Bureaucratization of DeathAccording to Chapter 10 in your textbook, the process of dying has become increasingly bureaucratized in that hospitals and long-term care facilities have made the handling of death a routine. In addition, the preparation of the deceased’s body for burial has also been allotted to funeral directors rather than the family of the deceased. After reading Chapter 10 in your textbook in preparation for this discussion, please address the following:Discuss how death has been bureaucratized and what that means in terms of the experience of dying for the elderly and their families.What are the sociological factors that have led to this bureaucratization of death?How has this bureaucratization impacted society?Your initial post should be at least 250 words in length. Support your claims with examples from the required material(s) and/or other scholarly resources, and properly cite any references.Reference:Markson, E. W. & Stein, P. J. (2012). Social gerontology: Issues & prospects. San Diego, CA: Bridgepoint Education, Inc.
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10
Chapter 10
Death, Dying, and
Bereavement
© AbleStock.com / Thinkstock
Learning Objectives
At the end of this chapter, you should be able to:
1. Describe life expectancy and today’s leading causes of death.
2. Explain how social class, race, ethnicity, and gender are related to longevity.
3. Explain the dying process.
4. Elucidate the bureaucratization of death and funerals.
5. Explain advance directives.
6. Argue for or against assisted suicide.
7. Differentiate bereavement, grief, and mourning.
Aging Quiz
Chapter 10
Aging Quiz
Take a moment to decide whether the following statements are true or false. Correct answers
can be found at the end of the chapter.
1. The top 10 causes of death have not really changed in the United States since 1900.
2. Heart disease, cancer, and stroke, which account for more than half of all deaths in the
United States, occur primarily after age 50.
3. Asian and Pacific Islanders have the highest mortality rate of any racial/ethnic group in
the United States.
4. Whether male or female, people in lower socioeconomic groups live shorter lives compared to their peers of higher social class.
5. Because of advances in medical technology, Americans on average live longer than people in other industrialized nations.
6. In all situations, a stopped heart determines death.
7. Advance directives permit physicians to perform assisted suicide.
8. Assisted suicide is illegal in all American states.
9. Bereavement and grief are expressed universally by all cultures.
At age 78, Morris Schwartz, known to everyone as Morrie, knew he was dying of the degenerative neurological disease amyotrophic lateral sclerosis (ALS), sometimes called Lou Gehrig’s
disease. ALS gradually destroys the nerves’ ability to send signals to the muscles. The disease
is fatal.
Still very much alive, Brandeis University emeritus sociology professor Schwartz used his
remaining strength to teach one last lesson: helping people to talk openly about illness, deterioration, and the inevitability of death. He appeared on national television shows, spoke on
the radio, and wrote. Even when unable to hold a microphone, he dictated his thoughts on
life and death into a tape recorder and published them as Morrie: In His Own Words (1997).
His former student Mitch Albom published a best-selling book, Tuesdays with Morrie (1997),
based on their conversations. It formed the basis for a feature film.
A sample of Schwartz’s (1997) reflections, from Morrie: In His Own Words:
I don’t think you can be totally prepared for diminished capacities. . . . You can think
about what might happen . . . but until the time actually arrives, you don’t have the
experience. . . . (p. 6)
Learn how to live, and you’ll know how to die; learn how to die, and you’ll know how
to live. . . . The goals I have set for myself . . . during this illness are not unlike those
most of us have aspired to since childhood: to behave with courage, dignity, generosity, humor, love, open heartedness, patience, and self-respect. When you are close to
death, it is not easier to achieve these goals than at other stages of your life, just more
urgent that you try. (pp. 125–127)
Morrie Schwartz died peacefully at home on November 4, 1995.
Twenty-First-Century Mortality Trends
Chapter 10
For most of us, death is an uncomfortable topic. Yet, life’s mortality rate is 100%—which
means death is a reality for every living organism. What are the leading causes of death today?
How does death relate to race, ethnicity, social class, and gender? How does our society view
death? What cultural values do our attitudes about mortality reflect? How do older people
react to the loss of a spouse or significant other? Should individuals have a right to end their
own life? What kind of end-of-life care do you want for your parents, yourself, and other family members? These are the issues raised in this chapter.
10.1 Twenty-First-Century Mortality Trends
In contemporary American society, as in all industrialized nations, death is most likely to occur
in old age. However, this is a relatively new phenomenon. For many centuries, childhood and
infant mortality rates from acute diseases were so high that many young children who died
did not even have their names recorded, in part because some died too young to be named,
and in part because such deaths were so common that recording systems—which were haphazard at the time anyway—could not keep up. Because infant and childhood death was
so common, the death of a child was an expected, and accepted, event. As a 17th-century
woman observed, “Before they are old enough to bother you, you will have lost half of them,
or perhaps all of them” (Aries, 1962, p. 38).
Nor were the deaths of infants or children always unwelcome. Unlike today, children were
not regarded as innocent and impressionable beings to be nurtured and treasured. Until the
rubber condom was invented about 150 years ago, children were often regarded as sinful
burdens. In poor families with many children, some parents wished openly and loudly for their
children to die or to leave home. Smallpox, a major cause of infant and childhood death, was
actually known as the “poor man’s friend” (Van de Walle & Knodel, 1980). Infanticide, abandonment, and starvation of children were common as late as the 19th century. According to
one London observer in the 1860s, “The police seemed to think no more of finding a dead
child than they did of finding a dead cat or a dead dog” (as cited in Skolnick, 1987, p. 97).
In today’s industrialized nations, abandonment and death of children are rare thanks to the
eradication of many infectious diseases and a relatively plentiful food supply.
During the past century, the top 10 leading causes of death have changed dramatically (see
Table 10.1). With the exception of pneumonia and flu, chronic diseases, suicide, and accidents
(including motor vehicle accidents) have replaced the infectious diseases that accounted for
the greatest number of deaths in 1900.
Just a little more than a century ago, average life expectancy at birth in the United States was
around 47 years. Today, average life expectancy is more than 78 years, and people are far
more likely to live into their 70s, 80s, 90s, and even to exceed 100.
The Changing Demography of Death
Although death occurs mostly in old age in the United States, infants are particularly likely to
die during the first year of life. Because of their greater susceptibility during the first year, the
infant mortality rate (the number of deaths among infants under age 1 per 1,000 births)
is often used as a key measure of quality of life. As children age, their chances of survival
substantially increase. Major causes of death at all ages in the United States are shown in
Figure 10.1.
Twenty-First-Century Mortality Trends
Chapter 10
Table 10.1 Leading Causes of Death in the United States, 1900 and 2010
Rank
1900
2010
1
Pneumonia and influenza
Heart disease
2
Tuberculosis
Cancer
3
Gastroenteritis
Chronic lower respiratory diseases
4
Heart disease
Cerebrovascular diseases (stroke)
5
Cerebrovascular diseases (stroke)
Accidents
6
Chronic nephritis
Alzheimer’s disease
7
Accidents
Diabetes
8
Cancer
Nephritis
9
Senility
Influenza and pneumonia
10
Diphtheria
Suicide
Source: Murphy, S. L., Xu, J., & Kochanek, K. D. (2012). Deaths: Preliminary data for 2010. National Vital Statistics Reports, 60(4). Retrieved
from http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf.
Heart disease, cancer, and stroke, which account for more than half of all deaths in the
United States, occur primarily after age 50. According to the National Center for Health
Statistics, the principal causes of death among those aged 65 and older are (a) heart
disease, (b) cancer, (c) lower respiratory disease, and (d) stroke. Primary cause of death,
however, understates the numerous health problems experienced toward the end of life.
It also does not take into account the fact that many older people die of multiple causes.
For example, an elderly person who dies with a lower respiratory disease may have many
other chronic and potentially lethal diseases, such as cancer, heart disease, diabetes, AIDS,
and so forth.
That people expect to live longer lives is a relatively recent phenomenon. As you will recall
from earlier in this book, life expectancy does not describe any one specific person. We use it
because of what it stands for: the average amount of time people in a society can expect to
live. Interestingly, the older we are, the longer our probable life expectancy. This is because
the longer we live, the healthier we are likely to have been throughout our lives; people with
more severe, life-threatening diseases are likely to die earlier. This was true even centuries
ago. In 1900, for example, only about 3% of all Americans lived to see their 65th birthday,
but those who did could expect on average to live another 11.9 years (Treas, 1995). Today
they can expect to enjoy an average of 19.2 more years of life, and at age 75 an average
of about 12 more years. Some will live longer than that and some shorter, but according to
data from the National Center for Health Statistics, on average, those at age 75 today will
live to age 87.
Although death comes to all of us, any individual’s chances of dying vary not only by age but
also by one’s membership in the social hierarchies of gender, social class, race, and ethnicity.
Political factors also play a role. For example, life expectancy in Russia decreased by more than
6 years following the breakup of the former Soviet Union, which left public health systems in
disorder and many Russians in poverty (Popov, 2010).
Twenty-First-Century Mortality Trends
Chapter 10
Figure 10.1 Death Rates for All Ages
While the major causes of death are similar for men and women, there are some discrepancies, as
shown below. What are they? In what significant ways do men and women differ?
Male
Female
Deaths per 100,000 population (log scale)
10,000
All causes
1,000
All causes
Heart disease
Heart disease
Cancer
Cancer
100
Chronic lower
respiratory diseases
Stroke
Chronic lower
respiratory diseases
Stroke
Unintentional injuries
Unintentional injuries
Diabetes
Alzheimer’s disease
10
Alzheimer’s disease
2008 1998
1998
Year
Diabetes
2008
Year
Notes: Rates are age-adjusted, rates for Alzheimer’s disease are not comparable before 1999. Starting with 1999 data, cause
of death is coded according to ICD-10.
Source: CDC/NCHS, Health, United States, 2011, Figure 3. Data from the National Vital Statistics System.
Genetic predisposition for a variety of F10.01_SOC304
diseases, such as breast cancer, cystic fibrosis, and
Parkinson’s disease, also influences when and how people die. For this reason, people who
Source: National Center for Health Statistics, Center for Disease Control and Prevention, US Department of Health and
share similar
social
characteristics
very No.
different
causes
at different
ages.
Human
Services.
(2011). Health, Unitedmay
States die
(DHHSof
Publication
2012-1232).
Hyattsville,and
MD: Author,
Figure 3.
However, social variables—age, sex, social status, and race/ethnicity—are most closely allied
to life expectancy and mortality rates.
Sex, Race, and Ethnicity
At every age, females can expect to live longer than males. Regardless of gender, racial and
ethnic minorities are likely to die earlier than Whites, primarily because they are more likely to
be socioeconomically disadvantaged (see Figure 10.2).
In 1900 Blacks could expect to die about 15 years earlier than Whites. This racial gap is narrower today, but has not closed. Blacks remain more likely than Whites to have heart disease
and high blood pressure, and their rate of death from stroke and diabetes is twice as high as
Whites. According to one study, socioeconomic status rather than race accounts for 60% of
Blacks’ higher mortality rates (Thorpe et al., 2012).
Twenty-First-Century Mortality Trends
Chapter 10
Figure 10.2 Life Expectancy at Birth, by Race and Sex: United States, Preliminary 2007
Socioeconomic status and gender, rather than race, has the greatest impact on life expectancy.
100
All races
White
Black
Age in years
90
80
77.9
80.4
78.3
73.7
75.3
80.7
77.0
75.8
70.2
70
60
0
Both sexes
Male
Female
Source: National Vital Statistics System Mortality.
As you will recall, however, at very old ages Blacks have lower mortality rates than Whites,
a pattern demographers call the Black-White mortality crossover. Researchers pose various
F10.02_SOC304
explanations for this, including survival of the fittest; that is, those Blacks who live into their
80s have successfully survived numerous threats to their health imposed by poverty and other
disadvantages suffered by minorities (Yao & Robert, 2011).
Among other racial and ethnic minorities, life expectancy and mortality also vary. Asian and
Pacific Islanders have a death rate about half that of non-Hispanics Whites, explained in part
by their generally high socioeconomic status. Data from the 2010 U.S. Census show that the
average family income for Asians is slightly above that of non-Hispanic Whites, and the poverty rates for most Asian groups are lower than for the nation as a whole. Their educational
attainment is also the highest of any racial or ethnic subgroup.
Non-Hispanic Blacks, however, had a death rate 25.5% higher than non-Hispanic Whites.
Since 2000 the Hispanic population experienced the largest decrease in mortality (20.3%),
and the non-Hispanic White population experienced the smallest mortality decline (10.4 %)
(Murphy, Xu, & Kochanek, 2012). Figure 10.3 presents death rates by race/ethnicity.
Social Class
Our position in the social class structure influences not only how we live but also how we
die. The death of a public official or popular culture figure is likely to receive more attention
than a drunken derelict, a homeless person, or others of low social status. For example, the
1997 death of British princess Diana, who died in a Parisian car accident, reportedly resulted
in prolonged, intensive attempts to resuscitate her, despite her clear unlikelihood to respond.
Discrimination stemming from gender, race, or ability to pay often influences the care received
by the ill and dying. For example, research repeatedly shows that women, minorities, rural
residents, and the poor are less likely to receive a transplant than are White, relatively affluent
males (Ozminkowski, Friedman, & Taylor, 1993).
Twenty-First-Century Mortality Trends
Chapter 10
Figure 10.3 Age-Adjusted Death Rates, by Race and Hispanic Origin: United States, Preliminary 2007
Figure 10.3 indicates the number of deaths (per 100,000) in a given year by race. In 2007, nonHispanic Blacks had the highest mortality rate of any other racial group. Studies indicate that socioeconomic status and educational attainment play an important role in this phenomenon.
Rate per 100,000 U.S. population
1,200
1,000
961.9
766.5
800
625.3
600
530.7
409.7
400
200
0
Non-Hispanic
black
Non-Hispanic American Indian or
white
Alaska Native
Hispanic
Asian or Pacific
Islander
Source: National Center for Health Statistics, Center for Disease Control and Prevention, U.S. Department of Health and Human
Services. (2011). Health, United States (DHHS Publication No. 2012-1232). Hyattsville, MD: Author.
Whether male or female, people in lower socioeconomic groups live shorter lives than their
higher-class peers. As Antonovsky (1972)
pointed out more than 40 years ago, “class influF10.03_SOC304
ences one’s chances of staying alive” (p. 28), and this still holds true today. Research studies
conducted over many years exhibit that the major measures of social class membership, such
as income, education, and occupation, show a strong relationship between social class membership and mortality (Marmot, 1996; Winkleby, Jatulis, Frank, & Fortmann, 1992; Kaplan et
al., 1988; Stringhini et al., 2011).
© iStockphoto / Thinkstock
© iStockphoto / Thinkstock
Where we stand in the social class structure influences how we live and die. Wealthy and prominent
Americans are laid to rest in ornate tombs, while mostly working class soldiers rest in identical graves at
Arlington National Cemetery in Washington, D.C.
Twenty-First-Century Mortality Trends
Chapter 10
Figure 10.4 Life Expectancy at Age 25 in 1996 and 2006
This figure demonstrates how educational level can be used as a rough indicator of life expectancy.
It shows the change in life expectancy at age 25 for men and women in 1996 and again in 2006.
The higher one’s level of education, the more years they can expect to live.
Men
1996
No high school diploma
Women
47
53
High school graduate
or GED
50
Some college
51
Bachelor’s degree
or higher
57
58
54
2006
No high school diploma
59
47
52
High school graduate
or GED
51
57
Some college
52
58
Bachelor’s degree
or higher
56
0
20
40
60
Years of expected life
remaining at age 25
60
80 0
20
40
60
80
Years of expected life
remaining at age 25
Note: GED is General Educational Development high school equivalency diploma.
Source: National Center for Health Statistics, Center for Disease Control and Prevention, U.S. Department of
Health and Human Services. (2011). Health, United States (DHHS Publication No. 2012-1232). Hyattsville,
MD: Author, Figure 32.
F10.04_SOC304
Even early in life—long before the onset of age-related diseases—a parent’s lower socioeconomic status affects his or her children’s cell aging (Needham, Fernandez, Lin, Epel, &
Blackburn, 2009). The chronic stress associated with socioeconomic disparities causes cells to
age more rapidly, which puts these children at greater risk of chronic illnesses—and perhaps
premature mortality—earlier in life than their more advantaged counterparts.
The United States does not collect official mortality statistics that use social class as a variable;
vital statistics are only available by educational level, which can roughly indicate social class
in the absence of more sensitive indicators. As shown in Figure 10.4, as early as age 25, life
expectancy differs noticeably among people with different educational levels. Keep in mind
that as we age, this inverse relationship between social class and disease becomes more pronounced in both the United States and elsewhere (Marmot & Shipley, 1996; Fiscella & Franks,
1997; Thorpe et al., 2012).
Paradoxically, although Americans live in the richest nation in the world, at age 65 they are
more likely, on average, to die sooner than their age counterparts in other industrialized
nations, including Japan and the United Kingdom. Table 10.2 summarizes some of these
differences.
Death in American Society
Chapter 10
Table 10.2 Life Expectancy at Birth by Sex, Selected Industrialized Nations, 2009
Nation
Males at Birth
Females at Birth
Japan
79.6
86.4
Switzerland
79.9
84.6
Sweden
79.4
83.4
Australia
79.3
83.9
Norway
78.7
83.2
Netherlands
78.5
82.7
United Kingdom
78.3
82.5
France
77.7
84.4
United States
76.0
80.9
Source: Health, United States, 2011, Table 21. Center for Disease Control.
The United States’ low ranking is due to differential access to health care that is associated with
ethnicity, race, and class. During the period from 2002 to 2008, Hispanics, Blacks, American
Indians, and Alaska Natives received worse access to care than Whites on more than 60% of
about 250 health care measures collected by the Agency for Healthcare Research and Quality
(AHRQ, 2011a). Despite our disproportionately higher spending, there is no measurable indicator that American health care is superior to other developed nations (Davidson, 2010).
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