CONTEXTUALIZING
DEATH
Sonya Merrill, MD, PhD
Presbyterian Hospital of Dallas
January 27, 2004
OUTLINE
DEATH IN THE CONTEXT OF:
 Two Ancient Cultures
 Four Major World Religions
 Modern Medicine
 Society: Nationality, Ethnicity and Class
 The Individual
Ancient Cultures
Egypt
Mesopotamia
ANCIENT EGYPT
General Principles
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Preoccupation with life and desire to “continue
living” after death
Belief that Afterlife would resemble but
improve upon earthly life
Importance of continuing bodily existence (e.g.,
mummification, attempts to recover bodies, fear
of being eaten by animals)
“Ideal” life span: 100 years
ANCIENT EGYPT
The Soul

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Ba: the soul which animates the body, usually
represented as a bird flying away at the time of death
Akh: the spirit which also survives death and which
can be good or evil, equipped with “spells” that would
be useful after death
Ka: difficult to conceptualize but often represented by
a person’s image or statue and thought to be a
“protecting genius” after death
Suyt: a person’s shadow
ANCIENT EGYPT
The Body and its Preservation

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Mummification: removal of the decay-prone viscera
enabling preservation of the majority of the body
parts; process lasting 30-200 days
Step 1: Removal of entrails through left-sided thoracic
incision and storage in canopic jars bearing images of
the sons of the god, Horus
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Liver (human son, Imesty)
Lungs (ape son, Hapy)
Stomach (jackal son, Duamutef)
Intestines (hawk son, Qebekhsenuef)
ANCIENT EGYPT
The Body and Its Preservation

Step 2: Removal of other organs
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Heart: “seat of intelligence” so after removal was wrapped in
linen and replaced/sewn into chest cavity
Brain: not always removed as not deemed very important; when
removed, long hooked rods inserted into nostrils to snag tissue
Step 3: Application of the natron, a natural desiccant
Step 4: Complete drainage of all bodily fluids
Step 5: Careful wrapping of the body in hundreds of
yards of linen
ANCIENT EGYPT
The Body and Its Burial

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The Opening of the Mouth ceremony: eyes, ears, nostrils and mouth
touched to symbolize opening and person’s revival
Tombs: contained biographical information to preserve
occupant’s name, reputation; varied according to importance of
deceased
VIP burial arrangements:
 Old Kingdom: wooden coffin inside stone sarcophagus
 Middle Kingdom: human-shaped wooden coffin with mask over
mummy’s head inside stone sarcophagus
 New Kingdom: elaborately painted anthropoid nested coffins, e.g.,
Tutankhamun’s 3 nested coffins
ANCIENT EGYPT
Afterlife: The Rough Guide

How to get there:
Funerary texts: provided deceased with all necessary
information to navigate the afterlife
 By boat: sailing on day-night journey with the Sun God
 attainable using basic spells which were left in guidebooks near
the body
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Where to go when you arrive:
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Field of Offerings: land in the western horizon where deceased
would work in lush fields and orchards to produce offerings for
the god Osiris
Paradise: deceased reaps the fruits of his own labor and enjoys a
blissful existence
ANCIENT EGYPT
Afterlife: The Rough Guide

What to pack:
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Premise: deceased require basic provisions to survive in the
afterlife
Initially, basic provisions such as bread, beer, meat, wine, linens
were placed in tomb
Later, models of provisions were deposited to guarantee that
supplies would last
Who to bring with you:

Models of servants responsible for provisions were included so
that they could continue to produce necessary supplies forever
ANCIENT EGYPT
Conclusions
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Optimistic belief that all bodily and spiritual
aspects of person survived in afterlife
Great effort to ensure that deceased not only
survived but thrived in afterlife:
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Mummification
Opening of the Mouth ceremony
Elaborate burials with provisions
Guide books to the afterlife
Spells to ensure deceased’s safety
ANCIENT MESOPOTAMIA
General Principles
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Death is inevitable: “when the gods created men, they set aside
death for mankind and kept eternal life in their own hands”
Use of euphemisms: speaking of death summoned it, so “to die”
was: “to cross the Khubur,” “to go up to heaven,” “to go to one’s
fate,” “to be invited by one’s gods,” “to come to land on one’s
mountain,” “to go on the road of one’s forefathers”
A gradual process rather than an instantaneous end of earthly
existence:
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The individual corpse
The individual ancestor dependent on descendents’ offerings
After several generations, collective ancestral spirits
Finally, annihilation of individual and recycling into new soul
ANCIENT MESOPOTAMIA
The Soul
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Etemmu: ghost closely associated with physical
remains
Napistu: life force or “breath of life”
Zaqiqu: birdlike spirit able to fly and slip through
small spaces, associated with dreaming as it could
leave body when person was asleep; closest to modern
equivalent of soul
Both etemmu and zaqiqu descended with the body to
the netherworld at death; if the body had been
destroyed, then etemmu was also destroyed leaving
only shadowy zaqiqu which was deemed harmless
ANCIENT MESOPOTAMIA
The Body and Its Burial
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Preparation of body: ceremonial washing, tying the
mouth shut, perfuming, dressing in clean clothes
Public viewing: before the funeral
Burial: in the ground in a coffin, sarcophagus or tomb
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Elite buried in vaults below their house or palace while others buried
in public cemeteries
Last rite: a burnt offering, which in the case of the king
consisted of burning his throne, table, weapon and
scepter
ANCIENT MESOPOTAMIA
Funeral Customs
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Mourning rituals could last up to 7 days
Family and close friends were expected to participate;
in the case of the death of royalty, the entire population
had to mourn
Professional mourners sometimes employed
Funeral laments expressed mourners’ grief and
eulogized the deceased
Physical displays of grief: wearing plain clothes,
tearing clothes, wearing sackcloth, not bathing or
grooming, fasting
ANCIENT MESOPOTAMIA
Afterlife: The Rough Guide

How to pack:

take as many personal items as you can afford
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Travel provisions for the journey: food and sandals (or
a chariot, if you were wealthy)
Things you might need when you arrive: food,
weapons, toiletries, jewelry
Hostess gifts: to placate the netherworld gods
ANCIENT MESOPOTAMIA
Afterlife: The Rough Guide
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Where: underground
Climate: a rather dark, damp and dreary place
How to get there: cross demon-infested lands, pass the Khubur
River with the aid of its guardian god, gain entry through 7 gates to
the city of the netherworld with its gatekeeper’s permission
Your hosts: the royal couple, Nergal and Ereshkigal, and their court;
they welcome the dead, instruct them as to the local rules, and show
them to their lodgings in the netherworld (which did not appear to
be based on the deceased’s earthly behavior)
ANCIENT MESOPOTAMIA
Afterlife: The Rough Guide
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How to be happy there: your happiness after death depended on the
quality and quantity of offerings made to you by your relatives;
offerings had to be made continually to ensure continued success in
the afterlife
How to have an awful time: without offerings, or if your death had
been violent or premature, you’d be restless and your ghost would
wander the earth attacking people
Multiple-entry visas: the deceased generally received offerings
from behind the gates of the netherworld but were allowed “out”
(and back in) several times a year to visit relatives (e.g., the month
of Abu = July/August)
Recycling policies: eventually old souls were recycled into new
human beings
ANCIENT MESOPOTAMIA
Conclusions
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Some sort of ghostly existence after death which was
accessed only via burial and mourning rituals
No bodily resurrection or judgment
The ideal death: surrounded by family and friends
while lying on the special funerary bed with a chair at
one’s left which served as the seat for the soul after its
release from the body
Four Major World
Religions
Judaism
Christianity
Islam
Hinduism
JUDAISM
The Origin of Death

“God saw all that he had made, and it was very good”
Gen 1.31
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The first humans disobey God Gen 3
Death introduced to the world as a consequence of
human disobedience: “for dust you are and to dust
you will return” Gen 3.19
Being bene Adam (sons of Adam) makes all future
people subject to the penalty of death
Thus death is an inevitable and feared event
JUDAISM
What happens when we die?

Death occurs when rwh, the divine life-giving
force, leaves the body; rwh distinguishes the
living from the dead
JUDAISM
What happens after we die?
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At death, the body returns to dust, and the breath which
God breathed into it initially (rwh) returns to the air, or
to God: nothing can survive
God makes his covenant (promises) with the Jews
regarding their future on earth (e.g., the continuity of
the nation and of one’s descendents), not with regard to
an individual’s survival after death
Thus death is acceptable only at the end of a long life
when one has descendants who can preserve one’s
memory
JUDAISM
What happens after we die?

Sheol as a metaphor for death:
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a ghostly, subterranean land of the dead
an inferior copy of life on earth
not necessarily hell (i.e., a place of torment), but
certainly a place to avoid for as long as possible
chiefly because it entails permanent separation from
God – even for the righteous
Sheol

“The days of my life are few enough: turn your
eyes away, leave me a little joy, before I go to
the place of no return, the land of murk and
deep shadow, where dimness and disorder hold
sway, and light itself is like the dead of night.”
Job 10.18-22
JUDAISM
What happens after we die?

The possibility of an afterlife
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If God has been the Jew’s creator (in the past) and guardian (in
the present), why not his sustainer (in the future)?
During the Babylonian exile, there was an emphasis on the
future restoration of Israel to peace and prosperity by the
Messiah
And if those Jews alive at this future time could be restored,
why couldn’t the faithful dead also experience a restoration to
life (return of blood and breath)?
Hope of an individual’s life after death became widespread by
the Rabbinic period: Maimonides said that anyone who doesn’t
believe in the resurrection of the dead is not a true Jew
JUDAISM
What happens after we die?

“O my God, the soul which you gave me is
pure: you created it, you formed it, you
breathed it into me, you preserve it within me;
and you will take it from me. But you will
restore it to me in the hereafter.” Authorized Daily
Prayer Book p. 5
JUDAISM
What happens after we die?

Transmigration:
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According to the Kabbalah, souls can go from one
body to another (gilgul, or transmigration): those
deserving punishment or those who are extremely
righteous
JUDAISM
How is death observed?
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Be present at the time of death/departure of the soul
Recite at least the last part of the Shema at the moment of death
Accompany the body to the grave
Funeral lamentations in the presence of the corpse
Burial of the corpse (and in ancient times, preservation of the bones
in an ossuary)
Shivah: week-long period of mourning – in ancient times sprinkling
of ashes, rolling on the ground, tearing clothes, dressing in
sackcloth; in modern times, forsaking one’s everyday work and
routine
Kaddish: to be said at the Yahrzeit (first anniversary of death)
CHRISTIANITY
The Origin of Death
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Shared with Judaism (and later with Islam)
“Original sin” of the first humans brought the
penalty of death not only to Adam and Eve but
to all people
CHRISTIANITY
The most important death…
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The crucifixion of Jesus
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a common means of execution of criminals in the
Roman Empire
“…the soldiers took charge of Jesus. Carrying his own
cross, he went out to the place of the Skull (which in
Aramaic is called Golgotha). Here they crucified
him….” John 19.16-18
CHRISTIANITY
…because it ends all Death

Centrality of the death and resurrection of Jesus
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Based on people’s eye-witness accounts of his death and
resurrection as well as on his teachings, the Christian doctrine of
resurrection was formulated
“For as by man came death, by a man has come also the
resurrection of the dead. For as in Adam all die, so also in Christ
shall all be made alive.” I Cor 15.21-22
“…our Savior Jesus Christ ...destroyed death and has brought
life and immortality…” 2 Tim 1.10
“Death is swallowed up in victory: O Death, where is thy sting?
O grave, where is thy victory?” Hosea 13.14/1 Cor 15.54-55
CHRISTIANITY
What happens after we die?

The Afterlife
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Destination determined by the individual’s acceptance or
rejection of the salvific death and resurrection of Jesus
Heaven
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Eternal life for the believer in a “perfected” body
Life in the continual presence of God
Absence of death, pain, grief, war, conflict
Metaphors of “streets of gold”, etc.
Hell
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Separation from God
Limited period (annihilationism) or eternal punishment
Metaphors of “lakes of fire and brimstone”
CHRISTIANITY
How is death observed?
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During life: through the Sacraments
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Baptism: “we were buried with him [Christ] through
baptism into death in order that, just as Christ was
raised from the dead through the glory of the Father,
we too may live a new life [on earth and in the
afterlife].” Rom 6.4
Eucharist: “whenever you eat this bread and drink this
cup, you proclaim the Lord’s death until he comes.” 1
Cor 11.26
CHRISTIANITY
How is death observed?

At and after death:
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Last rites: “into thy hands, Merciful Savior, we
commend the soul of thy servant, now departed from
the body … receive him into the arms of thy
mercy…”The Book of Common Prayer
Christian burial
Requiem mass
Prayers for the dead
ISLAM
The origin and purpose of death
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The origin of death: as in Judaism and Christianity
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The will of God:
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the original sin of Adam and Eve, and the punishment: “In the
earth you will live, and in it you will die …” Quran 7.24
“It is not possible for a soul to die except with the permission of
God at a term set down on record.” Quran 3.139
A time of trial:

Life is a time of probation and decision: while alive, individuals
are free to direct their lives along the straight path back to God
(sirat ulMustaqim) or to reject God Quran 1.5
ISLAM
What happens when we die?
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Human beings are body and spirit: separated, then
reunited
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Bashar: “flesh”, the body
Ruh: God’s “breath” or soul with which he infuses the bashar
and which continues to live apart from the body after death until
its reunion with the body on the Day of Resurrection
Nafs: the “spiritual vitality” linking body and soul, which
escapes at the time of death (and also departs the body at night
in sleep and returns in the morning) Quran 6.60f
ISLAM
What happens after we die?
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The angel of death gathers those who are due to die
Quran 32.10/9-11
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The body is buried and decays
The soul escapes the body and may either be raised
into an interim body or be in a suspended state
The body and soul are reunited on the Day of
Resurrection (yaum ulQiyama): “…we will raise him
up on the day of resurrection…”Quran 20.125
The appearance before God on the Day of Judgment
(yaum udDin)
ISLAM
Judgment and the Afterlife
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Day of Judgment: “on the Day of Resurrection we will
bring out a written record: each man will see it spread
open” Quran 17.14
No one can “redeem” or “atone” for the misdeeds of
another (contra Christianity)
The Garden of Reward: for the ones who turn to God
during life (eternal pleasure)
The Fire of Jahannam: for those who reject God during
life (eternal burning with fire)
ISLAM
How is death observed?
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Washing and burying the body within 8 hours of death
Respect for the body (because it will be restored on the
Day of Resurrection)
Prayers over the dead (the four takbirs: proclamations
of God’s greatness)
Recitation of the whole Quran if possible
Mourning should not be excessive, as this would
disturb the dead as well as show lack of acceptance of
God’s will and purpose regarding death
HINDUISM
Traversing a continuum
“Hinduism is the map of how to live
appropriately … in order to move
towards (and perhaps attain) the goal.”
J Bowker, The Meanings of Death. Cambridge: CUP, p. 131.
HINDUISM
The soul is eternal

Souls are eternal and do not die with the body:
as Krishna said,
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“Those who are truly wise do not mourn for the dead
any more than they do for the living. … Just as
embodied selves pass through childhood, youth and
old age in their bodies, so too there is a passing [at
death] to another body.” Bhagavad Gita 2.12
To attain this condition of wisdom about the soul’s
eternality is to attain brahman
HINDUISM
The goal is to free the self
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Brahman/nirvana: the freed self who has attained a
state of wisdom regarding the eternality of the soul
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A state of power experienced both in this life and after death
Liberation achieved by renouncing all desired objects and not
experiencing any cravings for them, absence of preoccupation
with the bodily self Gita 2.71f
The state of happiness and peace from being eternally with
Krishna (and yet distinct from him)
HINDUISM
The cycle of death and rebirth
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The self is unchanged, yet reborn repeatedly until it
finds it way to liberation using the Gita and other
scriptures as a guide
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Samsara: the cycle of rebirth which continues until
brahman/nirvana is reached
Karma: actions and their consequences; bad karma can only be
overcome by achieving moksha, or the release that comes when
one realizes that one cannot influence the process of karma
Kashi: dying in the right city is a shortcut to moksha…
HINDUISM
Death is not that important
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During samsara death will occur many times;
thus it is of little importance
One death is merely a stage, a milestone, in a
long process
The continuing self has already passed on when
a “person” dies (or is cremated)

if one is good, the soul leaves through the
brahmarandhra (a small opening in the crown of the
head); if one is evil, through the anus
HINDUISM
The afterlife before reentering samsara
Preta: an intermediate condition taken by the
soul immediately after death
 Judgment and the afterlife:
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Early literature: the domain of Yama, the ruler of the
ancestors: a place where families are reunited and the
pain and sorrow of this life is removed
Later and post-Vedic literature: vivid descriptions of
hell-like places of torture and punishment (narakas),
where the punishment fits the crime
HINDUISM
How is death observed?
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Meditation on God at the time of death:
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Ritual return of the dead on the funeral pyre:
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the soul can influence what form it will take next
aided by namakirtana, or chanting the name of a god until one ceases
to be aware of anything else
the eye to the sun, the breath (atman) to the wind, the body to the
plants Rg Veda 10.16.3
Ekoddista: ritual to render benign the deceased individual’s preta
Sraddha: 16-stage ritual taking up to a year and including not only
one deceased individual but also up to 4 generations of ancestors

to construct an interim body for the preta
Modern Medicine
How Doctors took the Place of Priests at
the Deathbed
The Medicalization of Death
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In ancient times, the doctor’s presence at the deathbed was rare: this
was the priest’s role
When involved at all, the doctor’s role was merely to predict the
time of death (so the priest could do his job)
After the Enlightenment, it became a “status symbol” to die under
medical care, as medicine was seen to be able to “do battle” with
death
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Dissection enabled improved understanding of pathophysiology of
death
Diseases were being described and categorized
New vision of “natural death” was thus available: death at the end of a
long life as the result of a clinically identifiable illness
Death may even be prevented (or at least delayed) by understanding
disease
C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 76-78.
Religion, Medicine and Death
“… modern rationality, of which medicine
is an example, is itself a religious
orientation, providing an imagined
community, rites of inclusion and
membership, and guidance for a
meaningful death.”
Seale. Constructing Death. Cambridge: CUP, 1998, pp. 75-76.
Death as Biological Imperative
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Cells are preprogrammed to stop dividing after
a certain number of divisions, and then to die
(apoptosis)
DNA errors accumulate over time and with
continued environmental exposures
Cumulative effects of cell death impair organ
functions needed to sustain life
Teleologically, death may be adaptive at
population level: people don’t compete with
their offspring for scarce resources
Searle. Constructing Death. Cambridge: CUP, 1998, pp. 35-36.
Medical Definitions of Death
Cardiopulmonary Death
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Previously easily diagnosed by irreversible cessation of respiration
and circulation which necessarily led to death of all organs within a
short time
After advent of ventilators, death could not be equated with absence
of vital signs of circulation and respiration since machines can
fulfill these functions
If this definition of death was used, organ harvesting for transplants
would be jeopardized by deterioration of the organs during the time
immediately after cessation of respiration and circulation
Currently accepted in the USA as one of two valid definitions of
death
A Scholthauer and B Liang, “Definitions and implications of death.” Hematology/oncology Clinics of North America 16:6 (2002).
Medical Definitions of Death
Whole-Brain Death
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1968: Harvard Medical School committee defines death as
irreversible coma: “a state of unreceptivity and unresponsivity, with
no movement, breathing, or reflexes, accompanied by a flat EEG”
1970: Kansas is first state to legally recognize “the absence of
spontaneous brain function” as equivalent to cardiopulmonary death
1980: Uniform Determination of Death Act declares that “an
individual who has sustained either (1) irreversible cessation of
circulatory and respiratory functions, or (2) irreversible cessation of
all functions of the entire brain, including the brain stem, is dead”
Medical Definitions of Death
Whole-Brain Death

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This definition means that healthy organs can be
harvested as artificial ventilation and respiration are
maintained
It also implies that once a diagnosis of whole-brain
death is made, further medical treatment is futile; this
has financial implications: medical insurance generally
will not cover that is not medically necessary, leaving
families and hospitals with the bill for further
“treatment”
USA, Germany, Japan, and France all accept this
definition of death
Medical Definitions of Death
Higher-Brain Death
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Applicable to PVS patients: those without brain
functions that control emotion, cognition and
consciousness but who maintain at least partial brain
stem function
In general, courts are reluctant to adopt this definition
because the absence of higher, cortical brain activity is
harder to prove with certainty, at least in the short term
However, some courts have allowed “life”-sustaining
treatment of PVS patients to be discontinued (e.g.,
Quinlan, Cruzan, Schiavo?)
Modern Medical Death Rites
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Life insurance: to ameliorate the consequences of one’s death, to
gain greater control over death
Wills: to determine what happens to one’s possessions after death
Death certificates: to enshrine in law the “cause of death”
Autopsies: to identify the cause of death if not obvious
Inquests: to identify the cause of death if suspected to be
“unnatural”
Burial of the body (+/- embalming) OR cremation and interment of
ashes: to confine the deceased to a known “resting place” which can
also serve as a memorial
Death in Society:
Doctors and Patients
Nationality
Ethnicity
Class
DOCTORS
Differences in End-of-life Care

Death in ICU preceded by decision to limit care:

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Decisions to withhold versus withdraw care (in a survey of western
European physicians)
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Belgium: 65%
Canada: 70%
USA: 75%
Israel: 91%
93% sometimes withheld treatment
77% sometimes withdrew treatment
Physicians with strong religious beliefs (and those from countries with deeper religious roots such as
Greece, Italy and Portugal) were less likely to withdraw life support
Withdrawal of nutrition is considered acceptable in PVS patients:

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USA: 89%
Britain: 65%
Belgium: 56%
Japan: 17%
J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine 29:2 (2001).
PATIENTS
Differences in End-of-Life Decisions

Nationality

Canadian patients more likely to want the details of
their terminal illness than patients in Europe or South
America
J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine. 29:2 (2001).
PATIENTS
Differences in End-of-Life Decisions

Ethnicity:
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Cultures which are more individualistic, secular, pragmatic,
scientific tend to prefer full open awareness (as opposed to
cultures which are familial, sacred, traditional, emotional)
In favor of closed awareness: Mexican, Japanese
In favor of full open awareness: Anglos
Most interested in carrying out wishes of the dying: Japanese
Most wills and life insurance: Anglos
C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 179-181.
PATIENTS
Differences in End-of-Life Decisions

Ethnicity:

In USA, whites significantly more likely than blacks:




to discuss treatment preferences before death
to complete a living will
to designate Durable Medical Power of Attorney
to limit care in certain situations and withhold treatment
before death
S Hopp and S Duffy, “Racial variations in end-of-life care.” Journal of the American Geriatrics Society 48:6 (2000).
PATIENTS
Differences in End-of-Life Decisions

Class:

Persons of higher socioeconomic class 2.7 times more
likely to desire full open awareness of a terminal
diagnosis
C Seale. Constructing Death. Cambridge: CUP, 1998, p. 179
The Individual
“My Death”
“I Will Die”

What is required to understand the notion, “I will die”?
To bridge the gap between what I’ve experienced of
life to a construct of its negation?



Self-awareness
Logical thought
Conceptions of:






Probability
Necessity
Causation
Time
Finality
Separation
R Kastenbaum. The Psychology of Death. New York: Springer, 2000, pp. 30-35.
Death and Psychological Development
Developmental Stages

Up to age 5
1.
–
–
–
2.
Death is not final
Death is a diminution of aliveness
Death involves separation
Ages 5-9
–
Death is final
–
–
Death is not inevitable – if one is clever and lucky
Death personification – death as a separate person
Age 10 and older
3.
–
–
Death is final
Death is inevitable
Death is universal
–
Nagy, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, pp. 51-53.
Stages of Dying
1.
2.
3.
4.
5.
Denial
Anger
Bargaining
Depression
Acceptance
E Kubler-Ross, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, pp. 216-217.
Getting the Timing Right



“The material end of the body is only roughly
congruent with the end of the social self. In extreme
old age, or in disease, when mind and personality
disintegrate, social death may precede biological death.
Ghosts, memories and ancestor worship are examples
of the opposite: a social presence outlasting the body.”
Euthanasia: social death is preempted by actively
hastening biological death
Hospice: social death is pushed back as far as possible
until biological death occurs
C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 34, 184.