Treatise of Thanatology

Dear Sir,

Thanatology is the scientific study of death and the practices associated with it, including the study of the needs of the terminally ill and their families. The word is derived from Greek. In Greek mythology, Thanatos is the personification of death.^[1] Though Hades, the great lord of the underworld is The God of Death, Thanatos escorted people to the afterlife and separated them from the realm of the living. According to the myth, Thanatos is the son of Nyx (the Night) and Erebos (the Darkness). He has a twin brother, who is Hypnos (the Sleep). Thanatos is merciless and does not discriminate among mortals. Thanatos is a ‘Daimon,’ one of the minor Gods of the Greek Pantheon. There were hundreds of these spirits who personified a specific aspect of the world. Like most of the personification spirits in Greek mythology, his name is a literal translation of his purpose. He is generally seen as one with a sense of seriousness and purpose. Thanatos is not cruel, but he is a stoic God who showed no mercy or regret in the execution of his duties. Begging, bribes and threats never sways Thanatos. He performs his job with emotionless efficiency.^[2] His Roman equivalent is Mors and Sanskrit equivalent is Yama. The English suffix-ology, defined as ‘Branch of knowledge: Science’^[3] derives from the Greek suffix-logia (speaking).

The concept of death has been historically excluded from social dialogues. Thanatology is a new field of Science^[4] hence scientific literature about death and dying is limited. Thanatology invokes an interdisciplinary approach to practice the death science. This domain is constantly evolving through intense interaction with social, economic and political realms of life. Competency of the healthcare workers including doctors, nurses, psychologists, social workers to engage with the dying patient is an important but ill-addressed skill set. Provision of raw materials to develop that skill set is challenging. Medical science should take priority on the overall experience of dying.

Thanatology emerged as a domain in psychology after the publication of the landmark book written and edited by Herman Feifel (1915–2003), ‘The Meaning of Death’ (1959) thus making him the founder of modern death psychology. Feifel influenced generations of scholars in the field of thanatology. ‘Meaning of death’ is considered as the most important single work to galvanise the scholarly community into studying dying, death and bereavement, as opined by the American Psychological Association^[5] Feifel, who de-demonised death, stated that ‘the democracy of death encompasses us all. Even before its actual arrival, it is an absent presence. To deny or ignore it distorts life’s pattern. In gaining an awareness of death, we sharpen and intensify our awareness of life.’^[6]

Feifel compared attitudes toward death and in many cases, he found that those facing impending death preferred honest and open conversations about their condition and were thankful for the opportunity to air their feelings about dying, contrary to the dire warnings of their physicians that the subject would be too stressful for them.^[7]

The medical community, especially the doctors, is ill-equipped to deal with end-of-life talks. The resistance of the doctors to talk openly about death stemmed in part from their own fears.

After the publication of Kübler-Ross’s (1926–2004) ‘on Death and Dying’ in 1969, the groundbreaking book on death, life and transition, the attitudes toward death education started changing drastically. Through sample interviews and conversations, she gave the reader a better understanding of how imminent death affects the patient, the professionals who serve that patient and the patient’s family, bringing hope to all who are involved. In her book, she postulated five stages of Grief that every individual experience as they move toward death. These are Denial of reality, Anger towards the whole world, Bargaining with the God, moving into Depression and finally Accepting the truth. In later years, she extended these stages to other forms of Grief, not only to those with impending death. This includes suffering any major loss, death of loved ones, loss of job, failure in marriage.^[8] ‘On death and dying’ remains as a widely accepted tool to deal with people in different forms of Grief.

Cicely Saunders (1918–2005) is another pioneer in the field of death education. Her name is synonymous with the modern hospice movement. Hospice care is a great social innovation of the twentieth century. She devoted her entire career to the care of dying people. She suggested that the dying are the only ones who know how to die, based on their unique character, personality and background. In 1967, the first modern Hospice centre of the world, the St Christopher Hospice was opened by her to accommodate dying people. The term ‘Total Pain’ which included physical, emotional, social and spiritual dimensions of distress was coined by Saunders. She introduced an effective pain management strategy. She believed that every dying individual has the right to be treated with dignity, compassion and respect. Meticulous scientific methodology to test the treatment strategies was incorporated.^[9]

Globally acknowledged expert in Thanatology, Kastenbaum (1932–2013) established the first University-based educational research centre on death and dying at the Wayne State University in 1966. He founded and served as the first editor of two major journals in the field of death education: International Journal of Aging and Human Development and Omega: Journal of Death and Dying. His contributions paved the way for a major shift in the societal attitude: from a death-denying one to a death accepting one. Kastenbaum’s book titled ‘Death, Society and Human Experience,’ draws on contributions from the social and behavioural sciences as well as the humanities, such as history, philosophy, religion, literature and the arts, to provide thorough coverage of understanding death and the dying process.^[10]

The boldness to address a taboo witnessed a burgeoning of end-of-life care institutions, hospices and other movements. As a result, workshops and college courses on the topic began. Contributions of Hannelore Wass (1926–2013) to the field of death education are phenomenal. Born and brought up in Nazi Germany, death was a constant companion for Wass. She was the founding editor of the journal: Death education (now Death studies) which is in its 44^th year of publication. She authored an early textbook titled ‘Dying, facing the facts’ in 1979. ‘Death education: An annotated Resource Guide,’ ‘Helping Children Cope with Death’ are other books written by Wass. She remained a strong advocate for death education for all ages and the books written by Wass are a solid knowledge base for dying, death and bereavement. The current body of information in Thanatology is largely indebted to Hannelore Wass. She developed one of the first teaching courses in Death and played a pivotal role in setting up the Association of Death education and counselling.^[11]

Chochinov (1958-) is a contemporary palliative care physician and the founder of Dignity therapy.^[12] Dignity Therapy is an end-of-life psychological intervention that focuses on the creation of a legacy document to address psychosocial and existential distress among the terminally ill. This brief course designed by Chochinov can be learned as a self-study online method as well as taught course.

In one way or other, modern medical science is constantly trying to downplay the questions related to death and dying. Questions related to the meaning of life and death are addressed as absurd and futile in most of medical books. Thanatology does not directly explore the meaning of life and of death. However, the questions related to death and dying are truly relevant to the psychological health of those involved in the process: individuals, families, communities and cultures. Thanatology explores how the question affects those involved, not the question itself.

Working with the dying is not an easy task. Specific skill set, competency and authoritative knowledge on Thanatology are some of the prerequisites to work with the dying. Faith issues have been excluded from public space and the Western world is thriving on secular credentials.^[13] In such a sphere, health care practice and by extension, the practice of working with the dying is driven by aspects that have nothing to do with the fact that death is experienced through religious and/or non-religious beliefs and vice versa.^[14] A concerted action by all concerned should be employed to harness the competencies, capabilities and resources of the health workers involved in the care of dying patients.