Is Acceptance a Denial of Death? Another Look at Kubler-Ross
by Roy Branson
Dr. Branson is a research scholar at the Joseph and Rose Kennedy Institute for the Study of Human Reproduction and Bioethics at Georgetown University, Washington, D.C. This article appeared in The Christian Century, May 7, 1975, pp. 464-468. Copyright by The Christian Century Foundation; used by permission. Current articles and subscription information can be found at www.christiancentury.org. This material was prepared for Religion Online by Ted and Winnie Brock.
The recent publication of Elisabeth Kübler-Rossís second book on death and dying provides an opportunity to examine the views of the American scholar most widely read and quoted on that subject. Since the publication six years ago of On Death and Dying (Macmillan, 1969), chaplains, pastors and Christian laypeople have joined other readers in hailing Dr. Kübler-Ross not only as an obviously sensitive and compassionate psychiatrist but also as a wise thinker on the subject of death. The format of her new book, Questions and Answers on Death and Dying (Macmillan, 1974), underlines the wide attention her work has received. It is a compilation of typical answers to questions asked of her "in approximately seven hundred workshops, lectures and seminars since her first book appeared. Her professional colleagues have also acknowledged her preeminence in the field. The preface to a recent collection of articles by psychologists and psychiatrists notes that "the Kübler-Ross book was the beginning of a frank and vivid discussion about the implications of death in our modern society" (The Interpretation of Death, edited by Henrik M. Ruitenbeek [Jason Aronson, 1973]).
But Kübler-Rossís new volume reveals that some professionals are now challenging the concept that has established the core of her reputation -- her scheme of five stages of coping with death: denial, anger, bargaining, depression and acceptance. The fundamental objection: that the stages she outlines are not merely descriptive but prescriptive. She explicitly denies the charge: "Our goal should not be to help people through the five stages and reach the stage of acceptance. . . . Our goal should be to elicit the patientís needs, to find out where he is, and then to see in what form and manner we can help him best." But her disclaimers have to be considered within the context of her total work. Even in her latest book, where she is sensitive to the issue, some statements strongly suggest that in regard to her five-part scheme, Dr. Kübler-Ross does not simply report; she recommends.
She herself says that her stages do not describe an invariable sequence of emotions exhibited by terminally ill patients when they receive notice of their impending death. "Most of my patients have exhibited two or three stages simultaneously and these do not always occur in the same order." Furthermore, the fact that, "many do not flow from stage one to five in a chronological order" is "totally irrelevant to their well-being." Obviously, Dr. Kübler-Ross does not assume that individuals inevitably complete one phase before passing to another. But if sequence is not crucial, then perhaps denial, anger, bargaining, depression and acceptance might more accurately be termed types of response to apparently certain death. But Dr. Kübler-Ross cannot accept such a suggestion because she is committed to calling one response -- acceptance -- the final one.
Kübler-Ross is not distressed if a terminally ill patient moves back and forth from one emotional response to another -- unless he (or she) reaches a point of acceptance and then departs from it again. A patientís moving from acceptance to another reaction is called a "regression." It is, in her view, evidence either that the therapist is failing or that the patient resists overcoming his long-standing problems. "When a patient has reached a genuine, true stage of acceptance and he begins to regress, this is often because we do not allow the patient to let go. . . . It is in this last stage especially that a regression is usually a sign of our inappropriate handling of the patient. This is not true in other stages."
If a patient does not ever reach the stage of acceptance, it is because he "has no intention of really accepting his finiteness," or because he "has been angry all his life," or "has been a depressed personality and is filled with self-pity." And, she adds, "It is very unlikely that he will be cheerful and that he will accept his own dying with a smile on his face and a sense of equanimity." Such a person will die in a state of denial, anger or depression, or will reach resignation -- a counterfeit stage of acceptance:
People in the stage of resignation are very often indignant, full of bitterness and anguish, and very often express the statements "whatís the use," "Iím tired of fighting." Itís a feeling of futility, of uselessness and lack of peace which is quite easily distinguishable from a genuine stage of acceptance.
It would appear that denial, anger, bargaining and depression are called "stages" because in Kübler-Rossís view, acceptance ought to be the last response to death. Her use of a terminology implying sequence has been dictated by normative considerations.
Not only does the author describe in terms of failure the state of those who cannot achieve, or remain in, a condition of acceptance: "The ideal would be if both the dying patient and the patientís family could reach the stage of acceptance before death occurs." Unlike those who remain angry and depressed, "patients who are in the stage of acceptance show a very outstanding feeling of equanimity and peace. There is something very dignified about these patients."
Kübler-Ross goes into some detail describing the patient in the ideal stage of acceptance. He "will be tired and in most cases, quite weak. He will also have a need to doze off to sleep often and in brief intervals . . . a gradually increasing need to extend the hours of sleep." The patientís "circle of interest diminishes. He wishes to be left alone. . . . Visitors are often not desired, and if they come the patient is no longer in a talkative mood . . . moments of silence may be the most meaningful communication." Being neither depressed nor bitter about his fate, he "will contemplate his end with a certain degree of quiet expectation."
Throughout both of her books Kübler-Ross charges medical personnel, and even relatives, with communicating to the dying patient their own fear of and hostility toward death.
I think most of our patients would reach the stage of acceptance if it were not for the members of the helping professions, especially the physicians, who cannot accept the death of a patient . . . the second and quantitatively more frequent problem is the immediate family which "hangs on" and cannot "let go."
In her second book the author answers a question she has presumably been asked many times:
Q. Would you please tell us how you feel about your own death; what does your own death mean to you?
One wonders if she hasnít fallen prey to a subjectivity similar to that which she detects in the performance of other health professionals. Perhaps her own attitude toward death has influenced her perception of her patientsí final emotional condition as death approaches. Is it not possible that her own feeling that death signifies "peace" has entered into her judgment of acceptance as the ideal?
There are those counselors, chaplains and pastors -- many, in fact -- who rely on Kübler-Rossís work not only for analysis but for guidance in how to aid dying patients to move toward the stage of acceptance. They might well consider whether they wish to identify with her attitude toward death and the meaning it has for her. They might also examine the presuppositions that underlie a peaceful acceptance of death.
Chaplains might conclude from some passages in Questions and Answers that Dr. Kübler-Rossís views have in recent years become even more compatible with their own outlook, for she reports that she has become religious. "Working with dying patients over many years has made me much more religious than I have ever been." She is able to declare that "I now do believe in a life after death, beyond a shadow of a doubt," and she suggests that "truly religious people with a deep abiding relationship with God have found it much easier to face death with equanimity." But no more in Questions and Answers than in her first book does Kübler-Ross commend acceptance of death primarily because it is a prelude to another form of life.
In both volumes her attitude toward acceptance stems from her assumption that dying is a natural process. Death, like birth, is a part of life. In Death and Dying, she notes that acceptance, devoid of turbulent emotions, can be
perhaps best compared with what Bettelheim describes about early infancy: "Indeed it was an age when nothing was asked of us and all that we wanted was given. Psychoanalysis views earliest infancy as a time of passivity, an age of primary narcissism when we experience the self as being all."
And so, maybe at the end of our days, when we have worked and given, enjoyed ourselves and suffered, we are going back to the stage that we started out with and the circle of life is closed.
In that book she sees the death of a person as not only a stage in natureís biological rhythms but as a small part of an immense, physical universe. "Watching a peaceful death of a human being reminds us of a falling star; one of the million lights in a vast sky that flares up for a brief moment only to disappear into the endless night forever." In her latest book, Kübler-Ross still regards death as natural, and because death is a part of nature, it is only rational to accept it. "Acceptance of death is the most realistic thing that a person can work through since all of us have to die sooner or later." As in Death and Dying, she suggests that patients should accept "the reality of their own finiteness."
With or without belief in life after death, Kübler-Rossís views on the acceptance of death place her well within what Reinhold Niebuhr called "classical naturalism" (The Nature and Destiny of Man, Vol. II [Scribnerís, 1949], p. 8). Within that tradition her comments coincide at many points with the philosophy of the Stoics. Her description of the stage of acceptance as "almost void of feelings" except for peace and tranquillity echoes the Stoic concept of apathy. That too was a condition in which the emotions were, to conform to nature and reason, even in the face of death. "I cannot escape death: am I not to escape the fear of it? Am I to die in tears and trembling? For trouble of mind springs from this, from wishing for a thing which does not come to pass" (The Discourses of Epictetus, translated by P. E. Matheson [Heritage, i968], p. 58). Epictetus explained that death is not something to be frightened of, but to be accepted as part of the rhythms of nature.
What is death? A body. Turn it around and see what it is: You see it does not bite. The stuff of the body was found to be parted from the airy element, either now or hereafter, as it existed apart from it before . . . Why so? That the revolution of the universe may be accomplished, for it has need of things present, things future, and things past and done with [ibid., p. 72].
Marcus Aurelius recommended "waiting for death with a cheerful mind." Like Epictetus, he assumed that people should not fear or oppose that which is natural. "Why should a man have, any apprehension about the change and dissolution of all the elements? For it is according to nature, and nothing is evil which is according to nature" (The Harvard Classics, Vol. II, edited by Charles W. Eliot [Collier, 1969], p. 204). To fear death was regarded as "inconsistent with honouring reason" (ibid., p.300).
Christian clergy and laity, so taken with Dr. Kübler-Rossís similar position, might find it relevant to remember that Niebuhr pointed out the contrast between the classical naturalistic belief that death is part of a good nature, and the view of "orthodox Christianity" that death is the result of sin. Though he himself had some problems with the latter interpretation, Niebuhr insisted that Athanasius, Irenaeus, Gregory of Nyssa, Augustine, Aquinas and Martin Luther all believed that death is a consequence of sin -- a conviction they correctly regarded as conforming to Paulís teachings. Athanasius was typical, Niebuhr thought, in affirming that if Adam had not sinned, Godís grace would have "repelled his natural corruption" and he would have "remained incorruptible" (Niebuhr, p. 175).
True, the first pair was finite, but "by grace of the participation of the Word they would have avoided what was according to nature, if they had remained perfect" (ibid.).
Of course, some contemporary Christian theologians would concede that Christianity historically considered the continual presence of death a result of the fall from an original perfection, but they could not themselves attribute death so unequivocally to sin. "Death itself has an ambiguous character," according to John Macquarrie. It is a mark of human finitude. But Macquarrie, like many theologians writing today, would be far clearer than Kübler-Ross that death, whatever else it is, is a part of the human condition of sinfulness. "While we have rightly criticized the view that links death exclusively to sin and fails to see that death is also implicit in finitude, nevertheless there is a profound truth in the thought of death as the consequence of sin" (Principles of Christian Theology [Scribnerís, 1966], pp. 243-244).
One theologian and New Testament, scholar who can forthrightly identify with the position of "orthodox Christianity" is Oscar Cullmann. In one of the strongest recent attacks on the assumptions underlying Kübler-Rossís position, Cullmann argues that Christian doctrine "presupposed the Jewish connection between death and sin. Death is not something natural, willed by God, as in the thought of the Greek philosophers; it is rather something unnatural, abnormal, opposed to God. . . . Death is a curse, and the whole creation has become involved in the curse" ("Immortality of the Soul or Resurrection of the Dead," in Immortality and Resurrection, edited by Krister Stendahl [Macmillan, 1965], p. 20).
As have so many theologians before him, Cullmann found in Paulís letters to the Corinthians and the Romans the locus classicus for the Christian connection of death with sin and evil. God created humanity, not death. The new creature rebelling against the Creator brought death into human experience, since "the wages of sin is death" (Rom. 6:16). Death, the avenger, was set loose by the human beingís own hand. With Adamís disobedience, "sin came into the world through one man and death through sin" (Rom. 5:12). Of course, with the resurrection of Christ, death was defeated, the enemy conquered, and there is cause for exulting. "Death is swallowed up -- in victory! O death, where is thy victory? O death, where is thy sting?" (I Cor. 15:54 if.). In Cullmannís interpretation of Paul, the decisive battle has been won in the resurrection. D day was the crucial triumph, but V day, the Parousia, lies ahead. Now there is the mopping-up operation. Paul, while confident, remains implacably hostile to death. "The last enemy to be destroyed is death" (I Cor.15:26). Coinciding with Paulís negative attitude is the Revelatorís promise for a certain and glorious future when "death will be cast into a pool of fire" and "death will be no more" (Rev. 20:14).
Cullmann sharpens the contrast between the Stoic acceptance of and the Christian antagonism toward death by citing the deaths of Socrates and Christ. In answer to the tradition epitomized by Epictetusí statement "If I am not Socrates yet I ought to live as one seeking to be Socrates" (The Meaning of Stoicism, by Ludwig Edelstein [Harvard University Press, 1966], p. 12), Cullmann offers the alternative example of Christ -- a Christ "greatly distressed and troubled" (Mark 14:33) at the prospect of death.
According to Plato in the Phaedo, Socrates urges his followers to be of good cheer, "drains his cup with no difficulty or distaste whatsoever," and passes into another dimension after offhandedly reminding his companion Crito that "we owe a cock to Asklepios, pray do not forget to pay the debt" (The Phaedo, translated by R. Hackforth [Cambridge University Press, 1955], pp. 189, 190). Socrates displays total calm, an acceptance of death that the Stoics considered the essence of dignity.
Christ, on the other hand, confronted with the prospect of dying, "offered up prayers and supplication, with loud cries and tears, to him who was able to save him from death" (Heb. 5:7). In the garden, he pleads, "Father, all things are possible to thee, remove this cup from me" (Mark 14:36). Cullmann finds a New Testament Christ who has no time for trivialities at the moment of death, a Christ who struggles to the end against a terrifying enemy, crying out from the cross, "My God, my God, why hast thou forsaken me?" (Mark 15:34).
Christians who believe with Cullmann that "the whole thinking of the New Testament is governed by belief in the Resurrection" will no doubt join him in denouncing all attempts, ancient or contemporary, to make of death a natural phenomenon (Cullmann, p. 19). For them, the resurrection is robbed of its crucial significance if it is not a triumph over an awesomely powerful evil. Other Christians, even if they are hesitant to affirm a physical resurrection, will surely balk, if they take the New Testament seriously, at following Kübler-Rossís chatty recommendation that "it might be helpful if more people would talk about death and dying as an intrinsic part of life, just as they do not hesitate to mention when someone is expecting a new baby." It is one thing to acknowledge death as a mark of finitude. It is another to discuss death calmly, if not cheerfully, as a biological counterpart to birth.
Dr. Kübler-Ross is not convincing when she tries to make death more acceptable as a part of some natural cycle. Indeed, the Christian may become persuaded that the authorís stages of dying describe a circle of their own: from denial through anger, bargaining and despair, back to another form of denial called acceptance. In fact, it may well be that acceptance of death returns the dying to a juvenile inability to face the facts; that the infantlike dependence and passivity of Kübler-Rossís stage of acceptance is the greatest sort of denial of deathís reality.
Kübler-Ross herself reports that her patients consistently recoiled from death.
In listening to our terminally ill patients, we were always impressed that even the most accepting, the most realistic patients left the possibility open for some cure, for the discovery of a new drug or the "last minute success in a research project." . . . No matter the stage of illness or coping mechanism used, all our patients maintained some form of hope until the last moments.
The clash of the New Testament Christian perspective of death with that of Kübler-Ross has some concrete implications for care of the dying. While the Christian pastor or chaplain must applaud Elisabeth Kübler-Ross for virtually leading an entire nation back to the beds of the dying with a concern that allows terminally ill patients to maintain their dignity, he (or she) will not assume that calm acceptance is the ideal toward which the dying should be moved. Rather, the Christian, more than Kübler-Ross and those colleagues who agree with her, will be the true realist. He will expect to find the dying person rejecting the prospect of death, angry at its destructive finality, depressed at the loss of friends and family. He will not feel compelled to urge a dying patient with these emotions to move on to a condition of peace and tranquillity, because the responses he finds will impress him as understandable and appropriate responses to impending annihilation. He will not expect to persuade the dying person to accept the unacceptable.
Of course, if the dying can find assurance from a belief in life after death, can put confidence in the Conqueror of death, the Christian will be grateful. But he will not attempt to make Stoic heroes out of them. The chaplain will accept the challenge Dr. Kübler-Ross has forcefully given him to stop and listen to the dying, but he will further face the prospect of ministering to patients who are not able to speak peacefully and calmly about death. With many dying patients, especially those who cannot affirm a life after death, he will expect to share what he considers to be their justifiable anger and pain. Unlike Dr. Kübler-Ross, the Christian pastor and chaplain, whatever other meanings for human finitude he finds in dying, will accept death for what it is -- the implacable foe, "the last enemy to be destroyed."