The semantics of death and dying: metaphor and mortality.

In his The Encheiridion or "Handbook," stoic philosopher Epictetus speaks repeatedly of the importance of keeping death and dying in one's consciousness. Being aware of the reality of death is emphasized by Epictetus, who suggests that the individual, "Let death and exile and everything that is terrible appear before your eyes every day, especially death," as doing so will prevent "anything contemptible in your thoughts," as well as "craving anything excessively." (p.16) The philosopher does not, however, reserve his discourse only for the matter of when death is contemplated, but also offers advice on how such contemplation should take place. He states:

Did your child die? It was given back. Did your wife die? She was given back. How does the way the giver asked for it back concern you? As long as he gives it, take care of it as something that is not your own, just as the travelers treat an inn. (p.14)

In suggesting the use of "given back" as a metaphor for death, Epictetus brings to light several points regarding the nature of our conception of death and dying, which neither he, nor other investigators of death, seem to have taken any further: he recognizes the role of metaphor in providing a foundation for our understanding of the "unknown"; he recognizes these metaphors as culturally constructed, and culturally reinforced; finally, and perhaps most importantly, he realizes that these metaphors, since they are our own creations, may be replaced when they no longer offer us the increased understanding, or at least reduced perplexity, which they are intended to provide.

Epictetus was on to something. However, it would appear that he, as well as much of the world's thinkers on death and dying, have not pursued his discovery further. In doing so it appears that they may have abandoned a critical factor in our personal and cultural understanding of death. They confuse, as in the ancient Zen saying, "A finger pointing at the moon for the moon itself."

The Name of Death - A Rose By Any Other Name

"Death is a displaced name for a linguistic predicament."

- Paul de Man (1919Y-83)

In his essay, "The Information Environment," cultural critic Neil Postman asserts: "The means by which people communicate comprise an environment just as real and influential as the terrain on which they live." (p.29) Perhaps this is a reason why many of the most prominent researchers/writers on the subject of death and dying have touched on the role of communication in the dying process. However, much of this discussion is limited to an interpersonal context, involving the family or caregivers in communication with the dying person. Researchers on death, or "thanatologists," often look to Elizabeth Kubler-Ross as a critical pioneer in advancing cultural acceptance of, and intellectual inquiry into, the nature of death and dying. In her groundbreaking work, On Death and Dying, Dr. Kubler-Ross is quite clear in her assessment of our culture's reservations when discussing mortality in general. This practice of refusing to discuss the topic of our own mortality may be symptomatic of our culture's overall discomfort with the topic as whole. "In a society where death is regarded as a taboo," asserts Dr. Kubler-Ross, "discussion of it is regarded as morbid, and children are excluded with the presumption and pretext that it would be 'too much' for them." (p.6) One cannot help but speculate that regardless of the prevailing attitudes which underlie such a semantic condition, the results of it are surely predictable. What is not discussed, and instead denied or avoided, is quickly removed or at the very least diminished, from our cultural consciousness. Whichever came first, the denial of death, or the refusal to speak of it freely, the situation we find ourselves in remains much the same.

Perhaps the most notable recent "ground breaking" addition to the field of thanatology has been the 1995 publication of Dr. Sherwin Nuland's How We Die. Nuland, much like Kubler-Ross, observed in his medical practice the generalized denial and fear of death so prevalent in our culture. In assessing the role of communication in remedying this problem, Dr. Nuland is quite clear: "Only by a flank discussion of the very details of dying can we best deal with those aspects that frighten us the most. It is by knowing the truth and being prepared for it that we rid ourselves of that fear of the 'terra incognita' of death that leads to self-deception and disillusions." (p.17) Dr. Nuland, like Dr. Kubler-Ross, agrees that an "increase" in the "frank discussion" of death and dying would raise our cultural comfort level regarding this topic.

The role of communication issues in our cultural and personal conception of human mortality is discussed by these, and many other writers on the topic of death. However, such discourse is limited in its choice of topics: how to discuss death with our children or how to discuss death with patients if you are a doctor. The interpersonal context of our discussion of death is scrutinized in some detail. In such a generalized scrutiny, however, some of the most critical subtleties may be excluded.

Metaphors - The Unacknowledged Foundations of Cultural Consciousness

Perhaps one of the most powerful forces in human consciousness, yet one of the least recognized, is the metaphor. As children, we are taught that a metaphor (unlike a simile) is a comparison between two things which does not use the words "like" or "as." Perhaps like many of you, this marked the end of my formal education on the topic of metaphor. "Where understanding fails" said Goethe, "a word comes to take its place." It would be difficult to find an area where understanding fails so completely, as in the area of human mortality.

In his book Crazy Talk, Stupid Talk, Neil Postman states: "Every semantic environment is controlled by metaphors, frequently hidden from the view of those who have created them, but through which people interpret the meaning and value of what is happening." (p.132) He also asserts: "In poetry and science, such metaphors are usually called to attention. They are, in fact, forced on our awareness by being placed at the center of what we are to consider, and they may be rigorously examined. But in everyday speech situations, we are apt to be unaware of how we are using our metaphors, and therein lies a source of considerable confusion." (p.125) The origins of metaphors in the formation of our consciousness is examined in even greater detail by Christine Nystrom in Human Symbolic Evolution. In chapter 5, "Metaphor," as she notes, "A metaphor is a way of dealing with the unfamiliar, the novel, the unknown, by likening it to something known, that is, to something we have already learned to predict and control with relative success." (p.81) If Dr. Nystrom is correct, and the roots of our formation of metaphor do reside in our desire to perceive control over that which we have little or no actual control of, it is no surprise that we, as a species, have such an array of metaphors for mortality.

Thus, as our metaphors are created by our consciousness, so is our consciousness created by our metaphors. What then is the role of the metaphor, our most unrecognized perceptual tool, in our cultural and personal consciousness of dying, the ultimate stage of life? Through interviews and interaction with individuals who through personal events, or professional choices are interacting with human mortality, it was my hope that such metaphors and their functions could be brought to light.

The sheer number of metaphors we use in reference to human mortality is an index of our cultural discomfort with the topic. In fact, one would be hard pressed to find a type of reference to death in this culture which is both frequently used and without metaphoric content. Rarely is death called by its own name.

The Battle Rages On - Clinical Metaphors For Death and Dying

Although each passing year introduces new illnesses and reminds us of those we have yet to find cures or prevention for, Western medical science continues to engage with undiminished vigor in an almost mythical battle against its sworn nemesis: human mortality. As Dr. Sherwin Nuland suggests, "We live today in the era not of the art of dying, but of the art of saving life, and the dilemmas in that are multitudinous." (p.265)

In Apology, Plato presents Socrates' address to his followers regarding fear of death:

To fear death, my friends, is only to think ourselves wise, without being wise: for it is to think that we know what we do not know. For anything that men can tell, death may be the greatest good that can happen to them: but they fear it as if they knew quite well that it was the greatest of evils. And what is this but that shameful ignorance of thinking that we know what we do not know? (sc.29)

How many times have we heard a physician or surgeon say "I don't know" in reference to a medical question? In modern Western culture, the role of the physician is analogous to the role of the Shaman in Native American culture. He is the one who knows that which cannot be known by the "common man" regarding the forces of life and death. It is the job of the physician to "know" not only that which is not known, but even sometimes that which cannot be known. Death however, in our current conceptual framework, could be viewed as the ultimate failure for Western medical science. It is incurable, it has a 100% fatality rate, and no matter how hard one studies, practices one's technique, or memorizes related formulas, it cannot and will not be prevented indefinitely. Perhaps this is why some of our most frequent and unapologetic uses of metaphor in relation to death continue to grow and spread unabated, especially in the antiseptic hallways of our medical institutions.

"Coded"

In medical school, you don't learn anything about human beings. It's incredibly clinical. A great deal of what people say or do is simply passed down, from person to person, within an institution. Doctors, and most other medical staff in hospitals, are not likely to refer to someone's death as "they died." Usually they are referred to as having "coded." Like, "How's the old woman in 4B?" "Oh, she coded last night." It's really curious to me because "coding" is a procedure, not an event. When we discuss someone's bypass surgery you don't ever hear someone say, "He bypassed yesterday." - Dr. G (Cardiologist)

The term "code," unshockingly enough, was born in the clinical setting of the hospital or medical center. A "code" was a term used on hospital PA systems, in order to alert medical staff that an important and usually life-threatening event was occurring (e.g., Code Blue - Heart Attack, Code Yellow - Fire in Hospital). Medical staff are assigned to the "code team," and responsible for measures such as CPR on clients who have "coded." How the term became a reference to the death of a patient is unclear. As noted in the interview with Dr. G, a prominent cardiologist who has worked at a variety of city hospitals, as well as a major heart center, the fact that the procedure of a "code" has come to refer to the event of a death is curious. That it is one of the few examples of this kind of referential shift in medical terminology could be indicative of a need for a "medical metaphor." "Code" is clinical in its tone, but still not completely honest.

"Lost"

The most common metaphor I hear clinicians use when speaking to nonmedical personnel and families is "lost." "We lost the patient," or "We attempted resuscitation, but lost him anyway." When I first came to this country this struck me as rather odd. I wanted to say, "Well, we didn't really lose your husband. We know where he is, it's just ... he's not breathing there anymore." - Dr. Y (Oncologist)

When discussing death with medical personnel, undoubtedly the most common metaphor is "lost." We are all familiar with this metaphor. From the "I am sorry for your loss" found so frequently on Hallmark sympathy cards, to "after a massive arrhythmia we lost the patient," this metaphor deeply pervades our cultural consciousness. But, how many of us have really ever considered the implications of this word choice. Why is the primary metaphor for death one which has such a wide range of meanings, all with somewhat dismal connotations? The American Heritage Dictionary (Third Edition) defines "lost" as: "To be unsuccessful in retaining possession of; to be deprived of ownership as by negligence, accident or theft; to fail to win." In a matter as inevitable as human mortality, how did we come to inject this oppositional tone? Does this metaphor perhaps reflect the almost mythic battle between the forces of Western Medicine and its sworn nemesis, the "grim reaper"? A battle which, if death marks the reaper's triumph, we are destined to "lose" every time.

"PBAB" and "Circling"

Most people, if they understood the codes we mask it in, would probably be really offended by the kind of morbid humor that goes on between medical staff. It's not that we're callous people, or evil, it's just that we have to find some way of coping with these emotional events. Humor is one way that we can do that. When we refer to a patient as PBAB, the medical staff involved know what it means, but it is hidden to everyone else involved, since physicians use so many acronyms anyway. - Dr. G (Cardiologist)

If people ever came into these offices when the doors are closed, and it's just the team, they would think we were really sick people. We have this tendency to joke about things that we all know aren't funny, but it lightens things up a bit, and probably prevents us from breaking down weeping every hour or so. - Ms. R (Hospice Administrator)

The necessity of humor in coping with stressful situations would appear to be a natural human response, not limited to any one profession. However, the sworn enemies of human mortality, the medical profession, seem the most reluctant to admit their own tendency to use humor as a coping mechanism. In interview after interview, each medical professional (from physicians and surgeons to nurses) admitted, with a low whisper, that many of the common metaphors for mortality were a sort of "black comedy," which they understood the necessity of, but believed those outside the profession would misunderstand. From referring to imminently dying individuals as "PBAB" (Pine Box At Bedside), to entering the offices of the hospice team asking "So ... who's circling today?" (a reference to the image of vultures circling the dying individual), the use of humorous metaphor abounds. There appears, among the medical professionals interviewed, a common acknowledgment, yet a common tone of guilt, over the need for these metaphors. In a culture where "humorous" metaphors for death abound (e.g., "kicked the bucket," "croaked") why does this group feel more reluctant to admit to this use?

"Gone"

Although mentioned less frequently by actual medical personnel, the term "gone" seems the most widespread metaphor for death, according to television and film. On how many television programs have we seen the surgeon, nurse, or family member with blood stained clothing stop CPR, or close the patient's eyes, and say, "He's gone"?

The use of "gone" presents an interesting dilemma, however. If the primary function of terms of reference regarding death and dying is to provide an analogous framework for understanding that which cannot be understood, why would we use a term as ambiguous as the name of "death" itself? Where has the deceased "gone" to? When should we expect them back? To be "gone" somewhere, without a destination, and without expectation of return, is incredibly ambiguous. If we are comfortable with this ambiguity, why then do we not simply use the name we have chosen for the phenomenon itself? Why is he "gone" instead of "dead"?

Our Eternal Rest - Sleep Metaphors

The way that most people seem comfortable looking at the cemetery as a place where their loved one's body is "laid to rest" or "put to rest." Not a place where the body deteriorates, or the "worms get you." Sometimes though the whole thing gets taken to almost humorous extremes, when people's perception is so fixed on the "rest" of their loved one. People ask for spots under trees, so that they aren't directly exposed to the sun, and have some shade. I had a woman tell me that she didn't want her husband in a plot near the end of the land, as there was a road nearby, and the sound of the cars would disturb him. I asked about his hobbies, and was told that he enjoyed exercise. So I told her that "I bet he would enjoy seeing the joggers that run along the road." She agreed with this, and picked a plot right alongside the roadway. - Mr. H (Cemetery Director)

It never surprises me when children in this culture are afraid to go to sleep. So many times, we use references like "Grandma went to sleep, and didn't wake up," or "Grandma is resting now." In fact it amazes me that children ever go to sleep at all after hearing things like that. But really, it's just the most common thing I hear parents tell their children. - Ms. C (Hospice Social Worker)

The number of metaphors for human mortality that in some way relate it to sleep is too great to be coincidental. It is not difficult to imagine how this phenomenon began. Perhaps to our prehistoric ancestors, the total cessation of bodily function, which we now know as death, only appeared to be an unending sleep. Not realizing that an absence of breathing and heartbeat are the most reliable indicators of death, they must have judged the death by the other absences that come with it - cessation of speech and of movement "symptoms" which are present virtually every 24 hours when we sleep. However, in the "modern" era, when we are much more dearly aware of the differences between sleep and death, why do the two remain so closely intertwined?

In The Hour of Our Death, his comprehensive and well researched historical examination of death in a cultural context, author Philip Aries encounters this metaphor repeatedly. "The belief that the dead are asleep is both ancient and constant," states Aries. He supports this point with a discussion of the stoning to death of St. Stephen, the martyr who is described as obdormivit in Domino, or "asleep in the lord" in the Acts of the Apostles. The inscriptions found on grave areas, now commonly replaced by "here lies," is revealed by Aries to in fact be derivative of hic pausat, hic requiescit, hic dormit or requiescit in isto tumolo, translatable as "here rests," "here sleeps," or "in this grave rests." (p.23)

The human tendency to compare that which we do not understand to that which is more familiar to us, is nothing new. Marshall McLuhan dubbed this mental and linguistic habit the "rear-view mirror effect." Talking about a train as an "iron horse" or the television as a "radio with pictures" can make for convenient thought, but can blur important differences in the characteristics of the two items compared. In discussing death and sleep, this could not be more true.

Closing

Perhaps the whole root of our trouble, the human trouble, is that we will sacrifice all the beauty of our lives, will imprison ourselves in totems, taboos, crosses, blood sacrifices, steeples, mosques, races, armies, flags and nations, in order to deny the fact of death, which is the only fact we have.

Letter From a Region in My Mind - James Baldwin 

We must be particularly cautious when dealing with metaphors of mortality, because unlike other subjects, death is one which not only is not understood by our culture, but which does not have the potential to be understood, no matter the vigor of our inquiry. In general, change is a difficult experience for the human animal. Metaphors as tools may assist us in better understanding life's turns into unknown territory. However, metaphors may also be the bandage which prevents us from exposing wounds which may on some level require attention. Metaphors may assist us to a certain extent in coping with the pain of loss and the fear of dying which we all have or will encounter at some point. However, they also may alter our perceptions and prevent us from facing uncertainties which we would do well to face.

The purpose of this inquiry, and the ideas which have grown from it, is not to suggest that we should discontinue our use of metaphors in regard to death. In fact, the alteration or elimination of such perceptual tools may cause us pain that is not needed, particularly at a time when we are dealing with issues painful enough in and of themselves. As a culture, we embrace the metaphors of human mortality. Metaphors offer us comfort in a time when it is sorely needed. They offer us answers in a time when all of our inquiries are prone to fail. By identifying the roles these invisible technologies play in our consciousness, we may increase that which is best in them, and prevent that which is most dangerous in them. Perhaps simply the process of identifying our use of these metaphors, and an acknowledgment of their possible psychological functions is enough. It is not the fact that our perceptions are altered by our metaphors that makes them potentially dangerous; it is that we are too often unaware of this alteration. This then may be our challenge: to become conscious of the words we use in reference to our own death, and the deaths of those near to us, and then to realize where these comparisons may lead us. This struggle for knowledge may be a difficult one at first, but then could it really be expected to be less? It is after all, a matter of life and death.

WORKS CITED

Aries, Philip. The Hour of Our Death. New York: Oxford University Press, 1981.

Baldwin, James. "Letter From a Region in My Mind." New Yorker, Nov. 17, 1962.

Epictetus. The Handbook. Trans. Nicholas P. White. Indianapolis: Hackett Publishing, 1983.

Kubler-Ross, Elisabeth. On Death and Dying. New York: Collier Books, 1969.

Nuland, Sherwin. How We Die. New York: Vintage Books, 1993.

Nystrom, Christine. Human Symbolic Evolution. New York University, 1997 (Forthcoming).

Postman, Neil. Crazy Talk, Stupid Talk. New York: Delacorte Press, 1976 (Out Of Print).

Postman, Neil. Teaching as a Conserving Activity. New York: Delacorte Press, 1979.

ACKNOWLEDGMENTS

My sincerest thanks to Julie Jakolat, Neil Postman, Gabe Moran, and John Zimmerman of New York University for their support and feedback on this work. Also special credit is due to Noah Sexton and my wife Mary Jane for listening to my endless theoretical rants. Most especially, my deepest appreciation to the patients and staff of United Hospice of Rockland, whose strength and compassion teach me every day.

James Sexton is currently teaching and conducting research at New York University's Department of Culture and Communication. He also teaches at Ramapo College of New Jersey. His research interests include sociological propaganda, thanatology, and the cultural implications of mass media. He volunteers for a community hospice, and lives in New Jersey with his wife Mary Jane.