From Threshold to Event Process and Experience

In his comprehensive history of death in the Western world, Philippe Aries (1974, p. 28) writes of the Middle Ages, "In death man encountered one of the great laws of the species, and he had no thought of escaping it or glorifying it. He merely accepted it with just the proper amount of solemnity due one of the important thresholds which each generation always has to cross." For well over a thousand years, death was a public event rather than the private family matter it now has become. Death was visible everywhere in life; it was intermingled with life and not conceived to be in opposition to life. "Thus death was not a personal drama but an ordeal for the community, which was responsible for maintaining the continuity of the race," Aries (1981, p. 603) writes. Death was "tamed" by ceremonies "both Christian and customary" (Aries, 1974, p. 12). The dying person's bedchamber was a place that the community could and did freely enter, where "each man would discover the secret of his individuality" (Aries, 1974, pp. 51-52). That individuality was built not on the psycho-emotional terms we associate it with today, but was instead a relationship between the worldly acts and passions of a lifetime and fate. Dying well, the artes moriendi of the 15th century, provided the model, until the 19th century, of how a spiritual passage, a crossing of a critical threshold from life into the unknown, should unfold. Though the deathbed scene was a public drama that encapsulated the fight of good against evil for the soul, it also embodied a private, intimate relationship between the act of crossing that threshold and the dying individual: "the fate of the dying man was decided for the last time, in which his whole life and all his passions and attachments were called into question" (Aries, 1981, p. 108).

For millennia, doctors were rare at the bedside and death was not conceived in a medical idiom. By the end of the 18th century, death began to be understood as located in the body, as resulting from something that happened to the body. Foucault (1975) describes the emergence of anatomic understandings of the body together with clinical understandings of disease in his history of modern medicine's "gaze," its apprehension of relationships among disease symptoms and internal organs. Then death came to be seen not as something that arrives from outside this world, but as a disease or a natural process to be known and attended to by doctors. The dying person became the patient. Medicine made death visible to the doctor who could see everything about disease and the body. In that transformation, the dying person became alienated from knowing, in the spiritual sense of an earlier era, his own death. By the 19th century, the terms in which death was understood had shifted from religion and the invisible, fateful crossing at the deathbed to medicine, a disease process, and the analyzable body. By the mid-20th century, that understanding came to include as well the "truth" of the dying patient as witness to and creator of his own identity (Armstrong, 1987; Arney & Bergen, 1984) and the fact that the biology of death itself could be negotiated for political purposes. Death became a process that encompassed life. Dying was a form, a style of living and its end-point was open both to varieties of psychological expression and to medical debate.

In their studies of death in the modern American hospital (which followed the unprecedented rise in hospital deaths in the United States), sociologists Glaser, Strauss, and Sudnow were the first to investigate how late 20th century dying is organized and understood through structural features of the hospital, especially medical and nursing staff interactions with patients and families. Who can speak about death and to whom, the ways in which emotions are revealed or concealed, and expectations about the timing and certainty of death all were shown to be socially elaborated, bureaucratically determined. Glaser and Strauss (1965, 1968) found that dying had a "trajectory," a duration and shape, which was conceptually useful in knowing how the passage from life to death was constituted. The work of psychiatrist Kubler-Ross (1969), published in the same period as the sociological studies, articulated and mapped the patient's voice through the dying transition so that it could be conceptually isolated as a process that lends itself to, and in fact needs, management by health professionals. A dying person, Kubler-Ross informed us, is a self-aware being with expressive needs. Dying came into its late-modern form as an experience that could be evaluated and inflected with value by the dying person and by others.

The modern hospice movement, generally considered to have started with the founding of St. Christopher's Hospice in Great Britain in 1967, arose during that same period. Fueled by the then widely acknowledged desire for individual control over the dying experience, the psychological staging of dying, and symptom management techniques, the hospice became a means of combining modern medical knowledge and practice with an imagined tradition of family and community that was thought to be an alternative to the growing bureaucratization and use of technology found in the hospital. Although less than 20% of persons in the United States and Great Britain die in hospice programs, hospice has become the symbol of the Western idea of "a good death," that is, a patient and family-centered process in which spiritual, emotional, and psychological labor are the focus of attention and in which symptom control is in the service of personal growth and awareness at the very end of life. Hospice has become a site of "healthy dying," moral order, and ultimate individualism (Seale, 1998; Walter, 1994). Yet the elderly, for whom biological death often follows social death, and for whom dying is frequently without reflexivity, lie outside the "good death" cultural ideal.

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