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It’s no secret that one of TalkDeath’s aims is to combat death denial, or repressing the reality that one day, we will all die. It is quite common in our culture to avoid openly talking about mortality, which harms people in so many ways and leaves many unprepared in some of their most difficult life transitions. But where did this avoidance come from, and why is it so prevalent?

Death denial is the product of many social developments over the past few centuries, but one of the less discussed areas of this history is the rise of the hospital.

Hospitals are such a normalized part of modern life that we regularly expect them to be in almost any place we go if we experience an accident or illness. This ubiquity is especially true when it comes to dying—it’s estimated that around 60% of Americans and Canadians die in hospitals.1 2 However, hospitals in their current form are a relatively recent development in the history of medicine. Given this, we thought it would be interesting to do a brief dive into how these institutions came to be, particularly in North America, and how they have irrevocably shaped contemporary ideas about death, dying, and the dead.

Hiding Death: The Hospital and Death Denial

Care in Early Hospitals

While cultures around the ancient world such as Persia, Egypt, Greece, India, Sri Lanka, Rome, and China all had documented institutions for caring for those with illness—usually temples where priests offered divine aid—these places did not resemble modern hospitals and are often characterized by historians as mere holding locations for the sick. However, this began to slowly change in the Middle Ages, when religious entities began to take even more active roles in the welfare of their communities through charitable action.




Medieval hospitals in Europe were almost exclusively run by Christian orders, who were more concerned about their patients’ souls than their medical needs. This focus was largely due to dominant philosophical beliefs at the time, which held that illness was supernatural and uncontrollable by human intervention. At best, monks and nuns had only basic medical knowledge and spent most of their time providing hospitality, as many wards were built along pilgrimage routes.

 The prevalence and hypervisibility of death at this time had significant impacts on medieval people’s relationships with mortality…they confronted death together as a community, meaning that a good death took place at home in bed, surrounded by friends and family. 

In many ways, these hospitals were almshouses that took in tired travellers or the poor. Wards were typically larger rooms or halls attached to existing monasteries, so those with contagious diseases were excluded lest they infect others. (It’s important to note that this differed in the Islamic world, where hospitals were much more advanced and had separate wards for different illnesses.)

The Hôtel-Dieu de Paris hospital, one of the few visual accounts of the inside of a medieval hospital.

As such, hospitals during this time were not the immediate places people went to get help when they were dying. Medical practice was unable to help in any meaningful way with many of the common causes of death at the time, including infant mortality, disease, famine, war, and serious injuries. The prevalence and hypervisibility of death at this time had significant impacts on medieval people’s relationships with mortality. As a defense against so many phenomena that could not be explained, they confronted death together as a community, meaning that a good death took place at home in bed, surrounded by friends and family. Ultimately, dying was a religious process, not a medical one.

Science and Curing Disease 

As formal scientific inquiry expanded during the Renaissance and Enlightenment periods, ideas that people could recover from disease significantly grew. This realization understandably had a dramatic impact on the practice of medicine and how such care was delivered. Universities gradually became centers where a new class of medical practitioners exchanged hypotheses and practiced new treatments and surgeries, which gradually made their ways into hospitals.




Hospitals also grew larger than their medieval predecessors and lost much of their initial religious orientations. However, well into the eighteenth century, these kinds of institutions were usually only found in cities. This was particularly true in the United States, which was still largely rural during the 1700s and did not yet have robust infrastructures in towns and villages. Almshouses that provided medical care were far more common than hospitals, and even then, they were typically only utilized by the poor.

Illustration of the New York City Almshouse, which created a six-bed ward in 1736 and eventually became Bellevue Hospital over a century later.

Due to this lack of access and longstanding cultural traditions, the home remained the predominant setting of the dying process. Most were nursed by their families if they fell ill, and even if they underwent surgery, a doctor came and performed it at their residence. People largely died at home, and as many in the death positive movement are aware, funerals and caring for the dead were seen as domestic responsibilities that typically fell to women in the family and surrounding community.

Scholars note that it was so common to attend the bedside of the dying that it would have been rarer for someone not to have witnessed a death at least once in their lifetime—a reality that contributed to open and robust discussions of mortality. Of course, familiarity did not banish fear, shame, or other difficult emotions in the face of death, but those who experienced them were certainly not alone.

Dying Behind Closed Doors 

That wouldn’t remain the case for long, however. Hospitals continued to grow in size and form during the nineteenth and early twentieth centuries, especially as society became more industrialized and mobile. In addition, as medical and epidemiological knowledge improved, there was more of an incentive to visit a hospital given the much higher chance of receiving life-saving treatments and care. Significant spatial developments in hospital design accompanied this remarkable transition.

 …These measures may not seem remarkable, but they hid death behind curtains and walls, invisibilizing it in ways it had never been before in human history. 

While early American hospitals consisted of open wards where the dying underwent operations and died in front of other patients, a new wave of hospitals built semi-private and private rooms as a way to charge their growing patient populations more fees. These measures may not seem remarkable, but they hid death behind curtains and walls, invisibilizing it in ways it had never been before in human history.

Displacing death from the home was also accompanied by other significant public health shifts in the mid-nineteenth century, such as the groundbreaking discovery that germs caused disease. Subsequent focuses on hygiene and sterilization in hospitals lead to a significant decrease in mortality rates, but they also came to dictate new ways of physically interacting with the dead. Doctors and nurses limited families’ access to their loved ones after death and dead bodies became too ‘dangerous’ for non-professionals to handle. It was also around this same time that cemeteries began to move from central locations to the edges of cities or towns, underlining how death increasingly came to be seen as a contagion that could be caught through proximity.

Image via Adhy Savala

Contemporary Consequences 

Dying in hospitals, away from extended family and friends in an unfamiliar bed, understandably necessitated changes in the understanding of endings and how people defined the good death in the twentieth century. Fewer personally witnessed death, making the final days of dying existentially disturbing in ways they had not been before when it was familiar to everyone.

 The logics of modern interventionist medicine, which most frequently try to stave off critical illness, have even led to common imaginations in which the end of life is seen as a personal failure (i.e. “they lost their battle with cancer”). 

As media scholar Jennifer Malkowski details in Dying in Full Detail, an “unconscious and speedy end proceeding as privately and invisibly as possible” increasingly became the most valued manifestation of death. This signaled a dramatic reversal from the desire for witnesses at the deathbed that was so dominant in earlier centuries, with some even arguing that death and mourning have now become two of the most private experiences of Western culture (at least, for some communities).




In many ways, the isolation or depersonalization of many hospital deaths is also indicative of how the emotional and spiritual needs of the dying and the bereaved came to be subordinated to the governorship of medical care. It is not unheard of for doctors and family members to conceal a terminal diagnosis from the dying person, lest knowledge of their imminent demise interfere with medical treatment or hospital routines. The logics of modern interventionist medicine, which most frequently try to stave off critical illness, have even led to common imaginations in which the end of life is seen as a personal failure (i.e. “they lost their battle with cancer”).

Image via Sharon McCutcheon

Death is also seen as a kind of accident or contingent event that greater prevention, technology, and research could do away with. While these attitudes are certainly not universal and manifest differently in a hospice ward than an ICU, such framings of death all contribute to unnecessary fear of dying by refusing to foreground it as a natural process. It is normal to experience a bevy of feelings when contemplating one’s own passing, but it doesn’t have to be like this.

Doing Death Differently 

Faced with such harmful consequences, many have come to the realization that dying does not have to be a medical event—nor does it have to take place in a hospital where one might be hooked up to machines and removed from the safety and comfort of familiar surroundings. More and more people are finding ways to die in ways that feel more comfortable to them, whether by utilizing hospice services and  support people like death doulas, and/or making their final wishes to die at home known and documented. If a hospital death is not something you desire, start the conversations with your loved ones now. It’s never too early to talk about death!


Sources:
1 – https://stanford.io/3ykuj8P
2 – https://bit.ly/3mCFU0S

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