African Americans

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The attitudes toward the elderly, death, and death-related rituals/practices in the African American community can be traced to lower socioeconomic status, general American culture, a previous history of slavery, and African culture (Kalish & Reynolds, 1976; Herskovits, 1941; Wylie, 1971). In my comparative research on moral reasoning in Mexican Americans, African Americans, and whites (Cortese, 1990), some African Americans expressed deep respect for their elderly. This veneration for older people, as well as the practice of ancestor deference, has been credited to West African values, specifically, the authority and prestige of the elderly within the family and village community. I did not find this same pattern of respect for the elderly in individuals of other ethnic groups within the semiclinical moral-judgment interview setting from which the data were gathered (Cortese, 1990).

Despite the survival of some African values in the African American community, the experience of African Americans is distinct and qualitatively diverse from African culture. In terms of social theory, this issue is highly significant. Ethnogenesis refers to people from the same or similar geographical origins

(e.g., West Africa) who blend to form a new ethnic group within a different society. Accordingly, African American culture in the United States represents exactly this.

This process may occur initially because the members of a group share certain historical and cultural characteristics, but from this perspective, the importance of these shared characteristics derives from the common experiences of the group's members in the new society, most notably for African Americans, slavery, discrimination, oppression, and rejection by the dominant group. This common experience, in turn, provides a basis for a transformed ethnicity, one that is not a simple derivative of the society from which the immigrants or refugees come. Immigrant communities usually are not communities when they come (slavery is an extreme example); their ethnic identities are, to a surprising extent, constructed in the United States.

The effects of slavery on the experience of death began early and often, during capture and the journey to the Western Hemisphere (Markides & Mindel, 1987). Millions of Africans never finished the trip to America: ''victims of starvation, suffocation, drowning, suicide, disease, and the whippings, beatings, mutilation, and direct killing by those who held them in bondage'' (Jackson, 1985, p. 203). The death-causing social structures of oppression and institutional discrimination continued during slavery (Weld, 1969) and afterwards, during segregation. Today death is common in ghettos in the United States. Within a context of deprivation, some African Americans have considered death as a covert form of desire for freedom (in spirituals, for example) (Markides & Mindel, 1987). Nevertheless, the spiritual image of African Americans has been misinterpreted (Jackson, 1972; S. A. Brown, 1958; M. M. Fischer, 1969). The significance of the African American church and religious beliefs lies not in its sacredness, but in its ability to address itself to everyday problems of human existence and survival, as well as providing rituals of social solidarity or communal bonding.

A review of African American history and literature shows that death (often in a violent manner) is sometimes a central theme. Scant empirical findings from the social sciences corroborate what has been termed a preoccupation (see Markides & Mindel, 1987, p. 152) with death. A preoccupation with violent death has been linked to negative self-image, frustration, and anger that eventually view violent death as more honorable than passive death, the symbol of acquiescence to the structures of white political authority.

Attitudes toward Life, Death, and Suicide Behavior

Case Study 2: African Americans

The only lights in the large hall of the worn but colorful community center were coming from the bright flames on the tops of the candles on a very large birthday cake. Too numerous to count, each candle represented one of the first hundred years in the life of Henry Hughes. Henry smiled while he listened to a roughly harmonized version of ''Happy Birthday'' and was deeply touched by an explosion of spirited shouts and ap plause that followed. The dozens of guests included five generations of family members, numerous friends, members of the local media, and some health care professionals. Henry was frail, reflecting a lifetime of heavy physical labor, but seemed in good spirits. One of the local television news reporters curiously asked, ''Mr. Hughes, to what do you attribute your long life?''

Henry thought for a couple of seconds and replied, ''Complete faith in God, a good attitude toward life, a never-ending quest for learning, and an occasional glass of red wine.'' He smiled as the crowd broke into laughter. ''I've tried to live a simple life. All I've ever needed was a clever accountant, a forgiving minister, and a passionate wife.'' Henry added. Henry had outlived each of his three wives, and rumor had it that he was courting a possible fourth.

The reporter then asked, ''Do you have any goals at this point in your life?'' Without hesitation, Henry retorted, ''I want to live to be 110.'' Everyone knew that Henry was serious by the conviction in his tone.

Henry had worked as a sharecropper in rural Mississippi and had lived his entire life in abject poverty. He had suffered continuous discrimination from a racially stratified social structure with a long history of demanding and enforcing pervasive public segregation. Despite his hard life, Henry was grateful and upbeat.

''The Chinese have a beautiful saying: 'As calm as the sea . . . and as long-lasting as the mountains.' In other words—happiness and a long life. And I thank God that I've had both of them. Just because life is often painful and you're real old—that don't give you the right to check out early—Dr. Kevorkian style. You just make do with the opportunities that God gives you.''

This case study illustrates African American subcultural scripts on aging and mortality. The ethical value of accountability discourages elderly suicide even in the event of terminal illness. There is subcultural resistance to autonomy that supports freedom to make decisions about ending one's own life. The ethical value of privacy is demonstrated by subcultural cues to pursue activities of daily living in any way one chooses as long as it does not cause harm to others. The African saying ''It takes a village to raise a child'' is consistent with the moral value of beneficence. Everyone is involved in the welfare of the individual and the community.

Despite the relatively short life expectancy of African Americans or their alleged preoccupation with death, African Americans expect to and wish to live longer than whites, Mexican Americans, and Japanese Americans (Bengston, Cuellar, & Ragan, 1977; Kalish & Reynolds, 1976; Reynolds & Kalish, 1974). Given the economic pressures, prejudice, and discrimination that African Americans endure, this seems to reflect optimism, hope, resiliency, an appreciation of life, and religious faith. Life seems to take on greater significance and appreciation in the wake of requiring so much energy, endurance, resourcefulness, and suffering. This clearly is an example of virtue ethics, with a focus on how adverse living conditions develop the character of the individual.

Older African Americans are much more likely than older whites to believe that one should live as long as one can and that pain and suffering do not justify dying (R. Koenig, Goldner, Kresojevich, & Lockwood, 1971) (death with dignity). More African Americans than whites are opposed to allowing people who wish to die to do so (Kalish & Reynolds, 1976, p. 100). This speaks highly of their self-determination even in the context of terminal illness.

The finding of greater expectations and desires for longevity by African Americans is consistent with the generally lower suicide rate among older African Americans (Seiden, 1981; Markides & Machalek, 1984). This is indicative of a high degree of integration into the community (Durkheim, 1951). While the suicide rate increases with age among whites, it declines with age for African Americans (Markides & Mindel, 1987). Low suicide rates among older African Americans, as well as high expectations and desires for a longer life, hint toward a high degree of acceptance of life. Given the relative inequalities of life that African Americans experience vis-a-vis whites, this is somewhat paradoxical. Perhaps recent gains by African Americans have exceeded the expectations of older African Americans. Meanwhile, they have not met the heightened expectations of young African Americans who display their frustration and hopelessness through increasing suicide (Seiden, 1970) and homicide rates. In addition, the low survival rate of African Americans may lead to a relatively robust group of those who attain old age and are much less disposed to commit suicide (Markides & Machalek, 1984; Seiden, 1981).

Funerals and the Church

African Americans and whites depend less on family support during death and dying than Mexican and Japanese Americans (Kalish & Reynolds, 1976). Church-related support, as surrogate family, in the African American community compensates for less traditional family emphasis. Lewis's (1971, pp. 103-104) narrative of funeral customs in a small southern town underlines the importance of the church in African American funerals. The funeral affirms self-worth and status (Markides & Mindel, 1987) and functions as an opportunity for social gathering (McDonald, 1973). Most important, funerals serve the purpose of facilitating grief. African American funerals engender emotional release, catharsis, and interaction and confrontation with the deceased through music that is appreciably rhythmic. The eulogy confirms significant respect for the deceased by focusing exclusively on positive attributes. Ostensibly, one can leave African American funerals with the belief that the deceased was saintlike.

Mexican Americans

While the effect of African values on the attitudes and behavior of African Americans is questionable, the influence of Mexican culture on Mexican Americans is undeniable. In contrast to Anglo conceptions of death, ''the Mexican ... is familiar with [it], jokes about it, caresses it, sleeps with it, celebrates it, it is one of his favorite toys and his most steadfast love'' (Paz, 1961, p. 58). Although evidence does not suggest less fear of death, Mexican Americans do seem to take a matter-of-fact attitude about it, refusing to hide it away. Mexicans and Mexican Americans even celebrate a Day of the Dead on November 2 (an equivalent to All Souls Day in the Catholic church).

There is great diversity within the Mexican American community regarding traditional rituals and beliefs about death (Markides & Mindel, 1987). Typical Day of the Dead activities include taking flowers to the graves of their loved ones or lighting candles in church (Kalish & Reynolds, 1976). This is not very different from what Catholics, in general, do (e.g., Memorial Day visits to cemeteries).

The intensity with which Mexican Americans deal with death is not unlike what is found in Mexico. Regular concern and absorption with death result from the amalgamation of Indian and Spanish culture as evidenced in Mexican literature, art, poetry, folk music, and folk proverbs (Perez-Tamayo, 1977). Outsiders do well to avoid the ethnocentric view that such occupation may appear morbid and disturbing. Mexican American culture supports more open overflowing of emotional responses to death by a larger network of kin than is found with the other groups.

Attitudes toward Life and Death

Mexican Americans expect to and wish to live fewer years than whites, African Americans, or Japanese Americans (Kalish & Reynolds, 1976). This appears inconsistent with the notion that Mexican American elderly occupy a reputable position within the family unless one considers a modernization approach (discussed later). The expectations and wishes of Mexican American elderly are fairly good matches to actual predictions of their life expectancies. One hypothesis is that Mexican Americans have greater acceptance of death than other racial/ethnic categories: ''the elderly Mexican American accepts death as a valued experience, a thing of beauty, and an entrance into another world that is real. For him, death is an inevitable event that takes place in the presence of his entire family'' (Madsen, 1969, p. 233). This hypothesis, as yet, has not received conclusive support. At any rate, death themes are abundant in Mexican cultural symbols, arts, and ceremonies (Markides & Mindel, 1987).

If we frame the discussion as an ethical dilemma between two moral values, autonomy versus beneficence (or nonmaleficence), we are better able to clarify the more important ethical issues that need to be addressed. What if preserving the autonomy of the individual conflicts with providing maximum support and care by others, including the highest standards of caregiver ability and training? If an elderly Latino has a terminal illness, subcultural scripts would point us in the direction of honoring an individual's autonomy over beneficence or non-maleficence. However, if an elderly Latino is considering suicide, subcultural scripts would perhaps signal us to devalue autonomy and to provide the maximum support and care available with the highest standards of ability and training (beneficence or nonmaleficence).

Death Issues and Suicide Rates

Mexican Americans and African Americans, more than whites or Japanese Americans, have ''experienced or felt the presence of someone after he had died'' (Kalish & Reynolds, 1976, p. 158). Such encounters tended to be pleasant or, at least, positive. Mexican Americans, nevertheless, varied from African Americans in that fewer reported knowing anyone who had died during the previous two years, and fewer knew eight or more persons who had died during this period. Mexican Americans were similar to whites on these two items. While nearly all Mexican Americans (96%) who knew someone who had died during the previous two years said that at least one of these deaths was the result of natural causes, 34% knew persons who had died in accidents, 10% in war, 5% by suicide, and 4% who were victims of homicide (Kalish & Reynolds, 1976, p. 164).

The self-reported knowledge of homicide victims was consistent with official homicide rates for the ethnic group—lower among Anglos, Mexican Americans, and Japanese Americans, and much higher among African Americans. However, knowledge of suicide victims by Mexican Americans was much higher than would be expected from the very low reported suicide rate for Mexican Americans. In response to the question ''Has anyone you have known well ever committed suicide?'' almost one-third of the Mexican Americans responded affirmatively, a proportion slightly higher than that among whites, but considerably higher than that among African Americans and Japanese Americans (Reynolds, Kalish, & Farberow, 1975). This unusually high level of knowledge about suicides among Mexican Americans raises doubts about the validity of official rates. Mexican Americans may be more likely than others to conceal suicide due to its religious implications. The Catholic church views suicide as a mortal sin against the fifth commandment, ''Thou shalt not kill.'' Suicide victims are not eligible for funeral masses or consecrative burials.

Theories of lower suicide rates among Mexican Americans have focused primarily on their Catholic background (the same reason that contributes to underreporting) and high integration into the family (Hoppe & Martin, 1978). Like African American suicide rates, but in contrast to the pattern displayed by whites, Mexican American suicide rates decline with age (Anatore & Loya, 1973; Hatcher & Hatcher, 1975). While older Mexican Americans are better integrated into the family and community than younger ones, recent increases in suicide rates among younger Mexican Americans may reflect greater acculturation into mainstream society or an increasing frustration with a lack of access to social mobility.

Religion, Family, and Acceptance of Death

Mexican Americans are more likely than African Americans, whites, and Japanese Americans to prefer to die in a hospital; fewer (except for African Americans) wish to die at home (Kalish & Reynolds, 1976). Proportionately fewer

Mexican Americans than whites actually do die at home (Richardson, Solis, & Hisserich, 1984). Considering the powerful bonding of Mexican American families, this is somewhat unexpected. Perhaps the elderly exhibit such attitudes and practices for altruistic reasons. III or dying elderly realize that their presence at home places a great deal of moral responsibility on the family and major demands upon available space. The strong emphasis that Mexican American culture places on familism translates into additional importance of the moral values of fidelity and beneficence where ill or dying elderly are concerned.

Contrary to the notion that Mexican Americans are more accepting of death than others, there is some indication that Mexican Americans desire to conceal death from the elderly family member, including her or his own. More Mexican Americans than members of other groups feel that dying persons should not be told that they will die; significantly fewer Mexican Americans feel capable of telling someone that she or he is about to die; and more said that they would not want young children to attend their funeral (Kalish & Reynolds, 1976, p. 166).

These data suggest potential ethical dilemmas for Mexican American families that pit the values of accountability and fidelity against the value of autonomy. The ethical value of accountability calls into question the issues of deception and withholding important information. Accountability means that everyone should be responsible for the truth and for his or her actions. Consequently, a dying person has the obligation to tell the truth about his or her condition. Moreover, the family and health professionals also have an obligation to be truthful with a dying individual about his or her circumstances. The ethical value of autonomy involves the individual's right to decide to exclude children from those who are to be told about the elderly's imminent death.

Fidelity requires everyone to show loyalty to one another and to offer assistance in times of need. An elderly person who is dying has the right to expect others to help him or her if he or she becomes dependent in any way. The family members are expected to offer help. The ethical value of autonomy gives the dying individual the right to make choices about one's health and well-being as long as he or she is competent and causes no harm to anyone else in the process. The family has an obligation to act on behalf of the client.

This leads us to the notion of best interest. Sometimes family members are authorized to make decisions regarding the welfare of an ill or dying family member. Decisions are based on what would be best for the family elder, but from the perspective of the broader Mexican American cultural system of values rather than what the family elder might personally wish. Thus subcultural beliefs that knowledge of impending death should not be revealed to a family member may take precedence over the individual's desire to know.

The notion of best interest may be contrasted with the concept of substituted judgment, which is an effort by someone to make ethical decisions for the dying family elder that are most congruent with what one believes the older person would wish. Best interest differs from paternalism because in the case of the latter someone preempts the individual's decision-making right because one feels that his or her judgment is better than that of the client.

There are two very different ways of interpreting such data. First, Mexican Americans attempt to ''protect people from openly acknowledging the personal encounter with their own death or with that of a close relative'' (Kalish & Reynolds, 1976, p. 170). Conversely, there may be greater resistance within Mexican American culture to accepting death. Clearly, there is ritualistic and symbolic acceptance of death on the cultural or macro level. Empirical data at the individual or micro level, however, suggest greater difficulty adjusting to death, whether a person's own or that of a loved one (Kalish & Reynolds, 1976). Ritualistic and symbolic preoccupation with death in ceremony, art, music, and literature does not necessarily imply acceptance of death by individuals.

Despite empirical refutation of the traditional stereotype that Mexican Americans are generally fatalistic (Farris & Glenn, 1976), it still may hold in the area of facing death. Proportionately more Mexican Americans than other ethnic groups believe that people cannot hasten or slow their own death through a will to live or a will to die (Kalish & Reynolds, 1976, p. 174). This represents a belief in an external versus an internal locus of control. More of them opposed the idea that people should be allowed to die if they wish. More Mexican Americans than other groups believed that ''accidental'' deaths indicate the power of God working among people. From this perspective, life and death contain a deeply spiritual or mysterious element.

If Mexican American immigrants do experience greater difficulty in accepting death, what is the cause? Perhaps greater fears and anxieties about death are found in persons socialized in traditional rural Mexican culture with pervasive symbolism and ritual regarding death who then migrate to urban areas in the United States, where this ritualistic support is considerably diminished. This is a question for future research.

Japanese Americans

The attitudes and practices surrounding death of Japanese Americans cover a wide range depending on the degree of assimilation into mainstream culture.

Japanese Ethical Systems

In order to evaluate how Japanese moral and religious frameworks affect attitudes and behavior about death in Japanese Americans, it is important to make an artificial, yet heuristically useful, distinction between individual and social ethics. This entails a brief sociohistorical examination of the major ethical and religious traditions in Japan (Confucianism, Shinto, and Buddhism; see Cortese, 1996) in order to sense why issues of social ethics (e.g., social justice and social equality) are not central to them. Rather, Japanese concerns focus on social aesthetics; a harmonious and orderly society without overt conflict and with minimal envy is beautiful. (See chapter 3 in this volume for a more detailed discussion of ethical principles in Far Eastern religions.)

Shintoism

Shinto, ''the way of the gods,'' is the name given to the faith possessed by the ancient Japanese. It is often considered to be the ''soul'' of Japan. While Confucianism had been imported from China, and Buddhism from India (through China and Korea), Shinto is native to Japan. Shinto is a system of nature (the physical world) and ancestor deference. Unlike Christianity, Judaism, Islam, Hinduism, and other theistic religions that include the belief in one or more supreme beings, Shinto is an animistic religion. It rejects the notion of a supreme being; instead, it empowers nature with supernatural power. Shinto has no particular teachings or dogma, but allows each person his or her own meaning. Perhaps its label as a religion is inappropriate. Shinto is merely a belief in the power of human spirits and in the natural elements.

Kami is the name given to spiritual power and may include one's ancestors or all of the dead. It is also possessed by natural phenomena such as trees, rocks, rain, wind, mountains, and the sun. Kami is benevolent to those who pay homage, but when it is neglected, it becomes indignant and may be provoked to wrath and possible calamity. Therefore, it is always prudent to respect kami. In short, Shinto provides a very simple basis for faith. As in other animistic religions, Shintoists appease the spirits in objects and ancestors by honoring them and by taking care of them. Lacking any real ethical system or meaningful concept of an afterlife, Shinto is a folk faith whose essentially austere nature is suggested by the fact that its word for god—kami—is associated with the homonym kami, meaning up, on top, or paper.

What has incorrectly been called ancestor worship by outsiders who study Japanese culture can be more accurately viewed as a system of symbolic communication with deceased relatives. This may entail keeping a family altar with offerings of food and drink (Yamamoto, Okonogi, Iwasaki, & Yoshimura, 1969). Those who adhere to the traditional beliefs and practices of so-called ancestor worship have less difficulty adapting to the loss of family members. Shintoism provides direct implications for resolving ethical issues concerning the terminal illness or potential suicide of a Japanese older person. It leans toward autonomy and a right-to-die position on the issue of euthanasia. Shin-toism also carries the moral values of fidelity and beneficence one step further than most other sacred or secular ethical ideologies. While fidelity requires us to show loyalty to one another and to not abandon someone, Shintoism urges continued loyalty, support, and nonabandonment even after the death of a family member. Consequently, the death of a loved one may not be viewed as a sorrowful catastrophe.

Ancestor deference symbolizes the need of the deceased for continued assistance from living relatives. This may also be viewed as an extension of beneficence: Everyone has a right to maximum support and care by others in the maintenance or enhancement of his or her well-being. Well-being has numerous dimensions: physical, psychological, social, legal, and spiritual. Shintoism may suggest that a family provide continuous reverence for dead family members. Consequently, the ritual of ancestor deference plays a role in ethical issues, but it does not represent a life-after-death ideology.

Buddhism

Shinto was inadequate to meet the spiritual needs of the increasingly sophisticated society that Prince Shotoku and his successors created in Japan. That void was filled by the arrival of Buddhism from China, with its concern for individual salvation and its complex philosophical overtones. Carrying with it a dynamic impact on architecture, the arts and literature, technology, and philosophical thought, Buddhism spread rapidly in the upper classes of Japan. From the ninth century on, it pervaded the intellectual and political life of the elite.

Buddhism has often been viewed as the road to enlightenment and was the first systematic method of thought brought to Japan. Buddhist teachings focus on how to resolve and persevere in the problems of life and death; perpetual change (also a feature of most North American Indian spiritual systems) is another dominant theme.

Buddha, a sixth-century B.C. Indian, believed that through meditation, one can escape suffering by liberating the self from all desires. Meditation involves stilling the mind in order to grasp universal truth. This is an ideal condition called nirvana. Zen Buddhism has traditionally contributed toward self-understanding and a deeper sense of one's place in the universe. Consequently, this challenges one to learn to live harmoniously within oneself, with one another, and with the earth that sustains us. In the pursuit of truth, Zen's most basic principle is not to rely on words. Since truth goes beyond the boundaries of rational thought, one must grasp truth directly through meditation. Buddhism assumes that humans possess a latent intuitive power. The goal of meditation is to ignite intuitive insight through unconscious, involuntary processes. The meditative and silent emphasis of Japanese culture is compatible with Zen.

In following the rules for harmonious social relations, self-affirmation or affirmation from others is difficult. It might lead to ostracism or create envy. Consequently, many Japanese often feel that they can only let their inner self show when they are alone or alone in nature. One's inner self is never socially affirmed; it has no social reality. Zen seems to make a positive attribute of this social arrangement (i.e., the selfless individual). Perhaps it is Zen that contributes to outsider complaints that the Japanese are difficult to understand or illogical.

According to Buddhism (Japan's dominant religion), life does not end with death; it is merely transformed and continues in a different form. Buddhism promotes and, in fact, ultimately requires acceptance of death. Death takes precedence over human desire. Since death may occur at any time without warning, recognition of the unpredictable, transitory, and trivial nature of life in the finite world must finally result in a weaning from action taken to satisfy desire. The ultimate is to detach oneself from pleasure and desire. Having accomplished this, the enlightened individual is free from hope, anxiety, ambition, and frustration (Long, 1975). The most effective way to detach oneself from desire is meditation that channels the unconscious toward the impermanence of life and the inevitability of death. In short, one conquers death by accepting it. Accepting death, for a Buddhist, is eased by the belief that it leads to a new life, which, depending on one's actions in the present life, may be preferred to the present one.

Confucianism

A considerable share of the world's population, especially India and East Asia, have religions that concentrate more on sets of ideal principles than on the supernatural power of gods, objects, or animals. The most major of these religions are Buddhism, Confucianism, and Taoism. Such religions tend to focus on how people can achieve a better life on earth. Confucianism has a long history in Japan; it has provided a practical ethic to guide individuals in their daily lives. Confucianism prevails in human relationships and has provided the normative grounding for the vertical structure of Japanese society.

Confucius, a sixth-century B.C. contemporary of Buddha, believed that salvation was based on acting according to correct manners and respecting those of higher social rank. The objective of a Confucianist is to always act in a manner whereby one can mesh harmoniously with one's environment, relationships, and circumstances. Salvation, for a Confucianist, is oriented to the present life; it is harmonious living according to the ideas of an orchestrated universe. Confucianism emphasizes respect for others and goodness and love as the means of attaining harmony with the universe. It also stresses respect for and subservience toward family elders and those in higher social classes. Confucian thought plays into the ethical value of autonomy. Is the individual ever free to make decisions about his or her life or death?

Confucianism demands support for maintaining the status quo of the existing social system as the means for ethical decision making. Because of this conservative stance, it can be criticized as deterministic and resistant to social change. Confucian ideology goes against the central notion of autonomy: Everyone has the right to make choices (as long as he or she is competent). Confucianism, meanwhile, strongly values fidelity—the expectation that everyone is expected to show loyalty to one another.

Essentially an ethical system rather than a religious faith, Confucianism, with its emphasis on loyalty, personal relationships, and etiquette and with the high value that it places on education and hard work, is ideally suited to the pragmatic Japanese character. Today Confucian values still permeate the Japanese and Japanese American populations. Those impressed by the seeming discipline of the Japanese Americans and the efficiency of Japanese society emphasize the authority of the group over the attitudes and behavior of the individual and the accountability of the individual to the group. This authority of the group over the individual flies in the face of the ethical value of autonomy. Accountability, however, is a moral value that is central to Confucian doctrine; the individual is responsible to the group for one's actions and for the truth.

Japanese American Attitudes toward Death

Case Study 3: Japanese Americans

Ichiro Hajime is an elderly Japanese American dying from stomach cancer. He has just suffered a third major relapse and is in the intensive-care unit of a public hospital. The prognosis is not good; physicians tell the family that Ichiro is not likely to live another month. His family plans to conceal the bad news from Ichiro. Ichiro, however, seems to realize that he is dying and has made peace with himself and his family.

As the days go by, Ichiro is removed from intensive care and placed in a private room. He begins to frequently complain to his family about the total lack of privacy; Ichiro is constantly being monitored by hospital staff. He feels very uncomfortable with the seemingly increasing frequency of interruptions by hospital staff and with the curt manner in which people approach and handle him.

Soon Ichiro tells his family that he wants to return to his own home to die. The medicine, radiation, and chemotherapies have not been able to improve his condition. The impersonal living conditions have also taken a heavy toll. Ichiro has become severely depressed. Family members, nevertheless, argue that Ichiro should remain in the hospital where his condition can be carefully monitored. Furthermore, family members will not always be able to stay and care for him at his home.

After an intense open dialogue and debate, a consensus is reached (communicative ethics). The family agrees that Ichiro should return home and hires a private nurse to assist in Ichiro's daily activity needs. Ichiro insists that for their own emotional well-being, his grandchildren are not to be told about the severity of his condition; the family concurs.

The ethical decision not to disclose the impending death of an elder relative to grandchildren is justified by the subcultural belief that it is in their best interest not to know. First-generation Japanese Americans (issei) demonstrate controlled acceptance of grieving and death, an attitude based in Buddhism (Kalish & Reynolds, 1976, p. 131). Third-generation Japanese Americans (sansei) are more likely to have a Western attitude toward death, involving understanding and control of the external world rather than acceptance of it. Sansei tend to fear and avoid thoughts of death, since it is a topic that does not comfortably fit in a rational worldview.

It is not clear whether Japanese Americans are very accepting of death. Fewer Japanese Americans than African Americans and whites (but not Mexican Americans) feel that a dying person should be told that he or she is dying (Kalish & Reynolds, 1976, p. 136). This shows the high degree of sensitivity Japanese Americans have regarding the feelings of others. Even fewer think about their own death. Sometimes dying patients in nursing homes are kept in separate rooms away from other patients. Such data may be interpreted as indicating difficulties in accepting death. Moreover, Japanese Americans (like Mexican Americans) are considerably more likely to express fear of death (Kalish & Reynolds, 1976, p. 145). The overwhelming majority of Japanese Americans, unlike Mexican Americans, reported that they wanted to die at home.

Japanese interaction rituals, in general, and Japanese American attitudes about death and dying, in particular, support a high degree of individual privacy. Accordingly, everyone has the right to maintain his or her privacy even within the context of information about himself or herself concerning a terminal illness or impending death. Data indicating that Japanese Americans prefer to die in the seclusion of their own homes or, at least, in private hospital rooms demonstrate the importance of privacy as an ethical value. Privacy includes the right to live and die wherever one chooses without interference so long as it does not infringe upon the rights of others.

Japanese Americans are not likely to believe in life after death, suggesting that they are not particularly religious in terms of traditional Christian and Buddhist teachings and practices (the two most common religious backgrounds). Perhaps devout Buddhists prefer nirvana (a state of bliss) to life after death. Nirvana represents an escape from the continuous cycle of reincarnations (Long, 1975). Japanese American elderly, who hold traditional Buddhist beliefs, may prefer death to life in an institution, since death may result in a better afterlife or possibly even nirvana. An alternate view is that the high degree of willingness to die among Japanese American elderly is linked to the strong cultural work ethic. Many elderly would rather die than be unproductive or a burden on others (Kalish & Reynolds, 1976). Either way, it would appear that death is viewed positively.

These Buddhist beliefs about death and dying potentially create a conflict between nonmaleficence and autonomy. The family and others in the informal support role are obliged to preserve the safety of the older family member. This includes providing the highest standards of care of which they are capable in order to prevent any adverse consequences for the older person. However, the optimistic nature of Buddhist reincarnation ideology (i.e., the possibility of a better afterlife or nirvana) slants ethical decision making toward an emphasis on autonomy. This gives the individual a right to make choices, even about one's death, as long as one is competent and causes no harm to anyone else in the process. Autonomy clearly conflicts with nonmaleficence in this context, setting up an ethical dilemma.

Acceptance of death is characteristic mainly in Japanese American elderly (Kiefer, 1974a). The younger generation has greater difficulty dealing with death. Buddhist tradition proposes that death is natural, and thus fear of death means fear of nature. Moreover, the elderly who are healthy have a clear notion of their obligations to the world, a notion that helps them achieve a sense of the completeness and wholeness of their lives (Kiefer, 1974b). Although fam-ilism is strong in the Japanese family, elderly Japanese Americans who lack the support and gratitude of family or followers may feel overwhelmed by the sig nificance of the end of their lives. Social isolation is especially unfortunate for them.

Suicide

It is sometimes difficult to know how deeply the roots of an ethnic group in the United States can be traced to its geographical origin. Japan has one of the highest suicide rates in the world (Markides & Mindel, 1987). This had been blamed on belief that suicide is an honorable way out of an intolerable situation, a rigid and hierarchical social structure, extreme emphasis placed on individual success, and the dysfunctions of rapid modernization (Iga & Tatai, 1975). Belief that suicide is a fair way out of a crushing predicament can be traced to the Buddhist notion that life is negative and death should be embraced.

The Japanese operate carefully on the basis of social rules. While these rules do not claim to be absolute, at times they may be rigid, incredibly autocratic, and capricious. These rules aim mainly to regulate individual behavior within the group. This points to a very coercive element of Japanese dynamics. Suicide may be viewed as the only reasonable alternative. This has significant ethical implications since a moral system based on constraint cannot satisfy a prerequisite of individual choice and cooperation.

Despite the high suicide rate for Japan, Japanese Americans have relatively low (Kalish, 1968; Yamamoto, 1976) to intermediate (Reynolds et al., 1975) rates. Perhaps the strong cohesiveness of the Japanese American community prevents many potential suicides. Conceivably, low suicide rates for Japanese Americans may also represent successful assimilation into U.S. society. This implies that their adjustment patterns would be more similar to those of Americans than to those of Japanese (in Japan) (Dunham, 1976). This, however, does not explain why the official Japanese American suicide rate is lower than the white rate. There is evidence that the reported suicide rate of Japanese Americans is artificially low (Kalish & Reynolds, 1976, p. 138). More Japanese Americans than other groups know of a suicide that has been concealed. Suicides, like many other potentially embarrassing events, are often concealed by Japanese American families who are greatly influenced by what others think of them (Kalish & Reynolds, 1976). This sets the stage for an ethical dilemma between autonomy and accountability. Autonomy is suggested by data that show that Japanese American suicide rates, like those of whites, increase with age (Mc-Intosh & Santos, 1981b). Similar patterns have also been observed among Filipino and Chinese Americans. A deemphasis on accountability is the trade-off that comes from choosing autonomy. Accountability would include exposing the deception of concealing a suicide in the family.

Funerals

Japanese Americans, more than any other racial/ethnic group, prefer simple funerals attended only by relatives and a few especially close friends (the moral value of privacy) (Kalish & Reynolds, 1976, p. 143). Social etiquette in the

Japanese American community, however, obliges representatives from the community to attend and financially contribute (koden) to the high cost of a funeral (the moral value of fidelity). This drives attendance up, which, in turn, drives the cost further up.

The majority of Japanese Americans wish to be cremated; one-third choose burial (Kalish & Reynolds, 1976). A small percentage (11%) want their remains sent to Japan. The majority of those desiring cremation have no travel plans for their remains. This makes sense because grave visiting is very important in the Japanese American community. It is not surprising that most Japanese Americans would prefer that their remains be near their relatives (Kalish & Reynolds, 1976, p. 153).

Besides visiting graves more often than other racial/ethnic groups, Japanese Americans attend more funerals than others. Kalish and Reynolds (1976) found that 84% of their sample had attended at least one funeral in the previous two years. It is not unanticipated that older Japanese Americans have higher rates of attendance than the younger generations (Kalish & Reynolds, 1976, p. 153). Few Japanese Americans make arrangements for their own funeral, suggesting communal responsibility for funerals and other matters of the deceased (the moral value of fidelity).

Native Americans

There is tremendous intertribal diversity regarding death-related beliefs and practices among Native Americans. Older people in such tribes as the Apache have relatively little fear and anxiety facing their own death (Opler, 1946). The Navajos, conversely, have an especially great fear of death and the dead (Markides & Mindel, 1987). Avoidance of the dead and related matters can be traced to belief in and intense fear of spirits (Kluckhohn, 1962). Traditional Navajos bury their dead quickly and unceremoniously away from the village since they are believed to have harmful effects on the living. This pattern was also common in Europe in the Middle Ages. Since people were ignorant about the spread of viruses and disease, they believed that the dead caused death. When workers quickly burned diseased infected bodies, rates of illness decreased. This fostered greater avoidance and fear of the dead.

Such apprehension about death was ingeniously captured, shaped, and expanded by Gothic writers like Bram Stoker. They created a most powerfully evil yet mysteriously enamoring cultural icon: the vampire. The simultaneous, rapid, and deadly spread of tuberculosis also helped to fuel fear of vampires. Victims of tuberculosis displayed the same symptoms that opportunistic writers characterized as vampirish: spitting up blood, rapid physical weakening, pale complexion, and difficulty breathing at night. Native American fear of death carries over into persons with terminal illness, who are often kept in shelters away from home (Markides & Mindel, 1987). Today terminally ill Navajos spend their last few days of life in a hospital. Indian Health Services or religious workers usually take care of funerals. This allows family members to avoid any contact with the corpse (Kunitz & Levy, 1981, p. 384).

Pueblo cultural beliefs about death help the dying neutralize fear that may arise at the time of death or a dangerous crisis (Markides & Mindel, 1987). When these cultural beliefs (e.g., the continuation of life, ancestral prayers for healthy crops) are internalized, as they seem to be here, death is calmly accepted.

Increasingly high suicide rates for Native Americans (McIntosh & Santos, 1981b) have received considerable attention from social scientists. Although the overall rate is high, there is a great deal of variance among tribes. Thus one should avoid the stereotype that Native Americans are suicidal.

Native American suicide rates are higher among younger persons than among the elderly (Markides & Mindel, 1987). Low rates for the elderly are possibly due to the high status they receive within their community. Moreover, since few Native Americans survive to old age, those who do are the hardiest and, presumably, would be less likely to have suicidal tendencies (McIntosh & Santos, 1981a). Finally, elderly Native Americans are less likely to undergo the stress of cultural assimilation (Ogden, Spector, & Hill, 1970).

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