Biological, Psychological, and Social Aspects of Death and Dying

Learning Objectives

By the end of this section, you will be able to:

• Define death from a variety of perspectives
• Describe the dying process in physical and psychological terms
• Compare and contrast global differences in life expectancy and causes of death
• Describe the social dimensions of death and dying
• Compare and contrast various cultural perspectives on death and dying

Mateo wants to protect his cardiovascular health. Given the relatively early and sudden deaths from heart disease of his father, abuelo, and uncle, he suspects his family has a genetic vulnerability to this illness, but he wonders whether lifestyle factors such as stressful jobs, lack of exercise, and unhealthy diets might also be to blame. He wishes he had better contact with his extended family in Argentina. Maybe they’re doing something differently than his family in the United States and living longer as a result.

Mateo also worries about the process of dying. He doesn’t want to endure a long period of declining health, feeling helpless or being regarded as a diagnosis rather than a person. But he doesn’t want to die suddenly and without warning either, leaving his loved ones unprepared for that loss.

Many people share Mateo’s concerns about death and what it will look like, physically and psychosocially. What happens to our body when we die? How are dying people treated by others, and how do they feel about themselves? What are common causes of death? This section will address these questions.

Defining Death

Death is a physical event in which our bodies stop working, including the absence of breathing and a heartbeat. However, even this statement on describing death is overly simplistic. Our body is far more complex than this, composed of an intricate set of systems working together. These systems don’t all play an equal role in keeping us alive, but if something happens to one of them, it’s likely to affect the functioning of other systems and our body overall. For example, if our heart, lungs, and/or brain lose function, the other organs in our body may also start to fail. However, due to current medical science and advances, the failure of one organ does not guarantee that other systems of the body will inevitably and immediately lose functioning.

Medical professionals sometimes distinguish between clinical death, in which vital organs have stopped working but could be resuscitated, and biological death, in which these organs can’t be resuscitated (Parish et al., 2018). Depending on what caused the death, clinical death may occur before biological death. In cardiac arrest, for example, it may be possible to start the heart beating again. Or biological death may occur on its own: If a person is stabbed in the heart, the heart may sustain too much damage to be repaired.

But death isn’t just a physical event. It has psychological aspects, such as the way people cope with death, prepare and make decisions about end-of-life care, and express grief. Social aspects of death include the way dying people are treated and the cultural factors like religious and spiritual values and beliefs that affect people’s perceptions of dying and choices related to it. A researcher who studies the biological, psychological, and social aspects of death is called a thanatologist.

Biological Aspects of Death

The stethoscope was invented in 1819 by a French doctor named René Laënnec, but it wasn’t until 1846 that Eugène Bouchut, another French doctor, suggested that its ability to amplify the sound of a heartbeat could help establish that death had occurred and prevent premature burial (Panna, 2021). Thus, death was primarily defined as cardiopulmonary death, a state in which a person’s heartbeat and breathing have stopped and can’t be restarted through cardiopulmonary resuscitation (CPR) or other means (Lewis et al., 2017; Panna, 2021; President’s Commission, 1981; Rodman & Breu, 2022). This medical understanding of death prevailed through the late 1960s.

However, the development of machines that can maintain heartbeat and breathing without resuscitation required new criteria to establish that death had occurred. In the 1970s, doctors and legal experts recognized the concept of brain death (Greer et al., 2023; Lewis et al., 2017), in which part of the brain stem, the area at the base of the brain just above the spinal cord, has stopped functioning. The brain stem contains the pons and medulla oblongata, structures that control basic functions like breathing, blood pressure, and heart rate. A person who is brain dead will have a heartbeat and breathe only with the aid of machines and medications.

This new definition of death wasn’t immediately universally adopted. In the late 1970s, a committee appointed by President Jimmy Carter composed the Uniform Determination of Death Act (UDDA), creating a standard definition of death to ensure more consistent practices across U.S. jurisdictions (Lewis et al., 2017; President’s Commission, 1981; Rodman & Breu, 2022). This definition, adopted by most states, says that:

An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards. (President’s Commission, 1981, p. 2)

While this seems straightforward, this committee didn’t define “acceptable medical standards,” which vary from state to state. For example, New Jersey allows exemptions for people whose religious faith doesn’t recognize brain death, and Virginia requires that both brain death and cardiopulmonary death occur (Nguyen, 2020; Nikas et al., 2016; Omelianchuk et al., 2022). This means someone could be considered alive in one U.S. state but dead in another (Rodman & Breu, 2021).

Life Expectancy across the World

The term mortality describes how we will all inevitably die, while mortality rate describes how common death is in a population. Mortality can be used to describe the prevalence of death in a group based on life stage (e.g., expectant mothers), or based on a demographic category (e.g., race or SES), or in a geographic region (e.g., in a specific country). Although we’ll all die eventually, we don’t share the same risk factors. We won’t live equally long or die of the same causes. Race, socioeconomic status, genetic characteristics, environmental factors, and lifestyle choices all affect the length of our lives and the level of health we’ll face along the way.

How long we live—life expectancy—varies person-to-person due to many individual factors, such as sex and age (as you learned in 15.1 Physical Aging in Late Adulthood) and it also varies across the world. Global life expectancy is an average of life expectancies in all the countries of the world (Figure 17.2).

Figure 17.2 Countries shown in green have higher life expectancies, and those in red and dark brown have the lowest. (credit: modification of work “Life expectancy map-world-2021” by “Lady3mlnm,” World Bank Group/Wikimedia Commons, CC0 1.0)

Research consistently shows that life expectancy in many African countries, especially in sub-Saharan Africa, is lower than in many other parts of the world (Abubakari et al., 2019; Cao et al., 2020; Djoumessi, 2022; Freeman et al., 2020; GBD 2019 Demographics Collaborators, 2020; Heuveline, 2022; WHO, 2020). For example, WHO data by region indicate that in 2019, the average life expectancy in Africa was 64.5 years, while life expectancies in southeast Asia, the western Pacific, the Americas, and Europe were all at least 71.4 years (WHO, 2020).

What causes these differences? Within Africa, nations like Rwanda and Lesotho that have experienced high rates of war, terrorism, and political unrest appear make the populations within them particularly vulnerable to higher mortality rates compared to countries with more economic and government stability like Ethiopia (Cao et al., 2020; Freeman et al., 2020; Heuveline, 2022). Sub-Saharan countries like Swaziland, Lesotho, and Mozambique have lower and declining life expectancies due to threats to mortality including outbreaks of wars and/or a higher prevalence of people living with HIV or AIDS (Abubakari et al., 2019; Cao et al., 2020). Many African nations have a high infant mortality rate, largely due to malnutrition and infectious diseases like cholera and malaria, and these deaths are believed to be largely preventable (Abubakari et al., 2019; Djoumessi, 2022; GBD 2019 Demographics Collaborators, 2020).

So how can these deaths be prevented? It might seem like improved economies are the answer, but increased economic resources aren’t always associated with increased life expectancy (Abubakari et al., 2019; Djoumessi, 2022; Freeman et al., 2020; Martinez et al., 2021). What seems to be more important is the way governments spend money—specifically, whether they improve sanitation, education, access to health care, and the status of women (Abubakari et al., 2019; Djoumessi, 2022; GBD 2019 Demographics Collaborators, 2020). For example, east African nations like Ethiopia have higher life expectancy than central and west African nations like Cameroon and Ghana, despite higher rates of HIV infection; this difference is attributed to governments’ allocating more money to provide universal health care, clean drinking water, and programs that increase health-care options in rural areas (Abubakari et al., 2019; Djoumessi, 2022; Freeman et al., 2020).

Common Causes of Death

Like life expectancy, the most common causes of death differ by demographic variables. For example, men worldwide are more likely to die of accidents, murder, and suicide than women (WHO, 2019). Geographic location also plays a role, usually due to the resources and living conditions in an area. For example, in Angola, diarrheal disease (cholera, rotavirus) is the most common cause of death, likely due to lack of clean drinking water; however, in Canada, the leading cause of death is heart disease (Global Health Observatory, n.d.-a).

As of 2019, heart disease was the most common cause of death worldwide. It accounted for 9 million deaths recorded that year; stroke and COPD were second and third (WHO, 2020). However, the COVID-19 pandemic changed the statistics somewhat. The WHO estimates that the excess mortality attributable to COVID-19 was 3 million people in 2020. In other words, in 2020, COVID-19 caused 3 million more deaths worldwide than would have occurred without it (WHO, 2021). In the United States, COVID-19 replaced unintentional injury/accidents as the third most common cause of death in 2020 and 2021 (Xu et al., 2022), then dropped to fourth in 2022 (Ahmad et al., 2023).

Falls are another frequent cause of injury-related death among adults ages sixty-five and older, and the death rate from falls is increasing (CDC, 2024). The age-adjusted fall death rate increased by 41 percent from 2012 to 2021, from approximately 55 to nearly 80 fall-related deaths per 100,000 older adults (CDC, 2024).

Common causes of death also vary by age. In the United States, the most common cause of death for infants less than one year old is congenital abnormality (WISQARS, 2022). From ages 1 to 44, the most common cause is unintentional injury/accident. Even within that category, however, there are age-related differences. For children aged 1 to 4, the most common type of fatal unintentional injury is drowning, while from 5 to 24, it is motor vehicle accidents (CDC, n.d.). In many developing nations, infectious diseases and malnutrition are more commonly the causes of death, especially in children under five (Abubakari et al., 2019; Djoumessi, 2022; GBD 2019 Demographics Collaborators, 2020).

Trajectories of Dying

In 1968, Glaser and Strauss proposed the existence of three dying trajectories, pathways to death that vary on dimensions such as the nature and rate of decline. Lunney and colleagues added a fourth dimension in 2002 (Figure 17.3) (Cohen-Mansfield et al., 2018). The four dying trajectories shown in Figure 17.4 are sudden death, terminal illness, organ failure, and frailty.

• Sudden death is an abrupt loss of function, as in heart attack, stroke, and accidents.
• Terminal illness is a more gradual loss of function, such as from cancer.
• Organ failure is characterized by an overall gradual decline with fluctuating cycles of illness and improvement, as in kidney failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure.
• Frailty is also gradual, but with a lower level of functioning and steadier decline without cycles of improvement, as in Alzheimer’s disease and diabetes.

Each dying trajectory may require different adaptation and adjustment (Cohen-Mansfield et al., 2018; Lunney et al., 2002). For example, terminal illness is associated with increased symptoms of depression and anxiety for the dying person (Tang et al., 2014), while frailty often increases emotional and financial burdens for caregivers (Covinsky et al., 2003).

Figure 17.3 In each proposed dying trajectory, the x-axis shows the length of time a person lives, and the y-axis shows the person’s level of functioning. Depending on the cause of death, the decline in functioning may be sudden, gradual, or fluctuating. (a) Sudden death and terminal illness are marked by a steep decline from a high level of functioning. (b) Deaths due to illness or disease begin from a lower level of functioning and demonstrate more noticeable fluctuation over time. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The Process of Dying

Along with there being many potential causes of death, a single cause of death can be experienced very differently by different individuals. The same cause of death can follow different timelines, depending on such factors as how a diagnosis of illness occurs. Regardless of the specific cause, there are biological processes that happen to our bodies when we die.

Death occurs either when certain types of cells (such as those in the pons and medulla oblongata in the brain) stop working, or when enough cells in an organ have stopped working that the organ no longer functions. In either case, the body can’t carry out its normal processes. “Whether gradual or sudden, death is actually a series of events that occurs over time” (Murray, 2010, p. 33). The time frame might be long or short, but even in sudden death, a series of events still takes place. The human body wasn’t designed to last forever (Murray, 2010). Our cells have life expectancies of their own—for example, red blood cells live for about four months—and we don’t always get new ones to replace cells that were worn out or damaged, particularly in our muscles and brain.

One well-documented phenomenon is terminal decline, a decline in functioning within the last few years of life and especially in the last five years before death (Figure 17.4). This decline can affect cognitive functions such as memory, visuospatial skills, and word knowledge, as well as physical functions such as balance and manual dexterity (Gerstorf & Ram, 2013). It occurs reliably in older adults, although the rate of decline appears to depend on how high-functioning the person is in old age, the presence of underlying diseases, and mental health problems like depression (Brandmaier et al., 2017; Gerstorf & Ram, 2013; Theill et al., 2018).

Figure 17.4 As people age, they may experience declines in physical and cognitive function. (credit: “Elderly male standing on walker in room” by rawpixel.com/nappy, CC0 1.0)

When a person dies slowly, from age or chronic illness, there’s often a noticeable period shortly before death during which they seem to change. They may stop eating and drinking, seem weak, and sleep more than usual. Lack of fluids and nutrients can affect the cardiovascular system, making it hard for blood to flow normally throughout the body. As a result, blood pressure drops, the kidneys start to fail, and the person’s arms and legs may get cold, blotchy, and/or turn blue, gray, or ashen in color due to lack of blood circulation (Figure 17.5). The heart rate may increase as the heart tries to push blood throughout the body (Murray, 2010; Parish et al., 2018). Lack of fluids and nutrients can also affect the brain, causing confusion and agitation, and preventing the brain from effectively monitoring breathing, heartbeat, and body temperature. Body temperature drops, breathing slows and becomes irregular, and the person enters an unconscious or semiconscious state. Eventually, all body systems stop working (Murray, 2010; Parish et al., 2018).

Figure 17.5 People who are dying may be cold and confused, and they can benefit from the soothing touch of a caregiver. (credit: modification of work “Me and Mom” by Eugene Kim/Flickr, CC BY 2.0)

Link to Learning

Does death on TV and in movies look like death in real life? Many health-care workers do not think so. National Public Radio tells a story about some efforts to portray death more realistically in popular media.

Psychological Aspects of Death

Death also has psychological aspects. The experience of death isn’t the same for everyone. Even when two people share the same cause of death, such as breast cancer, they may differ in the speed of progression, the pain they experience, and the kind and amount of support they have.

Being aware (or not) of impending death might affect a person’s self-concept, and how helpful that awareness is can vary person to person.

Being diagnosed with a terminal illness is likely to change a person’s self-perception (Aho, 2016; Greenberg et al., 1986; Kalish, 1968; Raju & Reddy, 2018; Zhang et al., 2023). When people are unable to care for themselves or participate in typical aspects of daily life, they may experience a loss of identity (Bryden, 2019; Fang et al., 2023; Gaignard & Hurst, 2019). This may also happen when people with dementia forget important memories or loved ones and lose a general sense of continuity in their lives (Blandin, 2016). In her 2019 account of living with dementia, biochemist Christine Bryden–diagnosed with early onset dementia at age forty-six—explained that her intellectual functioning was a key part of her identity and crucial to her career. She worried that her progressing illness was removing that aspect of herself, and that she would become her diagnosis, lose her individuality, and be seen as merely a dementia patient. A study of terminally ill brain cancer patients in India found such results: patients reported that others started to treat them as a sick person and not as an individual, whereas they wanted to be treated as they had been before getting sick (Raju & Reddy, 2018) (Figure 17.6).

Figure 17.6 Regardless of age or health status, people want to be treated as individuals who can practice autonomy such as (a) choosing to run errands and (b) deciding what to eat. (credit a: modification of work “Shoppers” by Maggie Jones/Flickr, Public Domain; credit b: modification of work “Just looking” by Thomas Luebke/Flickr, CC BY 2.0)

Death can be a difficult or awkward topic to discuss or even acknowledge (Figure 17.7). Psychologist Suzanne M. Miller (1995) proposed two relevant coping styles: monitoring, in which people seek out information about a problem even if it represents bad news, and blunting, in which people avoid potentially distressing information. These styles have implications for how much distress a person may feel when diagnosed with a terminal illness, and they may also influence how comfortable the person is discussing it with others (Pao & Mahoney, 2018).

Figure 17.7 People have different comfort levels discussing health-care matters with medical professionals. (credit: “Nurse administers chemotherapy” by Rhoda Baer, National Cancer Institute/Wikimedia Commons, Public Domain)

But do people benefit from knowing they’re dying? Does this knowledge make them scared or prepared? Does it cause them to seek comfort or push others away? These questions don’t have simple answers. In general, thinking about death makes people anxious; however, this anxiety will prompt some people to prepare, while others will feel helpless and overwhelmed. Thinking about their own death also affects the way people interact with others, particularly people they view as different. When people feel that their sense of self is threatened, as when they’re worried about their own death, they try to preserve that sense of self by becoming more committed to cultural values and showing more outgroup bias, negative feelings about people perceived as different (Greenberg et al., 1986; Juhl & Routledge, 2016; Ma-Kellams & Blascovich, 2011; Rubin, 2018). The idea that people try to preserve their identity in the face of a threat of impending death is called terror management theory (Greenberg et al., 1986). However, not everyone reacts to this threat the same way. European-Americans are more likely to react with outgroup bias than are Asian Americans. The collectivist orientation of many Asian cultures may emphasize bonding with others during times of trouble (Ma-Kellams & Blascovich, 2011; Kwon & Park, 2022), although not all research supports this (e.g., Otsubo & Yamaguchi, 2023).

People who worry about what awaits them after death may also experience death anxiety. Nichols and colleagues’ (2018) cross-cultural study looked at the relationship between views of the self and fear of death among Christians, Hindus, and Tibetan Buddhist monks. Christians generally view the soul (self) as separate from the body, existing continuously throughout life and after death. Hindus similarly view the self’s existence as continuous, but believe it is reincarnated after death. These two perspectives may make people fear death if they’re concerned about what might happen to them in the afterlife. Indo-Tibetan Buddhism, on the other hand, takes the perspective that nothing is permanent, including the self; therefore, death isn’t something to fear.

It Depends

Do Children Understand Death?

What do children understand about death? As you might expect, older children tend to understand more about death than younger children, although experiences such as having a death in the family and participating in cultural death rituals can change that (Menendez et al., 2020).

Understanding death requires comprehending that death is universal and irreversible—everyone dies, and once you die, you don’t come back. It also requires understanding that death can happen from a variety of causes, and that all functions of the body stop working. This last component is believed to be the most difficult to acquire, because it requires knowing how the body works (Bonoti et al., 2013; Carter, 2016; Menendez et al., 2020; Vázquez-Sánchez et al., 2019; Yang & Park, 2017). Understanding irreversibility appears to be especially challenging for children in the age range associated with Piaget’s preoperational stage of development, possibly because their egocentrism makes it hard for them to understand someone else’s experience (Yang & Park, 2017).

Traditionally, it was believed that children under the age of two or three had limited, if any, understanding of death, that children aged five to seven (sometimes five to nine) had partial understanding, and that full understanding of death occurred between seven and nine years (Carter, 2016; Vázquez-Sánchez et al., 2019; Yang & Park, 2017). However, in many cases, children appear to understand more at younger ages than previously believed. Evidence suggests they can often grasp irreversibility and universality by age five, and the idea that death can come from a variety of causes by age six (Bonoti et al., 2013; Carter, 2016; Menendez et al., 2020).

Link to Learning

Talking with children about death and grief can be challenging. Here are some resources for adults to use, both with children and for themselves.

• “Sesame Workshop”: This website provides resources and videos on how to talk to children about the loss of a loved one.
• National Public Radio: NPR’s “Life Kit” series discusses how to have difficult conversations with your child.
• UNICEF: UNICEF Parenting offers advice and tips on how to talk to children and teenagers about death.
• The Cove Center for Grieving Children: Read these FAQs about grieving children for more information on what to expect from a grieving child.

Social and Cultural Aspects of Death

Death affects not only the person who dies but also their friends, family, and acquaintances. It is thus a social occurrence. Even less intimate relationships may experience some level of adjustment to a loss. We often meet the social expectations associated with death by attending services or bringing food to the deceased person’s family, for example.

A social death occurs when a person is viewed as no longer part of society. This may happen in several ways. A person who is dying may be excluded from social invitations. Other people may not ask for their opinions and may talk about them in their presence without acknowledging them (Borgstrom, 2017; Ghane et al., 2021; Králová, 2015). The intentions may be good ones, such as trying to avoid upsetting the dying person with reminders of events they can’t attend (Figure 17.8). People who are dying may also choose to withdraw from social activities, imposing social death on themselves (Caswell & O’Connor, 2015). This might be a rational choice, but it may still create what Gaignard and Hurst call “loss of social significance” (2019, p. 5), in which a person feels lonely and useless. Social death may also occur if a person isn’t actively dying but has a chronic illness or stigmatizing condition, such as mental illness or AIDS (Ghane et al., 2021). Caregivers may also experience social death in that they tend to report more social isolation than non-caregivers (Kovaleva et al., 2018; Liang et al., 2023; Walker et al., 2023).

Figure 17.8 People who are dying may be excluded from—or exclude themselves from—social interactions. (credit: modification of work “UFV – Dr. Jean Scott 102” by University of the Fraser Valley/Wikimedia Commons, CC BY 2.0)

Religious and Spiritual Views of Death and Dying

Whether religion and spirituality influence views of death and dying, and in what way, is a complex topic. We might assume that people who report more religiosity or spirituality find comfort in their beliefs and thus report lower rates of death anxiety, but that’s not necessarily true. Religion can be comforting and help give death a sense of meaning, but death can cause people to question their faith, which may be distressing (Neimeyer et al., 2021). And not having any particular religious or spiritual beliefs doesn’t appear to have any significant negative impact. People with a more secular orientation do not report higher levels of stress or anxiety related to death or more difficulty coping (Ahmadi & Zandi, 2021; Schweda et al., 2017).

Religious views of death and dying often include ideas of an afterlife and a self-assessment of whether we made the “right” choices in life. Not surprisingly, if people believe a happy afterlife awaits them, they’re likely to be less anxious about dying than people who are worried about the possibility of a negative afterlife (Drążkowski & Trepanowski, 2021; Ghayas & Batool, 2021; Gire, 2014). Belief systems conveying that death is a punishment can increase anxiety as well (Ahmadi & Zandi, 2021). On the other hand, belief systems that emphasize death as natural or a transition instead of an ending, such as Buddhism, are often associated with lower anxiety (Dorji & Lapierre, 2022).

Religious views may also affect the way people feel about end-of-life treatments or even the way they define the end of life itself (Figure 17.9). For example, Christianity and Islam often regard their higher power (i.e., God, Allah) as a sovereign in control of what happens to them. This means that the use of end-of-life treatments or euthanasia may be frowned upon as going against “God’s will” (Daniels-Howell, 2022; Eyetsemitan, 2002; Krikorian et al., 2020; Nadeem et al., 2017; Searight, 2022; Testoni et al., 2020). Some branches of Judaism reject the notion of brain death and use cardiopulmonary death as an indicator of true death; as a result, some states require health-care providers to use that standard when requested.

Figure 17.9 Funeral practices may vary according to religious or spiritual beliefs, such as (a) a Catholic service at a cemetery burial or (b) A person wearing a tallit or prayer shawl. (credit a: modification of work “Burial” by Let Ideas Compete/Flickr, Public Domain; credit b: modification of work “A blue prayer shawl” by zeevveez/Flickr, CC BY 2.0)

Cultural Views of Death and Dying

What we think of as “culture” has many dimensions, including, but not limited to, religion, country of origin, gender, and ethnicity. Even people who share broad cultural labels may not share similar beliefs or engage in similar practices, however. For example, when a group emigrates from one country to another, they don’t all adopt the customs of the new country, maintain the customs of their old country, or balance the two in the same ways.

International views of death and dying may depend, at least in part, on the causes and contexts of death. As you’ve learned, causes of death and the ages at which it occurs differ worldwide. As a result, some countries may experience more sudden death, death from infectious disease, death from war and violence, and death at younger ages than other countries. Other factors such as gender roles and stigma may affect views of death. Before marriage equality, lesbian and gay couples faced unique struggles related to their rights to support their partner including being denied hospital visitation and medical decision making ability (Mohanty, 2010). Men and women in married relationships often face different challenges following the death of their spouse. Women traditionally bear a bigger financial burden than men following the loss of a spouse, whereas men struggle more with household tasks following the loss of a spouse (Dabergott, 2022). Regarding stigma, AIDS is a common cause of death in Africa, particularly in sub-Saharan nations (Abubakari et al., 2019; Cao et al., 2020), but it’s not always recorded as the cause of death due to the stigma associated with it (Bradshaw et al., 2016).

International views of death often vary by whether a county has a primarily individualistic or collectivistic orientation. In individualistic cultures, there’s a strong focus on individual autonomy and choice at the end of life (Karumathil & Tripathi, 2022; Walter, 2003). In collectivistic cultures, such as those in Turkey, Iran, China, and many Indigenous Native Americans, there tends to be more focus on making group decisions, building consensus, maintaining the social order, and trusting authority figures (Anderson & Woticky, 2018; Karumathil & Tripathi, 2022; Krikorian et al., 2020). For example, in Japan, patients tend to view trusting doctors as more important than exercising autonomy. This is consistent with the Japanese custom of omakase, which dictates that medical decisions are best left to medical experts (Krikorian et al., 2020). People living in collectivist cultures may also not ask the patient about their wishes or even be honest with them about their impending death (Karumathil & Tripathi, 2022).

Other international differences are country- or region-specific. For example, openly expressing grief is generally acceptable in Egypt, but not in Taiwan or Bali. Among the Achuar in eastern Ecuador, there is an attempt to forget about the dead as soon as possible, due to a fear that the dead person may cause trouble by bringing bad luck to the family or even seeking revenge for perceived mistreatment while they were alive (Gire, 2014). In Mexico, in contrast, an entire holiday, Dia de los Muertos or “Day of the Dead,” is devoted to remembering ancestors (Figure 17.10).

Figure 17.10 Dia de los Muertos observations may include activities such as (a) participating in a parade like this one in Albuquerque, New Mexico, or (b) remembering ancestors by setting up an altar, such as this one in Mexico City, Mexico. (credit a: modification of work “Dia de los Muertos” by Larry Lamsa/Flickr, CC BY 2.0; credit b: modification of work “Día de muertos en Milpa Alta” by Eneas De Troya/Flickr, CC BY 2.0)

It Depends

How Do Different Cultural Groups View Brain Death?

Not all cultures are equally accepting of brain death. In countries such as Japan, China, and the Republic of Korea, brain death is an acceptable diagnosis only in cases of organ donation and requires approval from the patient’s family, but not necessarily an advance directive from the patients themselves. In the Republic of Korea, a diagnosis of brain death also requires unanimous approval from a special committee (Terunuma & Mathis, 2021; Yang & Miller, 2015), making the process longer and more complicated.

We can also look at religious factors in acceptance of brain death. Buddhism views the body and soul holistically, as one entity, with body heat and a heartbeat being signs of life (Terunuma & Mathis, 2021; Yang & Miller, 2015). Because Buddhism has a strong belief in an afterlife and reincarnation, the body must be left intact; harvesting organs for donation is often seen as mutilation (Yang & Miller, 2015). This may explain why organ donation isn’t common in countries with a large Buddhist population, such as China, Japan, and the Republic of Korea (Terunuma & Mathis, 2021).

Within countries—intranationally—people vary in their views of death and dying. Due to the multicultural makeup of many nations, inhabitants may not share identical values and practices. The Canadian population, for example, is represented by about 200 distinct ethnic origins (Shooshtari et al., 2021).

Traditionally, Native American communities within the United States take a collectivistic perspective and regard death as a community experience, in which communities gather to support the bereaved and participate in rituals to honor the deceased. Traditional beliefs generally regard life as cyclical, and death as a natural part of that cycle. Native Americans may believe the afterlife is good and the spirit lives on after death, possibly even visiting and guiding loved ones through dreams and natural symbols such as animals. Traditionally, some Native Americans consider the number four sacred because some natural phenomena like winds and the seasons happen in fours, so they may wait four days after death to bury the deceased, to give the deceased person’s soul time to visit loved ones (Walker, 2019).

Of course, Native Americans in the United States are not uniform and experience some important differences. While Native Americans tend to be monotheistic, they differ in their views of what “God” is. The Lakota Sioux refer to their guiding spirit as “Grandfather,” while the Muscogee Creek think of a genderless energy. Although it’s a common tradition to put mementos in the deceased person’s casket, what those mementos are can also vary. The mementos might be personal belongings (Muscogee Creek), locks of hair (Lakota), or tobacco (Ojibwe). Burial and funeral practices differ as well. Apache, for example, bury the deceased person’s belongings in a separate grave next to the body, and Navajo people avoid saying the deceased person’s name after the funeral so they don’t accidentally call the person’s spirit back to earth (Walker, 2019).

Intersections and Contexts

Nigeria’s Diverse Views of Death

Nigeria provides an interesting example of how different traditions intersect in their views of death. Nigeria’s history and culture include a mix of Christian and Islamic religious practices as well as traditional ancestor worship; some Nigerians practice more than one tradition. In Islam, Allah is all-powerful and all-ruling, and will judge our actions after death. Christians believe their faith will lead them to a better place after death and that God has a plan for all life’s challenges and difficulties. In traditional ancestor worship, life is cyclical, and the dead can be reincarnated in new births and/or be alive in a different spirit world (Anizoba et al., 2021; Eyetsemitan, 2002; Ushe, 2017).

These differences can produce conflicts if a person adheres to more than one belief system. For example, a Nigerian who follows both ancestor worship and Christianity may have trouble reconciling the Christian notion of God’s will with the idea that someone’s death has been caused by witchcraft. Marriages are also regarded differently within these belief systems in ways relevant to death. In Nigerian Christian marriages, a widow is assumed by default to inherit all her husband’s assets, but in “customary law” marriages, widows inherit nothing and must rely on their husband’s relatives for financial support. Though its practice is relatively rare, Islamic law permits polygamy (Abbasi & Cheema, 2020; Rohmadi et al., 2022), so if a man has multiple wives, division of assets might not be clear; some people may marry within more than one system, which complicates matters further (Eyetsemitan, 2002).

Nigeria’s culture and diversity of beliefs demonstrates why we must be cautious in describing the beliefs and practices of various cultures and countries. There’s no single “Nigerian view” of death, because Nigerians adhere to a variety of traditions and belief systems. Many other nations also have diverse populations, and increased globalization multiplies this diversity. While knowing someone’s country of origin or residence may give clues to that person’s belief system, it’s not a substitute for getting to know them as an individual.