpretations of
motives, the news items warned that modernity brought risks and came with
costs. Such a reading, however, would represent only a part of the meaning of
these youth suicides. Taken together, the stories resonate with tension:
between the limited opportunities for the young to affect their social situations
and the power they claimed through acts of self destruction; between the
individual expression of death and the blurring of individual identity in the
explanations that followed; between the expectations of feminine behavior and
gruesome acts of self-destruction these women perpetrated; and between the
intimacy or privacy of death and the public forums in which young women
chose to exhibit suicidal behavior. In many ways, the suicidal behavior of
these young women can be read as one of the signs of modernity. By telling
suicide stories the reporters and the witnesses underscored the emotional
ambivalence with which this culture confronted modern life.
Notes
1
U.S. Department of Health and Human Services, Centers for

Disease Control and Prevention, National Center for Injury Prevention and
Control, Suicide in the United States,
http://www.cdc.gov/ncipc/factsheets/suifacts.htm. (December 20, 2003)
2
Soucrces I have found particularly insightful include Michael F.
Brown, Power, Gender, and the Social Meaning of Aguaruna Suicide, Man
204
(new series) 21 (1986): 311-328; Silvia S. Canetto and David Lester, Gender,
Culture, and Suicidal Behavior, Transactional Psychiatry 35 (1998): 163190; Lisa Lieberman, Leaving You; The Cultural Meaning of Suicide
(Chicago: Ivan R. Dee, 2003); and E. Thomas Ewing, "Personal Acts with
Public Meanings: Suicide by Soviet Women Teachers in the Stalin Era ,"
Gender & History 14 (2002): 117-137.
3
Suicide, to quote Barrie M. Ratcliffe, is a banality which is never
mundane. Suicides in the city: Perceptions and Realities of Self-Destruction
in Paris in the First halfof the Nineteenth Century, Historical
Reflections/Reflexions Historiques 18 (1992): 2.
4
Howard Kushner has argueded that in the nineteenth-century
psychiatry became the language used by the public to express a connection
between suicide and modernity. This essay suggest that folk beliefs about
suicide were much less influenced by psychiatric models than Kushner
suggests. See Howard I. Kushner, Suicide, Gender, and the Fear of
Modernity in Nineteenth-Century Medical and Social Thought, Journal of
Social History 26 (1993): 461-490.
5
See Laura Davidow Hirshbein, The Flapper and the Fogy:
Representations of Gender and Age in the 1920s, Journal of Family History
26 (2001): 112-137; and Paula S. Fass, The Damned and the Beautiful;
American Youth in the 1920s (New York: Oxford University Press, 1977).
Birgette Solands study of young women in Denmark also shows the
connection drawn between the flapper and modernity. See Becoming Modern;
Young Women and the Reconstruction of Womanhood in the 1920s (Princeton:
Princeton University Press, 2000).
6
Canetto discusses cultural scripting or patterning in her work on
gender and suicide, see the previously cited article Gender, Culture, and
Suicidal Behavior; and also Meanings of Gender and Suicidal Behavior
during Adolescence, Suicide and Life-Threatening Behavior 27 (1997): 339351.
7
Scar New York Times (NYT) 1/4/1925, p.28; leg deformity -- NYT,
12/3/1923, p. 13; freckles, NYT, 6/29/1922, p. 7.
8
Soland, Becoming Modern, discusses the significance of bobbed
hair. On the significance of body image see also Joan Jacobs Brumberg, The
Body Project; An Intimate History of American Girls (New York: Random
House, 1997); and Margaret A. Lowe, Looking Good; College Women and
Body Image, 1875-1930 (Baltimore: Johns Hopkins University Press, 2003).
Kathleen Jones
205
Bobbed hair stories: NYT, 7/28,1922, p. 1; 9/11/1922, p. 3; and

9/7/1927; on the significance of being denied the hair style see, Ruth Shonle
Cavan, Suicide (New York: Russell and Russell, 1928), 153-154.
10
Romance stories with staging: NYT, 3/17/1922, p. 1; 11/20/1922,
p. 3; 6/21/1923, p. 23.
11
See Kevin White, The First Sexual Revolution; The Emergence of
Male Heterosexuality in Modern America (New York: New York University
Press, 1993).
12
NYT, 6/17/1922.
13
NYT, 12/10/1920; 10/15/1921.
14
NYT, 6/11/1921 mangled, her head and leg fell into the street
below and the rest of her body was jammed under a truck.
15
See Silvia Sara Canetto, She Died for Love and He for Glory:
Gender Myths of Suicidal Behavior, Omega 26 (1992-1993): 1-17. I do not
mean to imply that this motive was new to the 1920s. Dying for love has a
long literary history and one can cite stories by both Shakespeare and Gothe as
evidence. I mean only to suggest that the familiar belief about female suicide
was perpetuated during the 1920s.
16
Canetto, She Died for Love . . . See also Margaret Higgonett
Suicide: Representations of the Feminine in the Nineteenth Century, Poetics
Today 6 (1985): 103-118, who argues that during the nineteenth century, a
woman who lost her man was presumed to have lost her identity.
17
NYT, 3/15/ 1923.
18
NYT, 9/1/1922.
19
It is somewhat surprising, given that the press so often recorded
love was as a motive, that with only one exception, the news stories did not
allude to pregnancy as a factor in the suicide. The single instance was a
suicide compact, as two adolescents ended a two-year romance with
strychnine. The boy was just beginning in business and not in a position to
support a wife, and then, the reporter wrote, the time came when they felt
they must marry quickly. The financial obstacles were insuperable, they
thought they could not tell their parents, and suicide seemed the only answer.
The death announcement was a detailed melodramatic account of the last
goodbye kiss and the downing of the poison, followed by the convulsions, the
terrible symptoms of that form of death. (NYT, 12/27/1921.) Yet it brings
together several of the themes in the stories of young female suicidal behavior
the romance and the sensual pleasures sought in modern courtship, the
poverty that made young people vulnerable, and the parental flaws that
206
prevented young women from developing trusting relationships with their

mothers.
Part XI
At The End of Life
I think experience and gut feeling go together:

Hospice Nurses Accounts of the Hours Immediately
Preceding and Following Death
Dr ET Waterhouse, Dr C Exley PhD, Dr M Lloyd-Williams
Abstract: A small-scale, exploratory, qualitative study using semi-structured
interviews and focus groups was conducted at two English hospices. Eight
nurses were interviewed. Interviews were audio-taped, transcribed verbatim
and analysed independently, using the constant comparative method, by two
research team members. Emergent themes were validated, in two focus
groups, which were also analysed.
This paper explores four emergent themes: maintaining patient
integrity, how nurses spoke to relatives and friends, how nurses cared for the
patient after death and how nurses personal experiences influenced the care
they gave.
Maintaining dignity and respect for the patient, friends and family
was vital. Nurses used two different forms of knowledge knowledge of
each patient and their own professional and personal experiences. This
knowledge influenced nurses communication style and the language they
used and allowed nurses to treat patients as individuals both before and after
death.
Nurses described care after death as an extension of their duty of care
and they attempted to maintain integrity and individuality until the patients
body left the building.
By talking about these issues, nurses provided an insight into the care
of patients and relatives and also explored what it means to be a palliative care
nurse. They also showed how strategies ostensibly used to maintain dignity
and respect for others also had benefits for nurses themselves.
1.
Introduction
In 1998 I (EW) moved to a new post in a hospice in Leicester. It was

a busy specialist unit with 24 beds, staffed by experienced nurses. On average,
there was one death a day.
I soon noticed that the nurses rarely used the word died, preferring
to say that a patient passed away - a common euphemism in English. This
led me to question why, in a specialist unit dealing with death, the nurses were
unable to use the words dead and died.
210
I think experience and gut feeling go together
I therefore set up a small project interviewing nurses, to talk to them

about the language that they used around death and dying. During the
interviews it became clear that there was much more to talk about and the
context widened to include the ways in which they supported the families and
dealt with the bodies of patients who had died.
2.
Methods
Clearly, it would have been inappropriate for me to conduct this

research in the hospice where I was working, because of the relationship I had
with colleagues. Therefore I contacted two hospices elsewhere in England and
gained permission to interview the staff.
Nurses volunteered to be interviewed and I travelled to their place of
work to conduct the interviews. I used semi-structured interviews and audiotaped the whole process. I transcribed all the tapes verbatim, and analysed the
data with my supervisor, a medical sociologist. We used a constant
comparative method, such that new themes that were identified in one
interview were explored in subsequent interviews. I stopped the interviews
when I had reached saturation - in other words, when no significant new
themes were being identified. In all I interviewed 8 nurses, ranging in seniority
from the ward sister (in charge of the ward) to Health Care Assistants
(unqualified nurses). 4 had done the ENB 931 course on the care of the dying.
1 has a Diploma and one a degree in Palliative Care. One is currently doing a
BSc in nursing practice.
My supervisor, Dr Exley, and I inspected the data, and identified
emergent themes. These were validated, and areas of divergent opinion
explored, in two focus groups, which were also taped, transcribed and
analysed to check and validate the findings of the interview data
3.
Results
The nurses all spoke at length, and with some passion, about their
work and the way in which they tried to do the best job possible for the
patients and their relatives. All the nurses said they tried to work within
professional boundaries and were proud of being able to maintain their
integrities as professionals. As we shall see later, this was not always as clear
cut as they thought! For the remainder of this paper I shall use the word
relatives to mean family and friends close to the patient and involved with
their care.
ET Waterhouse
211
Interestingly, many nurses found it difficult to put into words exactly

what their practices were when dealing with patients and their relatives before
and after death, and what the reasons for these practices were. We tried at the
focus groups to clarify their thinking with them, but this was very difficult.
Four main themes were identified - maintaining patients integrity,
how nurses spoke to family and friends, how nurses cared for the patients after
death and how nurses personal experiences influenced the care that they gave.
I will now explore each of these themes separately.
A. How nurses spoke to family and friends
When I started the interviewing process, I made an assumption that
the nurses used the language that they did because of their own concepts of
what the right language was. However, as so often is the case, things proved
not to be quite so simple! In fact, not all nurses felt the same about the
language that they used, and they fell into two quite distinct groups.
Some of the nurses felt that they should use nice language - in other
words they felt that the language they used should be gentle, and designed so
as not to involve any further harm (such as distress or upset) to relatives.
This involved avoiding the words dead and dying and using euphemisms.
Died seems a bit harsh and a bit abrupt and blunt I
suppose. Its not - I know its just a word and its
obvious whats happening so youre not shielding them it just seems a softer word than died.
I suppose if you used the words gone or passed away,
[you are] trying to protect them a little bit from the blow.
Others felt that the best way to approach this was to be very direct to
the families.
I say died because its a very direct thing. I think you
cant pussyfoot round itbecause that is whats actually
happened. Passed away they could think - well I dont
know what they might think. I need to be direct.
Nurses varied in their flexibility, with some using direct words such
as dead, dying and died all the time and others moderating their language to
suit the people to whom they were talking.
212
So how did nurses decide how to speak to families? They used

several different types of knowledge often using more than one method and
finding it difficult to express exactly what they were doing when
communicating.
Intimate knowledge of the patients and their families was vital:
knowing what language they used, how they were reacting to the illness and its
progression, and how they reacted to the stresses that they encountered.
You have to treat each family and patient differently and
its the skills I think of knowing how to deal with that
person and family at that moment.
Not all nurses had had formal training in communication skills, but
even those who had felt that their ward experiences were vitally important/
was more important? Value of practical experience over theoretical
knowledge? Experiential learning was seen as vital:
Theory-wise we do quite a lot of palliative and terminal
care, but nothing teaches you as much as the real thing.
You know I still observe the senior nurses and I still
learn every day from them but I suppose its your
experiences that teach you.
Its a privileged position because that family are going
through such emotions But you cant get that feeling out
of a book. You cant get that by someone telling you. You
have to be there and you have to be part of it.
B. Maintaining patients integrity
Because of the way in which the interviews were structured, this was
referring to the treatment of the patient during and after death. The only way to
maintain patients integrity as people was to find out what was important to
them before they died by building up a relationship with them:
I think probably if there wasnt any close family and wed
built a relationship with the patient and we knew it was
important then we would do it. (Nurse talking about how to
treat the patient after death)
ET Waterhouse
213
But integrity is closely linked to dignity and the nurses were keen to
maintain patients dignity before and after death. They tried to maintain
physical dignity for example by making sure that the patient wasnt exposed
in a way, physically, that they wouldnt have wanted.
We had a gentleman who was huge and who was nursed
without any clothes on. And he died and it was obvious
that we werent going to be able to get him into our
fridge we had just taken him down in the mortuary
area but not in a fridge and I came back up and realised this
chap had got no boxer shorts on. And that to me was just
awful. I mean people said youre actually going to hurt
yourself trying but in fact I managed to rope a couple of
people in and we found some boxer shorts and slit them
and put them on.
Maintaining patients integrity involves more than physical needs
though - it seems to involve treating the patients with respect.
I treat everybody and every person with respect and that
counts right up till their death.and after, till theyve
disappeared from here.
There was also an awareness of the patient as a person. This need to
respect integrity lasted through the period of dying into the initial care of the
dead body, which I will discuss below.
C. How nurses cared for the patients after death
All the nurses felt that their duty of care extended beyond the
patients death, until the body left the building, with one maintaining that it
continued until the funeral. Most of the time they treated the body as though it
were alive, or as they felt the patient would have wanted to have been treated.
You know ... it is still Mrs Jones or Mrs Smith isnt it and
[even though] theyre deceased theyre still a person arent
they still a human being...Im still identifying them with
being alive I supposeuntil they go from the ward.
One nurse found it difficult to talk of a dead patient as a body:
214

No I dont say body (Do you know why not?) Well, its
like theyre gone and its just a body, and the person isnt
there any more. It takes their person away really, which I
dont like.
In many ways the nurses treated the bodies as though the patient was
still biologically alive, with likes and dislikes still intact. This extended to
talking to the patients while laying them out - in the following quote one nurse
describes talking to a patient who has just died. She talks of laying out the
body, with the help of a colleague:
But I suppose whatever youre talking about well you might
say what do you think of that? and you know theyre not
going to answer but its like involving them. Still!
Not all nurses did this and for some it depended on whether they had
had a close relationship with the patient before death. It certainly seemed
easier for nurses to maintain the patients personhood if they had had a close
relationship with them before death.
I think when youve cared for somebody and got to know
them as a friendyou also find out if they like a
particular item of clothing say.... And I think its important
to me that I would carry that on after death as well.
Nurses drew on their own personal views and values when deciding
how to treat a body. With no patient preferences to guide them they used their
own personal experience, sometimes trying to imagine what they would want
if they were dead. For example, one of the hospices moved dead patients on a
bed through open areas of the building. There was then a dilemma over
whether to cover the dead patients face. One nurse expressed her strong
feelings:
I always used to say, Oh God dont ever cover my face up
like that when Im dead, when Ive gone
All of the nurses maintained that they were treating the bodies as they
did out of respect and acknowledgement of the person that they had been.
However, it seemed that the strategies they used also served to help them
personally to deal with the constant presence of dying and death in their work.
ET Waterhouse
215
Although they acknowledged that this might be a possibility they were

reluctant to confirm it, and found it difficult to explain.
One of the nurses explained why she puts a flower on the patients
pillow in the mortuary:
I dont think it makes a difference but it makes a difference to
me. It means its the last thing I can do for that patient and its a
respect not because Ive been taught it or I work in a hospice
I should put this on. [So how does it make you feel better to do
that?] It doesnt make me feel any betterits just respect.
For me its the final thing to do. Theyve died and thats the
final thing. I dont know.
This quote epitomises the difficulty that the nurses had in separating
out their needs as people from their role as nurses, and their difficulties in
explaining the different reasons they might have for acting in the ways that
they did.
D. Nurses personal experiences affecting the care that they gave
Many nurses described in detail epiphanies that had changed their
outlook on work and resulted in them choosing to enter Palliative Care as a
career. Some of these related to personal life and others involved experiences
at work. For example, one nurse described a death that she witnessed as a
student nurse in a general hospital:
I can remember my first death and the porter came and was
trying to drag this body onto the trolley, and being
absolutely horrified.
This event made the nurse very aware of the need to treat patients well even
after death.
Others described personal experiences such as the death of a parent or
general life experience:
I think you have to have been through life a little bit to deal
with death and relatives that are so upset. I think if youve
been there - Im not necessarily saying youve actually
experienced death - but I think you have to have had a few
ups and downs in life - you have to have lived a little bit
216

yourself to know how it feels inside. You cant relate to
those [issues] until youve been there and done a bit of it.
This study suggests that for the nurses interviewed the relationship
between themselves and the patient and family is of paramount importance.
Nurses spent a great deal of time explaining and illustrating how they took
great care to make a good relationship with the patient and family with
consequences both before and after death. They used different types of
knowledge personal, professional and intuitive - to gain as good an
understanding of the individual person as possible.
4.
Discussion
Communication was being led and influenced by the relationship with

the patient and the family. Glaser and Strauss developed the concept of
awareness contexts1; this was further developed by Timmermans, who
postulates that the concept of open awareness can itself be subdivided, and that
the level of awareness reached is conditioned by the individuals emotional
response to the information given.2 Field and Copp suggest that in the 1990s
doctors moved from closed awareness through open awareness back to what
they term conditional openness where the patient (or relative) is given
information at a level that is acceptable to them, with the understanding that
this level may change with time.3 We argue that the nurses in this study
worked hard to achieve this, but were pragmatic in the way they sought to do
so, developing individual and idiosyncratic approaches dependant upon the
family and the situation they found themselves in, and their own emotional
responses.
By using a variety of techniques to increase their knowledge of the
patients and relatives for whom they were caring, nurses were able to offer
individualised care, whether talking to relatives or dealing with a dead body.
They described treating the dead body with respect and meaning. In this
context, it may be useful to draw on the concept of social death. The
phenomenon of social death occurring before biological death is wellrecognised.4 There are many instances in which a person may be regarded as
being socially dead before biological functioning has ceased. I would argue
that, for the nurses I interviewed, social death occurred after biological death,
when the body left the building. This does not mean that the nurses thought the
patients were alive after death - but they accorded them social worth and
treated them with the same respect that they accorded a living patient. We
heard, from Garnet Crawford earlier in this conference, a definition of dignity
ET Waterhouse
217
as not what you do, but how you se the patient how better, then, to
maintain dignity after death than by seeing the body as somehow still alive.
Anna Taube talked earlier today about the need to maintain body image and
personhood when confronting serious illness. I argue that these nurses
maintain both of these at and beyond death, and hope to open up discussion as
to why they did this and how it helped them and the relatives. Perhaps this
type of care altered the care tenor of the institutions and was therefore
influential in the care of the living.
In her book, The Dying Process, Julia Lawton discusses the
phenomenon of patients being treated as bodies by hospice staff even while
they were alive.5 This leads to criticism of the hospice movements claim to
maintain patients integrity as people until the very end of their lives.
However, a recent study by Kabel and Roberts interviewed a large number of
staff in two inpatient units and found that they treated the unconscious patient
with respect, trying to maintain personhood.6 The nurses in my study described
extending this practice to the way in which they spoke to and interacted with
patients bodies after death.
5.
Further Work
The time surrounding death is difficult for families of the dying patients,
as well as for nurses. Whilst the number of nurses interviewed was small, the
recurrent themes which emerged from their interviews, and the personal and
professional experiences within the team, would seem to suggest that these nurses
experiences are not unusual within Specialist Palliative Care Units. It would be
interesting to replicate this study with hospital nurses, as this may illuminate
differences in philosophy and practice between different health care sectors, which
may in turn help with educational programmes to help improve care at the end of
life in non-specialist institutions.
Notes
1. Glaser BG and Strauss AL, Awareness and Dying (Chicago, Aldine
1965).
2. Timmermans S, Dying of awareness: the theory of awareness
contexts revisited, Sociology of Health and Illness 16 (1994): 322339.
3. Field D and Copp G, Communication and awareness about dying
in the 1990s, Palliative Medicine 13 (1999): 459468.
4. Mulkay M and Ernst J, The changing profile of social death,
European Journal of Sociology 2 (1991): 176-196.
218
5. Julia Lawton, The Dying Process, (Routledge, 2000).

6. Kabel A and Roberts D: Professionals perceptions of maintaining
personhood in hospice care Int J Palliative Nursing 9 (2003): 283-289.
Notes On Contributors
Dr Angela Armstrong-Coster
Dept. of Social Work
University of Southampton
Southampton, UK
aac@socsci.soton.ac.uk
Sally Cameron
Sue Cameron
Clinical Nurse Specialist
Centre for Palliative Learning
Pembridge Palliative Care Unit
Sungardens Hospice
St Charles Hospital
Pretoria, Ladbroke Grove
South Africa
Mira Crouch
Visiting Senior Research Fellow
School of Sociology
University of New South Wales
Sydney, Australia
Laura Cruz
Assistant Professor of History
Western Carolina University
Cullowhee, NC 28723, USA
lcruz@wcu.edu
Lawrence Fouraker
Department of History
St. John Fisher College
Rochester, NY 14618, USA
Elizabeth Gill, Ph.D.
Associate Professor of Sociology
Randolph-Macon College
Ashland, Virginia 23005 USA
220
Contributors
Jennifer Hart
Graduate Program in European History
Western Carolina University
Cullowhee, NC 28723 USA
Blake G. Hobby
Assistant Professor of English
University of North Carolina at Asheville
Asheville, NC, USA
Department of Health Care Programs
Iona College
New Rochelle, NY, USA
Kathleen Jones
Department of History
Virginia Polytechnic University
Blacksburg, VA, USA
Mikko Kallionsivu
The Finnish Graduate School of Literary Studies
Department of Literature and Arts
University of Tampere, Finland
Asa Kasher
Laura Schwarz-Kipp Professor of Professional Ethics
Philosophy of Practice and Professor of Philosophy
Tel-Aviv University, Israel
Kay Mitchell
Department of Psychology
University of Auckland, New Zealand
Siobhan ODriscoll,
Bereavement Co-ordinator,
Medical Social Work Department,
Beaumont Hospital,
Dublin,Ireland.
Contributors
221
Michele Angelo Petrone

Director of the MAP Foundation
www.mapfoundation.org
Centre for Medical Humanities
Dept of Primary Care & Pop. Sci,
Royal Free & UCL Medical School,
2-10 Highgate Hill, London N19 5LW UK
Antonio C. Sison, MD
Psychiatry, Psycho-Oncology
Department of Psychiatry
St Lukes Medical Center
Quezon City, Philippines
Karen Thornber
Department of East Asian Languages and Civilizations
Harvard University
Cambridge, MA, USA
Esther Waterhouse
Consultant in Palliative Medicine, LOROS Hospice, Leicester, UK;
Lecturer in Social Sciences applied to Medicine, Univ. of Leicester;
Director of Community Studies Unit, University of Liverpool
Medical School, UK
Jeremy Weinstein
Senior lecturer (part time)
London South Bank University
Faculty of Health and Social Care.
UKCP accredited gestalt psychotherapist
BACP accredited trainer.
Counsellor/psychotherapist
Researcher specialising in aspects of bereavement.
Kathleen Z. Young
Western Washington University
Bellingham, WA. 98225, USA

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Edited by

Making Sense Of:

Oxford, United Kingdom

Professor Diana Medlicott

First published 2004 by the Inter-Disciplinary Press

Inter-Disciplinary Press 2004

Cross-Cultural Practices of Mourning

Friends, Others, and a Postmodern Ars Moriendi

Images of Dying and Death

Extreme Makeovers and Reciprocal Relations

Death Beyond Words: The Art, Music, and Poetry of

Grief, Bereavement, and Counseling

The Context and Countours of Bereavement

Survivors and Protagonists

When the Protagonist is Death: Implicating Text and

Palliative Care and Hospice Organization

Cultural Interpretations of Delirium Symptoms in the

HIV and Grief

Diagnosis: The Receiving End

Between Organizations, Family and Death: Caring

Voluntary Death and Suicide

Gender, Youth, and Suicide: Life and the Meanings of

At the End of Life

of grief that does not have to be ascribed to any particular individual, we

this case nineteenth-century England and present day South Africa. By

forces in her re-evaluation of the role of non-traditional medical

their actions as contributing to their rather vaguely defined ideas of what

To you, the reader, these contributors are just names on a page.

Collective Emotions and National Mourning

John moved from the city to the country.

Speakers of English know how to use and understand simple sentences

Harry is very sad, having heard the news.

However, the similarity between ascription of collective actions,

Collective Emotions and National Mourning

Distributive meaning: What is ascribed to the group

Of course, sentence (4b) does not lend itself to such an analysis,

The town consists of six large communities. Each of

All members of a community that has suffered casualties

Assume, furthermore, that the sentence The town is sad is

Diffusive Meaning: What is ascribed to a group holds for

Under circumstances (S1)-(S6), sentence (4b) The nation is sad, having

Collective Emotions and National Mourning

The diffusive meaning is different from the distributive meaning

The family moved from the city to the country.

The town is happy. The war is over.

Generally speaking, it seems that when sentences that ascribe

Collective Emotions and National Mourning

mourning. The decision rested on no law or regulation but on a rarely

A criterion for proclamation of national mourning

What is meant by this constraint is that a criterion for proclamation of

National mourning should not be frequently proclaimed.

Notice that (C2) is a constraint on proposed criteria for proclamation of

Collective Emotions and National Mourning

National mourning ought to be proclaimed when one of the

Every municipality may proclaim a period of communal

Since the idea of a diffusive cover of a map is not easily

National mourning ought to be proclaimed when

The major justification for a bottom up criterion for

Collective Emotions and National Mourning

African American Population in Grief

My thesis is that the context of racism emanating from slavery

African American Population in Grief