Journal of Religion and Health, Vol. 17, No. 2, 1978

Medical Resistance, Crisis Ministry, and Terminal Illness DAVID M. MOSS; WILLIAM C. McGAGHIE; AND LEE I. RUBINSTEIN The pastoral curricula of America's most prominent divinity schools and seminaries emphasize a need for holistic ministry. A systems approach using interprofessional contact is being underscored, particularly in crisis situations (e.g., alcoholism, acute marital disharmony, and abortion counseling for the unwed). A primary area where this tenor is evidenced is in ministry to the terminally ill. It is frequently contended that the most effective pastoral care in these instances involves a mutual co-operation between physicians, pastors or institutional chaplains, and, at times, trust attorneys. Their work should be synchronized so that the probability of the terminal patient's acceptance of death is increased. It is a safe generalization to say that nearly a l l - i f not e v e r y o n e - f e a r s death or dying at some time. However, not all people are exposed to the complexities of biological change on a daily basis, at least not in the way members of the medical profession are. This exposure, coupled with the common sensitivity to death most of us are conscious of when we choose to be, places the physician in a potentially vulnerable position when a patient becomes terminally ill. Often such illnesses provoke physicians and nurses to resist psychologically thoughts David M. Moss, Ph.D., is a clinical staff member of the Center for Religion and Psychotherapy of Chicago. He is also the Pastoral Consultant to Northwestern University's Episcopal Chaplaincy and Chairman of the Diocese of Chicago's Advisory Commission on Alcoholism. He is the author of more than two dozen publications and an assistant editor of Pilgrimage: the Journal of Pastoral Psychotherapy. William C. McGaghie, Ph.D., is an assistant professor of the Center for Educational Development, University of Illinois Medical Center, Chicago. His experimental work is focused on instructional design and development, as well as self-directed learning and human self-control. He has written a number of professional papers and is co-author of two books including An Introduction to Competency Based Curriculum Development in Medical Education prepared for the World Health Organization. Lee I. Rubinstein, M.D., is a private practitioner in obstetrics and gynecology, a clinical instructor in the Department of Reproductive Biology, School of Medicine, Case Western Reserve University, and visiting obstetrician-gynecologist, University Hospitals, Mount Sinai Hospital, Cleveland. He is a diplomate of the American Board of Obstetrics and Gynecology and author of several American and British publications related to his specialty. This paper was first presented at the 84th Annual Convention of the American Psychological Association (Division 36: Psychologists Interested in Religious Issues), Washington, D:C. A critique of that presentation subsequently appeared in U.S. Medicine, 1976, 12 (20), 3, 9. The authors wish to express their gratitude to Mrs. Sue S, Rubinstein for her assistance, encouragement, and insight. 99

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of death, a defensiveness that carries over into their dealings with the terminal patient. Such resistance can create problems that are manifested in a wide variety of ways, ranging from a physician's avoidance of the terminal patient (e.g., skipping rounds) to more pronounced signs of "thanatophobia" (e.g., discharging or referring the terminal patient at an inappropriate time). Perhaps the most common expression of what we are referring to is the physician's resistance to talking explicitly about death with the dying patient. This tendency has been studied and explained in several ways, chiefly: the physician's fear of death; a professional dedication to the preservation of life; a common reluctance to transmit bad news directly to those involved; and the lack of psychosocial education in medical curricula on death and dying.2 We undertook the present research for three purposes. First, to extend earlier research projects showing that the failure to discuss terminal illness with dying patients is common within the medical profession. Second, to explore some variables hypothesized to underlie defensiveness among physicians that may account for their failure to communicate directly with dying patients. Third, to offer suggestions about how the crisis minister can contribute to the care of dying persons when holistic a t t e n t i o n - m e d i c a l and p a s t o r a l - i s needed. A t t i t u d e s T o w a r d Death

When Sigmund Freud was struggling with his own attitudes toward terminal illness he wrote: Would it not be better to give death the place in actuality and in our thoughts which properly belongs to it, and to yield a little more prominence to that unconscious attitude toward death which we have hither to so carefully repressed? . . . . We remember the old saying: Si vis pacem, para bellum. If you desire peace, prepare for war. It would be timely thus to paraphrase it: Si vis vitam, para mortem. If you would endure life, be prepared for death. ~ As in so many of his other writings, Freud went on to explain that what frequently concerns people most, both individually and collectively, is talked about least. Historically his line of reasoning forms a background for this paper as well as countless others devoted to the care of terminal patients. 4 Freud's notions about preparation for death were not original. Anthropologists have pointed out that humanity has been intrigued, preoccupied, and obsessed with death since the beginnings of life. 5 This assertion finds further support from the arts centuries before the birth of Jesus. Poets, composers, and painters expressed their feelings about death and dying in a kaleidescope of beauty, nobility, acceptance, resistance, indignation, and fear. Since the legalization of Christianity, this emotional range has maintained its breadth, but three of its attitudes have become most p r o m i n e n t - h o r r o r , calm, and hope. 6 Literary examples of the horror of physical death and of decomposition are

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best seen in fifteenth and s i x t e e n t h c e n t u r y poetry. For instance, P i e r r e de Nesson (1383-1442), in his Vigiles des morts: Paraphrase sur Job, writes: O carrion, who art no longer man. Who will hence keep thee company? Whatever issues from thy liquors, Worms engendered by the stench Ofthy vile carrion flesh. 7 A p r i m e illustration of a n a t t i t u d e of calm is to be found in A l e x a n d e r Solzhenitsyn's The Cancer Ward. Yefrem, who t h o u g h t he k n e w more about d e a t h t h a n the "old folk," is p o r t r a y e d as mistaken: The old folk who never even made it to town, they were scared while the Yefrem rode horses and fired pistols at thirteen . . . . But n o w . . , he remembered how the old folks used to die back home on the Kama . . . . They didn't puff themselves up or fight against it and brag that they weren't going to d i e - t h e y took death calmly. They didn't stall squaring things away, they prepared themselves quietly and in good time, deciding who would have the mare, who the foal . . . . And they departed easily, as if they were just moving into a new house. 8 And the notion of hope is clearly depicted in ~'Thanatopsis," William Cullen B r y a n t ' s classic contribution to the English g r a v e y a r d genre. So live, that when thy summons comes to join The innumerable caravan which moves To that mysterious realm where each shall take His chamber in the silent halls of death, Thou go not, like the quarry-slave at night, Scourged to his dungeon; but sustain'd and soothed By an unfaltering trust, approach thy grave, Like one who wraps the drapery of his couch About him, and lies down to pleasant dreams2 In the last ten years t h e r e h a v e b e e n a n u m b e r of excellent r e s e a r c h studies on d e a t h and dying, most of which h a v e investigated the r a n g e of feelings j u s t described. F u r t h e r m o r e , instructors and students i n t e r e s t e d in these works h a v e been assisted by such c o n t e m p o r a r y writers as William F a u l k n e r , J o h n G u n t h e r , Nikos Kazantzakis, and Miguel de U n a m u n o . 1~ It seems t h a t m a n y disciplines are coming t o g e t h e r to address themselves to a common theme: t h e r e is a h e a l t h y way to live d u r i n g the final phases of life j u s t as t h e r e is a h e a l t h y way to die. N e a r l y e v e r y responsible work in this a r e a c o n c u r r e n t l y discusses the m y r i a d effects in family relationships. For t h e senior author, d e a t h is a n occurrence of central professional concern. As minister, I a m k e e n l y a w a r e t h a t the way in which a burial r i t u a l is conducted will h a v e a n effect on how the family's grief-work is r i t u a l l y

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facilitated. In the proposed Burial Office of the Episcopal Church, no section illustrates concern with the mourning process better t han the following: We thank you, God, for this man who was so near and dear to us and who has now been taken from us. We thank you for the friendship that went out from him and the peace he brought. We thank you that through suffering he learned obedience and that he became a person others could love while he was with us here on earth. Let us pray for ourselves, who are severely tested by this death, that we do not try to minimize this loss or seek refuge from it in words and also that we do not brood over it so that it overwhelms us and isolates us from others. May God grant us new courage and confidence to face life.H Case i l l u s t r a t i o n s

The first occasions where I used these prayers publicly involved two longstanding terminal illnesses t ha t seem to have been emotionally intensified by a resistance I had previously been unaware of, but have subsequently witnessed during man y hospital visitations. Both of these disguised examples occurred while I was serving a large parish in Chicago.12 The first began as I was passing a patient's hospital room. The older members of the family were affiliates of my parish; the younger ones were inactive except for rare events. A medical doctor had just told them, "I've done all I can do," and they were shocked. Up until t hat time death had not been talked about by either the family or the doctor. The patient had tried, but the recurring replies to his efforts were: "Don't be silly. You're going to be out of here by June. We're all spending the summer in Maine"; "We're planning to run some more tests to see about the use of a new drug." A distraught daughter saw me in the hall. Nobody had been in touch with the church because "Dad was going to be all right," even though "dad" had been in a coma for much of the last week. She asked if I had a minute, and I told her I'd be there shortly. After talking with the floor nurse, I got an idea of what happened and went to the man's room to speak with the family. When I turned to the patient, they were somewhat surprised at my choice of prayers, two messages of h o p e - o n e for the patient and one for the f a m i l y - b o t h from the Burial Office. The patient opened his eyes during this short time and probably saw only a black suit and clerical

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collar. His lids were blurred with fluid. He closed them quickly and died. My impression was that he smiled. (In the months that followed, my ministry to the family frequently concentrated on their rage about a legal chaos. They were faced with trust complications that could be directly related to their intense denial of terminal i l l n e s s - a denial fostered by the resistance of their physician. Fortunately I was able to gain some support in my ministry to them through their attorney.) The second illustration points up the same issues as the first: the need for professionals and family to deal with death. J i m Cepin was a 43-year-old draftsman who was married to Jane, a 37-year-old housewife with a history of brief psychiatric hospitalizations. This was a second marriage for both; they had one child, aged 7. J i m had terminal cancer that had been diagnosed by an internist. In a rage, he changed physicians and discovered t h a t it was '~easy to find one who wouldn't talk about death. He'll just say something like 'of course, you'll die. Everybody does.'" Because of some gastrointestinal difficulties, Jane continued to see his former internist. He told her that her husband's death was imminent. Soon Jim had a team of four physicians, but still '~death" was not discussed. When he entered the hospital, I began to visit him and consulted with a resident who worked with Jim's doctors. He told me t h a t J i m was going to die within months, but that he had not been informed. I called one of the specialists, who said he or someone else would tell Jim. I left for vacation and returned two weeks later to find Jim under heavy medication and looking emaciated. At the end of our conversation he quoted a line attributed to Blake: ~'The grave is a bare and lonely place, 'tis none there to embrace." I called his doctors again. When they said he was dying but t h a t no one had explicitly told him so, I realized that it was a difficult issue for them to face. So I started visiting him daily and slowly initiated the topic of death. Sometimes he was furious and asked me to leave; other times he would try to fall asleep or vomit; other times he would complain that the pain was too great to talk. Slowly I learned that time was important. To be effective, a conversation could not immediately follow or directly precede his medication. The median was the period of greatest exchange.l~ Even more important t h a n timing, I learned what team work meant. I learned this mostly through its absence. And I periodically found myself at direct odds with the physicians. It seemed t h a t each time I made progress with J i m or Jane, some false hope would be engendered by another form of chemotherapy. Intellectually I realized t h a t the medical world was dedicated to the preservation of life, but the alternative of death was still not being raised. I felt very much alone in a ministry I knew to be intensely needed. Then a legality was discovered t h a t alarmed everyone. J i m had changed his name after World War II to Copin. The simple substitution of an '~o" for an '~e" had serious ramifications. He was a veteran; he had two insurance policies, two Social Security numbers; and it was now questionable whether or not his first wife was dead. Moreover, he had never changed his name by court action. The lawyer who was called in provided invaluable assistance. For one thing, he gave me support; he also allowed J i m to arrange his assets and to dispose of as much

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of the estate as possible. The day before he died, J i m told me t h a t he had a sense of worth and a u t o n o m y because "I've gotten m y house in order." With J a n e , we a r r a n g e d his funeral. Existentially, J i m h a d ingested a m a x i m of H e r b e r t Marcuse's: "Men can die without a n x i e t y if t h e y know w h a t t h e y love is protected from misery and oblivion. ''14 T h r o u g h o u t this experience, I found m y s e l f e n o r m o u s l y perplexed. Repeatedly I asked such questions as: "Why don't the doctors directly tell h i m t h a t he's going to die? After all, isn't the physician the central figure w h e n it comes to the reality of physical h e a l t h and illness, diagnosis and prognosis? W h y do I h a v e to rely on the legal world for p r i m a r y support?" Perplexed and discomfited by these questions, I b e g a n to ask ministers of o t h e r denominations if t h e y had encountered similar situations. Several of t h e m had, including a few chaplains of progressive, well-staffed hospitals. By coincidence, I t h e n came in contact with a one-act p l a y w r i t t e n by radical theologian William Hamilton. 15 The play concerns a college student's reactions and responses to the discovery t h a t she is dying. The first scene opens in the middle of a conversation t h a t m i g h t well h a v e been a v e r b a t i m account of e i t h e r of the previous vignettes. The s t u d e n t and the physician have been sparring. Hamilton comments: "He has been m a k i n g use of the ancient medical h a b i t of offering a s s u r a n c e w i t h o u t m a k i n g a n y s t a t e m e n t s of fact." Girl: Why can't you tell me what my chances are? Doctor: Because we simply don't know enough to come up with the nice decisive answer

you seem to expect. We can name the disease, we can make a very rough guess on the prognosis, and we can do a number of things to help you right now. We don't give up and we don't offer false hopes. Girl: Am I going to die? Doctor: That's what we call a typical patient's question. We're all going to die. Girl: And that's what I call a typical doctor's answer. If I wanted little nuggets of homely

wisdom, I'd ride around town and read the bulletin boards in front of the churches. Am I going to die as a result of this disease, s o o n . . . ? Doctor: You just can't expect me to answer such a question. I don't know what you mean

by soon. Girl: Doctor, I like you and I think you're very capable. But I must say you're almost as

ready with the non-answers to questions as a politician or a clergyman. Doctor: It's not as easy as you think to tell just how much a patient needs to know. Girl: So you sit there and play God and decide just how much of your precious wisdom

your patients deserve to receive.

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Doctor: My dear, only the saintly and the young imagine truth to be such a simple commodity. Look: when my word of truth to a seriously ill patient can actually hurt him physically, can even wipe out the will to live, what is truth in matters like this? Girl: An unfortunate question, considering the others in history who have asked it. Doctor: You can't intimidate me; as a matter of fact I've always thought that Pilate probably really wanted an answer to that question, and that Jesus showed a kind of insensitivity, even self-centeredness, in refusing to come up with something. So I really have no qualms in putting Pilate's question to you, who seem to accuse me of being a stuffy, middle-aged phony placed on this earth to deceive lovely young girls like you who have terminal illnesses. Girl: You know, I prefer you angry to bland. The word I wanted to hear was '~terminal." Is my illness, according to what you know at this time, a terminal one? Doctor: Yes. Girl: A general sense of man's mortality and knowing that one is likely to die fairly soon are really quite different. Doctor: I know. But we can still do a great deal. Girl: Except to answer my straightforward questions about death. Oh, I didn't mean to accuse you of anything like dishonesty. I think I understand that truth isn't simple, especially truth about important things like love and sex and death. But I did want a little more candor than you were prepared to give me at first. Not a general proposition about man's mortality, but a word about me, my disease, my future. Now I have it.

In this d r a m a t i c excerpt b o t h the p a t i e n t ' s n e e d to k n o w of h e r condition a n d the p h y s i c i a n ' s r e s i s t a n c e a r e clearly depicted. Likewise, we h a v e seen h o w both factors c a m e into p l a y in t h e p a r o c h i a l experiences described. On reflection, a r e p h r a s i n g of F r e u d ' s use of the L a t i n d i c t u m m i g h t be a p p r o p r i a t e : " I f you desire peacefulness in life, be p r e p a r e d for d e a t h . " T h e p h y s i c i a n ' s difficulty with t h e t e r m i n a l p a t i e n t becomes e v e n m o r e a p p a r e n t w h e n a b e t t e r - k n o w n a d a g e is coupled w i t h this redaction: " T h e r e is no s u b s t i t u t e for experience." C o m b i n i n g the i n t e n t of t h e s e expressions, one m i g h t reason: since t h e physician is in c o n s t a n t contact w i t h the life/death process, since life b e g i n s to t e r m i n a t e physically at birth; since f r e q u e n t l y t h e p h y s i c i a n ' s first e x p l o r a t i o n s of the h u m a n a n a t o m y a r e conducted on a cadaver, t h e p h y s i c i a n is a person well p r e p a r e d to deal w i t h d e a t h (his own as well as his patients'). W i t h o u t going into f o r m a l logic, this f o r m of deduction is not only false, b u t it s e e m s t h a t the r e v e r s e is true. To p a r a p h r a s e F r e u d ' s principle of indirect representation: "A t h i n g is e i t h e r exactly w h a t it a p p e a r s to be or exactly t h e opposite. ''16 R e l a t e d literature

As p a r t of a n o t h e r project, t h e senior a u t h o r i n t e r v i e w e d s e v e r a l depth-psychologists s h o r t l y a f t e r the b u r i a l s of the two p a r i s h i o n e r s whose cases a r e outlined

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above. A n u m b e r of times the subject of this p a p e r was raised. A tendency of responses was s u m m a r i z e d by Roy G r i n k e r , Sr., w h e n h e commented: Let me tell you that we have the greatest difficulty as physicians dealing with death9 We have, there is no question, a great deal of evidence that a doctor can't stand the dying patients. He can't stand death, neither can the nurses9 Strauss out in San Francisco has shown that the cancer ward with the dying patients is a neglected place; the nurses are angry with the patients9 Now we have an oncology section9 I have the greatest problem in getting any psychiatrists to work with them because they don't like to see death; they don't like to see dying patients die. It's hard, I think, for there are two aspects: first, they are brought up in their education with the idea of saving lives; of keeping people healthy9 And death can be a force of interference with their goals in life. Secondly, it reminds them of their own mortality. The fact that some day they too will die. The experience of Elisabeth Kfibler-Ross at the University of Chicago is a good example9 The persons that she had the greatest influence on were the divinity students9 She brought them in to see her interviews with patients9 The medical people didn't like it at all. As a matter of fact they dropped her from the faculty because they couldn't stand it. The doctors don't like death over and above the usual fear people have of dying9 In a n o t h e r interview A n n a F r e u d raised the subject of lost object-relations: 9 . . it's not one's own death that's so important. It is the death of those close to you which presents a serious problem. Lost objects are a source of pain and by comparison, one's own death seems insignificant. The person who dies is not nearly as important a concern as the individual who has been left.18 Miss Freud's c o m m e n t raised an issue we initially sought to investigate: t h a t the doctor/patient relationship becomes more complex w h e n it is directly verbal. If the relationship becomes more intimate, t h e n the patient's d e a t h m e a n s the physician experiences loss of r e l a t i o n s h i p - m a y b e even a "friend" - r a t h e r t h a n a "patient" who had been objectified in v a r y i n g degrees. While the research r e g a r d i n g this hypothesis will not be completed for several years, p r e l i m i n a r y evidence offers suggestions t h a t m a y be of i n t e r e s t to the crisis minister. The most i m p o r t a n t of these is the reality of medical resistance to t e r m i n a l i l l n e s s - a problem we contend requires investigation beyond a s u r v e y of physicians, psychiatrists, and pastoral counselors or even of the finest clinicians w i t h i n these related disciplines. In r e v i e w i n g the l i t e r a t u r e related to our topic, we find two o u t s t a n d i n g factors: a d e a r t h ofpsychosocial education in the n o r m a t i v e medical curriculum; and the so-called "MUM effect," or a pervasive reluctance to t r a n s m i t bad news directly to the party(ies) most involved. With r e g a r d to the first, t h e r e are several sound studies by h e a l t h professionals such as Barton, Olin, Rich, and K a l m a n s o n ; b u t the projects done by Liston and Dickinson are probably the most succinct.19 Liston began studying the educational neglect of d e a t h and dying in medical curricula after he discovered t h a t the Cumulative Index Medicus did not reveal one article from 1960 t h r o u g h 1971 addressing itself to the instruction of medical

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students about the psychosocial t r e a t m e n t of terminal patients. (We commissioned a computerized survey of the same source and arrived at the same results. However, from 1971 to 1975 there have been several articles published on the subject. We understand t hat more are scheduled for print in 1977 and 1978.) Liston argued t h a t ~'physicians in virtually every sector of medicine must from time to time deal with patients who are dying or who have illnesses which are either fatal or so serious as to be of uncertain outcome."[emphasis added] 2~ He then went on to argue that: There is ample evidence that teaching medical students about psychosocial aspects of life-threatening illness has been relatively neglected in formal medical education: Less than one half of the schools surveyed IN = 83] offer formal instruction in this area; those which do so provide on the average less than ten hours of instructional time per student; many courses are not required and elected by small numbers of students; most courses are of relatively recent introduction; and educational methods have apparently been considered of comparative insignificance, judging from the near absence of communications on this subject in the literature. Expanding medical knowledge and technology, together with the trends toward compressing medical school curricula and toward increasing class sizes have necessitated reduction or elimination of the teaching of some subjects and a tendency to teach by large class lectures rather than by small group seminars. But the importance of educating medical students about patients with life-threatening illnesses clearly overrides these issues. The humanistic approach to dealing with such patients needs to be imparted to students during their formative clinical years, not after their individual styles have become fixed. It is known that the patient who suffers from a fatal illness also may suffer from neglect in that his need for human contact and understanding, especially from his physician, often is unfulfilled. The patient tends to be avoided, because his dying is frightening and threatening to others. It is conceivable that this phenomenon of neglect also occurs in medical education for the same reasons. [emphasis added] 21 Like Liston, Dickinson also found education on death and dying to be a neglected subject in medical schools. He pointed out t hat most deaths in the United States now occur in hospitals or nursing homes. Thus, medical personnel (physicians, nurses, etc.) are in a strategic position to relate to dying patients. Yet his research of 107 medical schools showed a very limited degree of emphasis on death education. This condition is widespread because no statistically significant differences were found considering geographical regions, private or public medical schools, and average annual enrollment. Dickinson's paper added an interesting personal observation. One of the physicians with whom he discussed his project asserted t hat "relating to dying patients cannot be t aught by instruction but can only be learned ton the job. ,,,22 Taking a cue from Olin, Dickinson retorted t h a t what actually is acquired or reinforced in many medical students ~'on the job" is an attitude t h a t serves defensively to maintain an emotional distance between them and the dying patient. This emotional distance has its most blatant expression in the MUM effect, a

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reluctance to transmit bad news when the recipient is the person whose fate is altered by the circumstances described in the message. Tesser and Rosen have made a valuable contribution in this area by clarifying the dynamics behind why "most doctors favor not telling terminal patients that they are dying. ''23 They substantiated several classes of hypotheses to account for this resistance. They first argued that the communicator might well feel guilt about the fate of a recipient of bad news and, therefore, avoid communicating the bad news. Following this point, they went on to show how there is a greater telling of bad news when the communicator believes the fate is to be shared than when he does not. Another hypothesis Tesser and Rosen worked with is a fear-of-negativeevaluation. This hypothesis postulates that communicators wish to avoid a negative evaluation that they fear they will receive if they transmit bad news. While their study of this contention is fairly secure, the results contain enough contradictory evidence to render the hypothesis tentative. The MUM effect also involves a mood hypothesis, an unwillingness on the part of the communicator to adopt a negative affective state that is called for when he is delivering bad news. Virtually no data appeared to contradict this hypothesis. Joined with this contention are two specific hypotheses: the recipient's desire-to-hear and the recipient's emotionality hypothesis. Both deal with the communicator's concern for the recipient. First, good news is transmitted more frequently than bad news because the latter would upset the recipient emotionally. Second, communicators assume t h a t recipients want to be told good news, not bad news, and they act accordingly. Both hypotheses were supported. While the Tesser and Rosen review addressed itself to a general tendency, they concluded their report by focusing on our subject as a clear illustration of their topic: The MUM effect has been shown to be a pervasive, systematic bias in interpersonal communication. Over diverse settings, communicators, recipients, and messages, good news tends to be communicated more frequently, more quickly, more fully, and more spontaneously than bad news. This bias implies that persons with troubles or difficulties may be further disadvantaged by being insulated from full information concerning their problem. We noted, for example, the physician's reluctance to discuss terminal illness with patients and their families. Although lack of knowledge of imminent death might, temporarily, make the patient more comfortable and prevent familial grief, it also has dysfunctional aspects. The dying patient and his family may be denied enough time to come to grips with and accept his imminent fate . . . . On the practical side there are details that require attention, ranging from legal arrangements to new family arrangements, the accomplishment of which would be impaired by ignorance of the imminent death. 24 One other study that we found interesting involves an attitudinal comparison of physicians and clergymen regarding death. Arthur Burton, the author, found a marked difference between the criterion groups and indicated that the medical sample evidenced a strong use of at least three major defenses: denial, displacement, and compensation. The ministers, Burton further contended,

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showed a greater acceptance of death and less of an inhibition in dealing with terminal processes. 25 While Burton's comparison and inferences are subject to a host of criticismsnot the least of which was a biased sample of unordained Episcopal seminaria n s - the instrument he used to gather his data was a useful questionnaire. We redistributed this instrument with slight modifications to 110 physicians selected from the membership list of a medical professional association in the Cleveland metropolitan area. The instrument was introduced by a cover letter from a medical corporation and signed by a physician. (It was conjectured that physicians would be more likely to respond to members of the same professional background than to Ph.D.s.) The letter explained the study, assured anonymity, and informed participants that a copy of the resulting research report would be available on written request.

Data analysis The data were tabulated and analyzed by several methods. Descriptive statistics were calculated to show response frequencies and percentages for each questionnaire item and to permit inspection of the data in light of such demographic classifications as age and sex. The categorical data were cross-tabulated and analyzed using Chi-Square tests of independence. Statistically significant (p < .05) Chi-Square test results denote dependence (i.e., a relationship) among the entries in a contingency table. When significant test results were obtained, the data were subjected to further post hoc analysis using Cramer's V statistic to assess "the apparent strength of statistical association. ''26 A final analysis was an attempt to determine participant physicians' agreement among rankings of nine personal, social, and professional arrangements that most assume should be made before one's death. The relative importance of each option to the sample physicians was assessed from its rank sum over all respondents. Consensus among the physicians about the rank ordering of arrangements was assessed by Kendall's coefficient of concordance. 27

Results Usable data were returned by 83 of the 110 physicians contacted, a response rate of 75%. Rarely do response rates for studies using mailed questionnaires exceed 50%, an indication that the participants were both conscientious and highly motivated. All respondents were male. The physicians who agreed to participate represented 15 medical specialtiesa much wider range than Burton's study of psychiatrists. Sampled Medical Specialties Allergy Dermatology Ear, Nose, Throat General Practice Medicine

Neurology OB-Gyn Ophthalmology Orthopedics Pathology

Pediatrics Psychiatry Radiology Surgery Urology

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The specialties were then separated into two groups to facilitate data analysis. Physicians in the first group were those whose specialty results in frequent contact with terminally ill patients. Physicians in the second group are likely to have infrequent contact with dying patients. The doctors were also arranged into three age groups. The first age group included 20 physicians (24%) less than 45 years of age. The second age group had 36 physicians (43%) ranging from 45 to 55 years. The third group included 23 physicians (28%) whose ages were 56 years and above. Four participants (5%) failed to provide age data.

Descriptive data We have summarized participants' responses to 13 of 14 questionnaire items. Inspection of the descriptive data leads to several tentative conclusions about the religious orientation, sociability, and professional self-i'mage of the sample physicians. Their views about the process of dying, rights of persons regarding choice of death, modes of contact with dying patients, and how their colleagues react to dying patients can also be determined. Several items provide insight regarding the religious attitudes of the sample physicians. One item, for example, indicates that the largest percentage (65%) of the respondents report that death is "an end." Responses to another show that a large percentage (43%) believe the burial ritual is "outmoded," and responses to still another show the largest percentage of the participants (45%) believe the inevitability of death assures man only of his finiteness. These figures hint that most respondents are persons for whom matters of religious ritual and spiritual fulfillment are of small concern. Evidence that physicians are highly sociable persons is provided by two questionnaire items. The first reveals that most participants (69%) report more than ten people would miss them if they were to die today. Reciprocal attachment is shown in another item where the majority (63%) report they would miss more than ten persons if any of those persons were to die today. Must doctors feel immune to death in order to undertake their responsibilities? The largest percentage of those sampled (80%) do not subscribe to that belief, reporting such an outlook is an unnecessary fiction for the physician. Information about the sample physicians' views related to some features of the dying process is seen by responses to three questions. In response to the question, "What is the proper time to die?" 28% respond that there is none, while 21% agree the proper time is when one is either incapacitated or r it happens." When asked about the best way to die, the doctors show much variation among the alternatives presented with "fully prepared" (25%), r (24%), and r (13%) receiving the most frequent endorsements. Most of the participants are clearly provisional when asked if individuals should have the right to choose the circumstances of death. More than half (55%) believe such freedom should exist "sometimes," while absolute agreement and absolute disagreement with the statement are less common: 21% and 23%, respectively.

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Data about forms of contact between the sample physicians and terminally ill patients are requested in two items. While most (69%) do not subscribe to a policy that discussions about death should be avoided with their patients, only a relatively small proportion (34%) have informed even one patient that death is imminent. Doctors' views about the readiness of other members of the medical community to discuss death with terminally ill persons are also striking. In response to another item, 92% of the participants report a perception that most physicians "shy away" from discussions about death with the terminally ill. Only 4% indicated that such avoidance behavior is absent. What are the relationships among responses to the questionnaire items? Do patterns exist in the data to show that item responses are mutually dependent? To what extent do physician age and medical specialty relate to questionnaire responses? We will present the results derived from contingency table analyses where each questionnaire item was cross-tabulated with every other item. For purposes of brevity, tabular entries were made only for those X 2 tests where statistically significant results were obtained. Coefficients for Cramer's V statistic are available for each significant test result to indicate the strength of association (dependence) among the cross-tabulated items. 2s The data indicate that 18 of the 105 X 2 tests (17%) yield statistically significant outcomes. Responses to three of the questionnaire items were found to be independent of responses to the remaining ten items and to the two demographic variables. Data from (a) "Should an individual have the right to choose his or her own death?" (b) "Do you consider it best to avoid discussions about death with your patients?" and (c) "Would you be willing to write your own epitaph?" are unrelated to other item data. Each of these three independent items taps a unique dimension related to physicians' views about death, dying, and relationships with those experiencing the terminal process. Another noteworthy finding among the nonsignificant X 2 test results is the independence of physicians' responses to the item, "Do you consider it best to avoid discussions about death with your patients?" from another item, "Do you think physicians tend to shy away from discussions of death with the terminally ill?" The absence of any relationships between responses to these items shows that a sharp distinction exists between behavior that physicians attribute to themselves (i.e., transmitting bad news) and behavior attributed to professional colleagues (i.e., avoidance). Several of the cross-tabulations producing statistically significant X 2 outcomes also merit attention. However, instead of describing these cross-tabulations specifically, we think it is more appropriate to highlight some of their results. The significant cross-tabulations: 1. give evidence that physicians acknowledge personal mortality and do so in the absence of traditional forms of spiritual support; 2. suggest that older physicians have a greater tendency to believe that death is an end than their younger peers; 3. indicate that the desire to die fully prepared, suddenly, painlessly, and in one's sleep is related to doctor's sociability;

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4. suggest that agreement about preferred ways to die corresponds to agreement that physician avoid discussions about death with terminal patients; 5. strongly supports the notion that those doctors participating in this study see themselves as sociable, affable individuals with a broad circle of family and friends; 6. give further evidence that the sample physicians acknowledge personal finitude and that the acknowledgment relates to a belief that a feeling of immunity toward death is unnecessary for physicians; 7. show there is evidence that validates our coding scheme for medical specialties (the specialists classified as having frequent contact with terminal patients report a greater incidence of informing terminal patients that they will die, probably very soon); 8. indicate a tendency for older physicians to have more contact with terminal patients than their younger peers. The final analysis requested involved a ranking of nine alternative arrangements to be made before one's death. The following table gives the rank ordering with the respective sums. (Low sum of ranks indicates a higher priority for those in the study.) Rank Ordering of the Personal, Social, and Professional Arrangements That Should Be Made for One's Death Alternatives

1. 2. 3. 4. 5. 6. 7. 8. 9.

Care of Dependents and Insurance Disposal of Property and Will Prepare Friends and Relatives Psychological Preparation Transfer of Patients Spiritual Preparation Disposal of Files and Records Funeral Arrangements None

S u m of R a n k s

132 228 280 329 440 444 493 510 666

The ranked alternatives showed a clear concern for handling pragmatic affairs in advance of one's death, with care of dependents and insurance and disposal of property and will seen as most important. Preparing family and friends for the forthcoming loss and preparing oneself for death follow closely. The doctors ranked alternatives regarding their medical practice and spiritual preparation for death as being of much lesser importance than those preceding. Making no preparations for one's death was ranked last. In this area, as in most of the others discussed, there was a very close agreement among the different medical specialties within our sample. 29 Discussion and s um m ar y

Our study leads to several conclusions about physicians' views of death and dying, their relationships with terminal patients, and how the' crisis minister

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may contribute to the welfare of dying persons and to the medical personnel who care for them. While these conclusions are not unique, we believe that an awareness of them will assist the pastor who experiences medical resistance to the terminal process. Consequently, such clergy may experience less distance from and greater empathy for the medical practitioner who fears professional failure and personal finitude. First, it seems that physicians are highly pragmatic persons who are not religiously inclined. A profile of our subjects' self-presentation and/or perception emerged in the course of the data analysis. Philosophically, these doctors reflect a degree of epistemological realism that gives them a correct, if limited, account of objects and makes it possible for them to have accurate and direct knowledge of the world2 ~ A prominent example of this viewpoint is that death clearly demonstrates human finitude. When biological life nears termination, all concerned hope that death will occur "suddenly." The data show little concern for spiritual matters. The way to live until "life's end" is pragmatically and with self-determination. In other words, death is "final" for most doctors and no amount of spiritual readiness can adequately substitute for the preparation achieved from having one's financial, familial, and personal affairs in order. However, this does not minimize the physician's social needs. There is a clear indication of the wish to be missed as well as an other-directed tendency to form attachments. In general, most subjects believe that physicians avoid discussions about death with terminally ill patients. Yet these same subjects do not believe it is "best" to do s o - e v e n though a majority of them have never told a patient that he or she was about to die. Thus, our second conclusion is consonant with the findings of earlier research, which shows that doctors resist relating to persons who are terminally ill. While the data indicate that the sample physicians claim to be attentive to the terminal process and to communicate explicitly with patients who face imminent death, only about one-third have ever told a patient that death will occur soon. In addition, the data reveal that only a very small proportion of the doctors believe their colleagues are equally forthright. Apparently the hesitancy about communicating directly with terminal patients emerges from a general resistance to the process of dying. This resistance, in turn, seems to lead to ego defenses involving denial and projection, one facet of which is the assignment of objectionable (i.e., nonprofessional) attributes to colleagues. With these findings, our third conclusion pertains to the role of the pastoral counselor, chaplain, or members of the parochial clergy who minister to the terminally ill. While it is generally recognized that treatment of terminal patients should consider their biosocial and religious needs, rarely are clergymen involved or accepted as members of the health-care team. This can inhibit the patient's struggle to cope with death, because both medical personnel and the minister are central figures in the terminal process. It is vital that they tend human needs together. Their work should be synchronized, since the ideal form of crisis intervention or ministry to the dying is h o l i s t i c - a n integrated medical, pastoral, and sometimes legal system.

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Having accepted the data at a superficial level, we have some thoughts that relate to the crisis minister, especially one who pastorally recalls messages of existence on the other side of time. 31 As stated, the participants' attitude was that death is not talked about explicitly with the terminal patient by most physicians. Also most physicians believe that the cessation of biological life is "the end." Yet the sample's p r o f i l e - a p a r t from its realism and marked selfd e t e r m i n a t i o n - reflects social needs. Thus, the pastor or chaplain may find it helpful to respond to this characteristic in the physician, man or woman, who shows on one level self-assurance and confidence but is probably anxious about death and dying on a more elementary p l a n e - a plane t h a t is both resisted and projected onto professional colleagues who react similarly. It would be fortunate if this were not the case, but then we believe that the sample would be so unusual that the data gathered would be useless. Heinz Kohut states this well: Man's capacity to acknowledge finiteness of his existence and to act in accordance with this painful discovery may well be his greatest psychological achievement, despite the fact that it can often be demonstrated that a manifest acceptance of transience may go hand in hand with covert denials2~ The resistance and projection we believe to be operative in our study are but a few defenses with which the pastor must contend personally and with the medical personnel he seeks to work with holistically. Collectively, this could mean that the pastor must extend services to medical personnel in conjunction with a ministry to terminal patients and their families, not in an intrusive or directly interpretative fashion, but in an empathic or supportive style that reflects a common anxiety about death shared by most sensitive h u m a n beings. We also support modifications in the medical curricula that advocate a more deliberate exposure of clergy and health-care personnel to one another's work. Not only would ministers profit from a broader understanding of medical perspectives on terminal illness, but also increased attention to religious issues may help physicians curb the repression typically activated in the nonreligious when the subject of death arises. In making such suggestions we realize that we are not alone. 33 For centuries, similar types of desires have been voiced directly and indirectly. Nevertheless, the specific problem of medical resistance to death and dying is far from resolved. It is a product of an elementary fear of nonexistence, a condition that calls for an increased sensitivity to the terminal process and more holistic care for those who face imminent biological death. References

1. See, e.g., J. Pastoral Care, 1972,26 (2);Pastoral Psychology, 1972,23 (2). An illustration of the trust attorney's relevance in this instance is pointed up by Shafter, T., "AcceptingDeath: Guidelines for Professional Counselors Working in the Presence of Grief,"Estate Planning, 1973, 1 (1), pp. 14-18; and Bernstein, B., "The Lawyeron the CounselingTeam,"J. Religion and Health, 13, (3), pp. 180-185.

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2. While further studies will be cited, the reader interested in pursuing comments made thus far may find the following of interest: Feifel, H., and Branscomb, A., "Who's Afraid of Death?" J . Abnormal Psychology, 1973, 81 (3), pp. 282-288; Lester, D., "Experimental and Correlational Studies of the Fear of Death," Psychological Bull., 1967, 67 (1), pp. 27-36; Simpson, M., ~The Do-It-Yourself Death Certificate in Evoking and Estimating Student Attitudes toward Death," J. Medical Education, 1975, 50 (5), pp. 475-478; and Travis, T., et al., "The Attitudes of Physicians toward Prolonging Life," Internat. J. Psychiatry in Medicine, 1974, 5 (1), pp. 1726. 3. Freud, S., "Our Attitude Towards Death," The Standard Edition of the Complete Works of Sigmund Freud, XIV. London, Hogarth Press, 1914, pp. 299-300. Freud often wrote on man's problem in facing and dealing with death. The subject was a consistent ingredient of his own self-analysis. He poetically treated it in ~'The Theme of the Three Caskets" (XII, 1913, pp. 289-301), his paper '~On Transience" (XIV, 1915, pp. 303-307), and ~'Mourning and Melancholia" (XIV, 1917, pp. 237-258) as well as many other writings. He urged his readers to give up magical denials of death, enhance their lives by recognizing life's brevity, and strive for remembrance by means of humane achievements. 4. Peter Gay's description of Freud emphasizes his commitment to truth and honesty. Gay does this nicely by an integration of remarks Freud made in letters to three of his closest friends: ~"To live with one another,' he told Martha B e r n a y s . . . in 1882, 'does not mean concealing from one another . . . everything disagreeable; helping means sharing everything that happens.' He applied the same high standard of frankness in matters of greater gravity. 'The art of deceiving a sick man,' he wrote to Fliess i n . . . 1899, 5s really quite uncalled f o r . ' . . . He added with a Stoic's piety, 'I hope that when my time comes, I will find somebody who will treat me with more respect and tell me when I must be ready.' This w a s . . , when Freud was forty-two. He kept to this exacting ideal when his time did come: writing from London i n . . . 1939, very old and very ill, he told Marie Bonaparte that there was a concerted attempt to envelop him 'in an atmosphere of optimism.' He was being told that his cancer was receding, and his poor condition only temporary: 'I do not believe it, and do not like to be deceived-Ich glaube nicht daran, und mag es nicht, betrogen zu werden!"' Gay, P., "Freud/For the Marble Tablet," Berggasse 19: The Photographs of Edmund Engelman. New York, Basic Books, Inc., 1976, p. 48. 5. See Lessa W., and Vogt, E., eds., Reader in Comparative Religion: An Anthropological Approach. Evanston, Row, Peterson and Company, 1958, p. 245 ft. 6. Cf. Ari~s, P., Western Attitudes Toward Death from the Middle Ages to the Present. Baltimore, Johns Hopkins University Press, 1974; and Kfibler-Ross, E., Death the Final Stage of Growth. Englewood Cliffs, Prentice-Hall, Inc., 1975. 7. Nesson, P. de, "Vigiles des morts: Paraphrase sur Job," Anthologie podtique francaise. MoyenAge, II, Paris, 1967, p. 184. 8. Solzhenitsyn, A., Cancer Ward. New York, Harper & Row, 1969, pp. 96-97. 9. Bryant, W. C., '~Thanatopsis," The Oxford Book of English Verse 1250-1918. London, Oxford University Press, 1961, p. 763. 10. See Faulkner, W., As I Lay Dying. New York, Random House, 1930; Gunther, J., Death Be not Proud. New York, Harper & Row, 1949; Kazantzakis, N., The Odyssey: A Modern Sequel. New York, Simon and Schuster, 1958, pp. 680-775; and Unamuno, M. de, L'Agonie du Christianisme. Paris, Rieder, 1925. 11. '~Burial of the Dead," Services for Trial Use. New York, Church Hymnal Corporation, 1971, p. 414. 12. The illustrations have been disguised to conform with the ethical standards of the American Association of Pastoral Counselors and the American Psychological Association. Thus, the names we have used are fictitious. Two undisguised examples are: Forberg, A., '~Thoughts of a Terminal Patient," Pastoral Counseling Today. Washington and Baltimore, Pastoral Counseling Services Quarterly, 1975 (Spring-Summer), 1; and Jaffe, L., '~Dying by Stages," Miami Magazine, 1975, 27 (2), p. 30 ft. 13. Cf. Arkin, A., "The Use of Medications in the Management of the Dying Patient and the Bereaved," J. Thanatology, 1972, 2, pp. 630-633. 9 14. Marcuse, H., Eros and Civilization. Boston, Beacon Press, 1955, p. 216. 15. Hamilton, W., '~Death," On Taking God out of the Dictionary, New York, McGraw Hill, 1974, pp. 61-77. 16. See Freud, S., Standard Edition VIII. London, Hogarth Press, 1905, pp. 26, 70-74, 80, 115124, 173-174, and 203,206. 17. Moss, D., "Psychoanalysis with Sigmund Freud and New Frontiers in Mental Health: An

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18. 19.

20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

30. 31.

32. 33.

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Interview with Roy R. Grinker, Sr.," Pilgrimage: The Journal of Pastoral Psychotherapy, 1975, 3 (2), p. 33. Moss, D., "Dialogue at Maresfield Gardens: An Interview with Anna Freud," Pilgrimage: The Journal of Pastoral Psychotherapy, 1973, 2, (1), p. 6. Barton, D., et al., "Death and Dying, A Course for Medical Students," J. MedicalEducation, 1972, 47 (12), pp. 945-951; Olin, H., "A Proposed Model to Teach Medical Students the Care of the Dying Patient," loc. cit., 1972, 47 (7), pp. 564-567; Rich, T., and Kalmonson, G., 'r of Medical Residents toward the Dying Patient in a General Hospital," Postgraduate Medicine, 1966, 40 (4), pp. 127-130. Listen, E., "Education on Death and Dying: A Neglected Area in the Medical Curriculum," Omega, 1975, 6 (3), p. 193. Ibid., p. 197. Dickinson, G., "Death Education in U.S. Medical Schools," J. Medical Education, 1976, 51 (2), p. 197. Tesser, A., and Rosen, S., "The Reluctance to Transmit Bad News," Advances in Experimental Social Psychology, L. Berkowitz, ed., VIII, New York, Academic Press, 1975, pp. 193-232. Ibid., p. 228. Burton, A., "Fear of Death as Countertransference," Modern Humanistic Psychotherapy. San Francisco, Jossey-Bass, Inc., 1968, pp. 106-124. Hays, W., and Winkler, R., Statistics: Probability, Inference and Decision. New York, Holt, Rinehart and Winston, 1971, p. 108. Siegel, S., Nonparametric Statistics for the Behavioral Sciences. New York, McGraw-Hill, 1956. Detailed statistical accounts available upon request: The Rev. David M. Moss, c/o The Center for Religion and Psychotherapy of Chicago, P.O. Box 1533, Chicago, Illinois 60690. Consensus was evaluated using Kendall's coefficient of concordance (W). Values of the statistic range from 0 to 1 with higher values denoting greater consensus. For the doctors participating in this study W = .52, an outcome showing their agreement about the rank orderings is far beyond chance expectation (X 2 = 345.28, df. = 8, p