Clinical Ethics, Living and Dying: New Challenges for Changing Times

Article excerpt

In America, the land of the perpetually young, growing older is an embarrassment, and dying is a failure. Death has replaced sex as the taboo subject of our times.... Only our preoccupation with violence breaks through this shroud of silence. Killing yes; dying no.

-George Soros, 1994

Social workers help people make decisions about life and death. At the very edges of the most basic and painful aspects of human life, such work is increasingly complicated--the lines distinguishing life and death and the morality with which we treat both seem to blur with every new technological advance.

I recently attended a presentation at a local medical school on the growing disparity in infant mortality rates between black and white Americans. Only 40 percent of the seats were filled. The speaker, Dr. James Collins, an African American obstetrician from Northwestern University, pointed out that the mortality rate among black infants is still two to 2.5 times higher than among white infants, despite some 20 years of public health efforts and mortality improvements. Racial discrimination, environmental and occupational stress, and urban violence contribute to this persistently higher mortality for black infants (Collins et al., 2000). This disparity in hyper segregated Milwaukee is at least as bad as it is in Chicago, although it is not inconsequential that the white population in Milwaukee declined by about 110,000 during the past decade, while the black and Hispanic populations increased by about 80,000. As the complexion of our cities and the nation changes so does the moral urgency of this disparity i n health care.

Later the same day I attended a continuing education workshop on dying and bereavement. Underwritten by a local funeral home, this session was held in a serene suburban park, chirping birds and all. The packed audience, about 90 white Wisconsin social workers, heard about helping families handle normal grief, unexpected death, suicide, and the death of children. The workshop concluded with a multicultural panel on "Death in Other [sic] Cultures," giving the impression that religious rituals and cathartic grief is somehow abnormal or anachronistic to the homogenous "white American" antiseptic experience of dying. The disconnect between these two presentations on death in the United States left me feeling like I was on two different planets. Disparity in the probabilities and conditions of dying are not only taken for granted by many people, but are a very stable characteristic of U.S. society.

Many people are uncomfortable with death, and for many the dying process is a peculiarly repressed phenomenon. The very nature of the dying process in the United States changed dramatically during the past century (Bern-Klug, Gessert, & Forbes, 2001), moving from the home to hospitals and nursing homes where over 80 percent of deaths occur today, increasingly hidden from public view and disconnected from public life.

Dying in the United States probably will change even more in the next decade. Less likely to be the sanitized processes portrayed by Bill Moyers' PBS documentary, "Dying in America," the dying process will begin to reflect the dramatic population shifts reported in the recent U.S. census with many more older people being cared for by women of color and immigrants (Brookings Institution Center on Urban and Metropolitan Policy, 2001). Other areas in which death poses ethical dilemmas for helping professionals today include protection of vulnerable infants, disposition of fetuses under 1,500 grams, nascent fertility technologies, cloning, surrogate births, and the increasing incidence of genetic anomalies. Ethical dilemmas also exist in working with people who might die prematurely in the United States, such as the 3,530 Americans (of whom only 48 percent are white) on death row (Halperin, 2001), the disproportionate incidence among older white men of suicide, increasing rates of young adults dying of firearm su icide and homicide, and people of color whom hospice and organ donation programs fail to reach. …