Category: Cultural Practices of Mourning and Grief

Post-Mortuary Cannibalism and the Case of Kuru in the Fore Tribe of Papua New Guinea

Cannibalism, the act of consuming one’s own species, has been a long-winded, ethical debate between cultural anthropologists and Western ethics for centuries. The act of eating one’s own kind, not only creates the notion that individuals who practice cannibalism have unethically committed “the ultimate betrayal of humanity” [i], but additionally, raises several health concerns surrounding the cleanliness of consuming human flesh. These concerns have been amplified with the outbreak of kuru, a disease categorized by “’shivering’ or ‘trembling,’ [ii] in the Fore tribe of Papua New Guinea and its relationship to cannibalism, specifically as a funeral practice. Though the Fore tribe hasn’t practiced cannibalism in more than 50 years, Western views continue to challenge the value of their culture, raising questions that target our own cultural beliefs and practices: Why are our cultural practices valued while others’ are ridiculed as ‘outlandish’ and ‘disturbing’? How can the cultural mourning practice of cannibalism in the Fore tribe of Papua New Guinea be justified when examining our own Western cultural practices? Not only do cultural factors come to play, but additionally, ethical and scientific factors and effects are necessary to analyze and fully answer these questions. Looking at post-mortuary cannibalism through multiple lenses reveals new perspectives on the motivations and lasting effects that cannibalism as a funerary rite creates.

Before they ceased in the late 1950s, the Fore tribe used cannibalism as a funeral practice to honor the dead. When a member of the tribe died, the men “consumed the flesh of their dead relatives, while women and children ate the brain” [iii]. The Fore tribe believed that “it was much better that the body was eaten by people who loved the deceased than by worms and insects”[iv]. Due to this belief, utmost care was taken in order to prepare the body for consumption. While the men consumed the flesh, the women of the tribe “removed the brain, mixed it with ferns, and it cooked it in tubes of bamboo. They fire-roasted and ate everything except the gallbladder”[v] The roasting and consumption of the brain was typically completed by women because “their bodies were thought to be capable of housing and taming the dangerous spirit that would accompany the dead body” [vi]. However, what the Fore tribe didn’t expect was the ‘dangerous spirit’ of kuru that resulted from their cultural mourning practice.

This map outlines the location of the Fore tribe of Papua New Guinea.

The Fore people in Papua New Guinea practiced cannibalism traditionally until the mid-to-late 1900’s when this practice attracted international attention due to the discovery of kuru as an endemic disease within Papua New Guinea[vii]. Cannibalism, practiced less from a nutritional standpoint, was considered a way of forming social and familial ties and is known as endocannibalism.

The kuru disease is a “degenerative disease of the central nervous system” that “reported annual mortality rates of 1.6% and 0.8% for the South and North Fore respectively” [viii]. The disease is so deadly because it “can remain clinically silent for incubation periods as long as several decades” [ix]. Kuru begins with muscle coordination failure “and a tremor involving the trunk, extremities, and head” [x]. In a few months, the individual infected is “no longer able to walk or stand, and speech becomes unintelligible. As death approaches, the victim becomes completely incapacitated and is unable to eat, urinate, or defecate” [xi]

Kuru belongs within a disease classification of spongiform encephalopathies, all diseases caused by prions, misfolded proteins resulting in degenerative bodily effects. Similar diseases include Scabies and Mad Cow Disease. However, unlike Scabies and Mad Cow Disease, kuru is not seen to originate in any other hosts but humans[xii]. Kuru was once considered to be an unconventionally slow virus resulting in neural degeneration. However, after further research on affected brain tissue, kuru was shown to result from infectious particles called prions. These perpetrators of disease are proteinaceous particles that induce normal proteins to change shape, thus converting once healthy proteins into dangerous molecules. Because these infectious agents can be recycled, they begin a domino effect that ultimately creates holes in neural tissue in the brain leading to neuro-degradation and loss of muscular control [xiii]. Many scientists have tried to trace the origin of kuru in attempt to understand the pathology, spread and treatment of this disease. It was found that the Fore people had high frequencies of a certain codon coding for an allele that predisposed them to the mis-folding of the proteins specifically the PrP protein[xiv]. In a study conducted on the brain tissue of affected individuals, 38% of those affected by kuru carried this allele, where this allele was absent in all 129 survivors of the disease[xv]. After these findings, the allele in question is thought to harbor an unknown gene or mutation the predisposes a susceptible population to kuru.

This graph shows the trend of deaths caused by kuru that increased in the 1950’s and decreased around the 1980’s. This steep decline was caused by the halt of cannibalistic activity within the Fore tribe.

The genetic transfer and biological spread of kuru are widely questioned and highly speculated to have resulted from the Papua New Guinea’s common practice of cannibalizing the dead. Where some deceased were discarded and considered unclean, due to death by diseases like leprosy or dysentery, those who died from kuru were most likely to be consumed as their muscles atrophied making their body’s meat tender. It has been assumed the consuming of prions through cannibalism resulted in a cyclical reinfection of the disease in the consumer. This theory aliens with the historical observation of parallel the decline of cannibalism and kuru in the 1900’s. However, kuru cases emerging in the early 2000’s questioned this theory and some suggested non-oral transmission of the disease was possible[xvi]. Anthropologist Gajdusek suggested that kuru may have spread through the ceremonial cutting up and laying out of the deceased body in preparation for eating[xvii]. Regardless of the direct cause or transmission of the disease, the idea that kuru has been perpetuated by the practice of cannibalism in Papua New Guinea is accepted by the majority of scientists and anthropologists today. This notion is supported especially by kuru endemic amongst the Fore people as they practiced Cannibalism, not only as a post-mortuary practice, but as a social entry into kinship

Due to the recent kuru epidemic in Papua New Guinea, when one thinks of cannibalism, it evokes elements of disgust, terror, and vile behavior. Western societies have been engrained with these feelings of repulsion towards cannibalistic behavior for centuries, despite the overwhelming amount of cannibalism that occurs in the natural world in order to promote survive[xviii].  In some cases, we see cannibalism as “justified,” as in the case of survival or necessity. But where do we draw the line? For some cultures, cannibalism is a way of life. The necessity is drawn at a different spot in the sand, but the idea is the same- this type of cannibalism brings about good.

From a Western world perspective, cannibalism is justified only in extremely rare cases, such as survival. When cannibalism becomes a necessity to survive, it is not looked upon as an inherently bad thing. For example, in 1972 when a plane had crashed into in the Andes Mountains, the survivors had to consume the bodies of the already deceased as a means of survival[xix]. Due to the presence of a moral decision between life and death, the individuals involved believed that their actions were justified. The ethical principle of utilitarianism was in place, as the act itself would not necessarily be considered good, but became good because of the help that it provided. However, justification goes on a case to case basis for different groups.

This photo depicts the Wari’ people of Papua New Guinea. This tribe was one of many in Papua New Guinea to engage in cannibalism as a post-mortuary practice.          

For some cultures, although cannibalism is not based on survival, the reasons for the performance still justify the act itself. In the former tradition of the Wari’ people, cannibalism was also a matter of life and death, simply for the consumed rather than the consumer. As a funeral rite, people close to the recently deceased would consume almost the entire body[xx]. To the tribe, this act would be justified as a means of doing good for the deceased because friends and relatives are performing these actions rather than enemies. The Wari’ view cannibalism as a means of helping the soul of a deceased individual pass into the next life [xxi]. In a similar vein to the Western world, this form of cannibalism is viewed as just.  By performing this act of post-mortuary cannibalism, the Wari’ see themselves as “saving” the souls of those gone before them.  Cannibalism, once again, becomes an act that is providing good rather than evil, exemplifying the action itself as considered right by those acting.

The justification of post-mortuary cannibalism is not always completely felt while performing the act. Those who have participated in Wari’ mortuary cannibalism rituals have described the most difficult moment being when the deceased is initially taken away from mourners to be dismembered[xxii]. This is because the feelings of mourning are amplified and the loved one is appearing dehumanized while being cut up. The consuming, then, becomes the saving grace. The cannibalism, itself, is what really saves the individual, which is why it is looked at as the healing part of the process. This aspect is, once again, proving it a just action.

Differences exist within circles of cannibalism as a form of mourning, however.  In some groups, instead of the entire body being eaten, only parts are consumed.  The purpose of this cannibalism is not to benefit the eaten, but the eater[xxiii]. It is thought that the person consuming the body receives part of the spirit of the deceased. Although the reasoning for this post-mortuary cannibalism is different, the theme of justification is the same: the person believes that there is good coming from this act, so the act itself is right.

Post-mortuary cannibalism is practiced in different ways in different social groups, but the ethics of justification transcend those differences. In every circle, there exists a certain moral line where the consuming of the dead becomes justified. The differences are vast, ranging from absolute life or death to self-improvement, but each storyline carries a similar motive. When the actions bring about good in the end, the means of cannibalism is right. The folklore and fear that surrounds cannibalism cannot truly represent it, only a simple question can: When is cannibalism “OK?”

From a Western perspective, cannibalism is rarely accepted because it clearly diverges from our cultural norms. The main reason Western culture is so appalled by the practice of cannibalism is the fact that our culture loathes it [xxiv]. In Western culture, any outside practice or belief that does not line up with eurocentrism is distinctly ostracized as ‘unrighteous’ or ‘sinful.’ Despite the reasons justifying cannibalism as a funeral practice in both the Fore tribe and Wari’ people of Papua New Guinea, this symbolic rite does not line up with Western culture, thus creating issues surrounding its legitimacy and value in the world.

This photo depicts a drawing by one of the Wari’ people describing their mourning process involving cannibalism.

Culturally, we reject anything that diverges from our concept of the values of Christianity. When Western civilizations imposed their religion and its practices onto a group of indigenous people, they simultaneously condemned and destroyed that culture’s practices because they did not line up with the Western Christian lens. This rejection of differing cultural practices resulted in creation of the social stigma surrounding the practice of cannibalism.

Interestingly, though the West readily accepts it, the Western Catholic ritual of communion mirrors that of cannibalism. During the Eucharist, the technical term for the practice of communion, Catholics believe in the symbolic consumption of the body and blood of Christ. They do not believe that this is an act of cannibalism because “Christ is symbolically present” [xxv]rather than physical there. Using the word ‘transubstantiation,’ meaning “transformation of the substance,” [xxvi] Catholics ensure that the bread and wine transform into the body and blood of Christ respectively, justifying their belief that the ritual diverges far from the physical action of cannibalism.

We only devalue the Fore tribe’s cultural mourning ritual of cannibalism as barbaric, while simultaneously valuing Western Catholic transubstantiation as sacred, because “it has historically been convenient for Westerners to stigmatize cannibalism” [xxvii]. The act of condemning ‘outlandish’ and ‘barbaric’ behavior, such as consuming one’s own species, justifies Western colonization. During his conquest in 1492, ‘Western hero’ Christopher Columbus used the word “cannibal” to describe the “fascinating New World Natives” [xxviii]. In his journal, he writes of his concern over the ‘exotic’ behavior of the Caribe people by stating that he wishes “to send to Spain men and women from the islands which they inhabit, in the hope that they may one day be led to abandon their barbarous custom of eating their fellow-creatures” [xxix]. This statement excuses the further persecution of indigenous people because it labels groups of people who exhibit ‘exotic’ behavior as projects that need to be both Christianized and Westernized, rather than human beings that practice their own unique rituals and customs.

Practices of grief and mourning surrounding death largely vary across cultures, and though some practices may seem abnormal or foreign to an outsider, they serve purposes beyond what the eye can readily see. Cannibalism, a practice frowned upon by many cultures, is one such tradition arousing skepticism and discussion, ultimately leading to the degradation of this practice in many parts of the world. The Fore people would have non-kin consume their dead as a ritual to symbolize outsiders entering into kinship.

From the outside looking in, the practice of cannibalism arouses several questions from scientific, ethical and cultural perspectives that ultimately result in undefined answers. From an anthropological perspective, it is important to look into such topics with a prospective free of ethnocentricity. For the Fore people, their practice of consuming the dead was not done to meet nutritional need or out of mal intent, but rather it was seen to create bonds of “one blood” through a common ancestor, in this case the dead[xxx]. Without first knowing the significance of practices like cannibalism within a culture, it would be unsound to draw conclusions regarding the ethical or social intentions of such a practice. Understanding the reasons behind culture and custom is the appropriate way to address any issue at hand. This rings true in the case of Papua New Guinea where the cultural practice of cannibalism lead to an endemic of kuru within the region.

Kenzie Chasteen, Emma Uhrlass and Dominic Antonietti   

 

References:

[i] Worrall, Simon. “Cannibalism-the Ultimate Taboo-Is Surprisingly Common.” National Geographic. February 19, 2017. Accessed April 08, 2019. https://news.nationalgeographic.com/2017/02/cannibalism-common-natural-history-bill-schutt/.

[ii] Bichell, Rae Ellen. “When People Ate People, A Strange Disease Emerged.” NPR. September 06, 2016. Accessed April 08, 2019. https://www.npr.org/sections/thesalt/2016/09/06/482952588/when-people-ate-people-a-strange-disease-emerged.

[iii] Kaplan, Sarah. “How a History of Eating Human Brains Protected This Tribe from Brain Disease.” The Washington Post. June 11, 2015. Accessed April 08, 2019. https://www.washingtonpost.com/news/morning-mix/wp/2015/06/11/how-a-history-of-eating-human-brains-protected-this-tribe-from-brain-disease/?utm_term=.3233958108ae.

[iv] Refer to Footnote [i]

[v] Refer to Footnote [ii]

[vi] Refer to Footnote [ii]

[vii] Kusinitz, Marc. “Kuru.” In The Gale Encyclopedia of Science, 5th ed., edited by K. Lee Lerner and Brenda Wilmoth Lerner. Farmington Hills, MI: Gale, 2014. Science In Context (accessed April 5, 2019). http://link.galegroup.com.libproxy.lib.unc.edu/apps/doc/CV2644031265/SCIC?u=unc_main&sid=SCIC&xid=55b40db8.

[viii] Steadman, Lyle B., and Charles F. Merbs. “Kuru and Cannibalism?: Kuru: Early Letters and Field-Notes from the Collection of D. Carleton Gajdusek . Judith Farquhar, D. Carleton Gajdusek.” American Anthropologist84, no. 3 (1982): 611-27. doi:10.1525/aa.1982.84.3.02a00060.

[ix] Refer to Footnote [viii]

[x] Refer to Footnote [viii]

[xi] Refer to Footnote [viii]

[xii] “kuru.” In The Hutchinson Unabridged Encyclopedia with Atlas and Weather Guide, edited by Helicon. Helicon, 2018. http://libproxy.lib.unc.edu/login?url=https://search.credoreference.com/content/entry/heliconhe/kuru/0?institutionId=1724

[xiii] Liberski, Paweł P., Agata Gajos, Beata Sikorska, and Shirley Lindenbaum. “Kuru, the First Human Prion Disease.” Viruses 11, no. 3 (2019): 232.

[xiv] Wadsworth, Jonathan D. F., Susan Joiner, Jacqueline M. Linehan, Emmanuel A. Asante, Sebastian Brandner, and John Collinge. “The Origin of the Prion Agent of Kuru: Molecular and Biological Strain Typing.” Philosophical Transactions of the Royal Society B: Biological Sciences 363, no. 1510 (2008): 3747-3753.

[xv] Liberski, Pawel P., Beata Sikorska, Shirley Lindenbaum, Lev G. Goldfarb, Catriona McLean, Johannes A. Hainfellner, and Paul Brown. “Kuru: Genes, Cannibals and Neuropathology.” Journal of Neuropathology & Experimental Neurology 71, no. 2 (2012): 92-103.

[xvi] Refer to Footnote [xv]

[xvii] Refer to Footnote [xv]

[xviii] Baggini, Julian. “Eating Humans.” TheTLS. May 05, 2017. Accessed April 07, 2019. https://www.the-tls.co.uk/articles/public/eating-humans-cannibalism/.

[xix] “Death and Dying.” Encyclopedia of Death and Dying. Accessed April 07, 2019. http://www.deathreference.com/Bl-Ce/Cannibalism.html.

[xx] Conklin, B. (1995). “‘Thus Are Our Bodies, Thus Was Our Custom”: Mortuary Cannibalism in an Amazonian Society.” American Ethnologist, 22(1), 75-101.

[xxi] Conklin, Beth A. “Hunting the Ancestors: Death and Alliance in Wari Cannibalism.” The Latin American Anthropology Review 5, no. 2 (2008): 65-70. doi:10.1525/jlca.1993.5.2.65.

[xxii] Refer to Footnote [xv]

[xxiii] Conklin, Beth A. Consuming Grief: Compassionate Cannibalism in an Amazonian Society. Austin, TX: University of Texas Press, 2011, 27.

[xxiv] Diamond, Jared M. “Talk of Cannibalism.” Nature407 (September 7, 2000): 25-26. September 7, 2000. Accessed April 08, 2019. https://www.nature.com/articles/35024175.

[xxv] Staples, Tim. “Are Catholics Cannibals?” Catholic Answers. November 7, 2014. Accessed April 08, 2019. https://www.catholic.com/magazine/online-edition/are-catholics-cannibals.

[xxvi] Refer to Footnote [xxv]

[xxvii] Mufson, Beckett. “Everything You Know About Cannibalism Is Wrong.” Vice. June 21, 2018. Accessed April 08, 2019. https://www.vice.com/en_us/article/evk9ke/we-asked-an-expert-why-you-think-cannibalism-is-gross.

[xxviii] “How Columbus Created the Cannibals.” How Columbus Created the Cannibals. Accessed April 08, 2019. http://hartzog.org/j/cannibals.html.

[xxix] Refer to Footnote [xxviii]

[xxx] Refer to Footnote [xiv]

Turkish and American Death Practices

Grief is a universal and natural reaction to losing a loved one that has been documented across many cultures and even different species. [1]This makes sense thinking about attachment theory; “grief is a general reaction to separation”. [2] But even though grief is rooted in a reaction common to all people, there is a large amount of diversity when it comes to cultural and religious traditions related to death and bereavement. It is important to define the components of the grieving process in order to compare and contrast cultural differences of grief. There is a difference between grief and mourning. Grief is the emotional and psychological reaction to death, while mourning is the social expressions or acts in response to death. These practices are shaped by culture and society. [3]

The Kübler-Ross psychological model of the five stages of grief—formulated by Elisabeth Kübler-Ross—are considered normal in the Western world. It is broken down into denial, anger, bargaining, depression, and finally acceptance. She created it as a way for terminally ill patients to process their deaths, but now it is applicable to anyone who has lost a loved one as well. [4] Denial is the refusal to come to terms with impending death. Anger occurs when resentment encroaches, and the person begins to ask, “why me?” When there is hope that death can be delayed through negotiating with God, bargaining takes place. Depression begins with hopelessness, and the gravity of the losses that have occurred, and the ones to come. Ultimately, the model ends with acceptance, but this should not be understood as happiness. [5]Rather, it is peace.  This whole process can take months to years. [6] However, there are critiques of the Kübler-Ross model such as misrepresentation of grieving by creating a sequential process instead of a constant one. [7] It can give someone validation if their grieving process aligns with the model’s, but it can also produce negative effects if someone were to feel as though they are not going through the process correctly. [8]

It is especially important for practitioners to be cautious of using these stages of grief as a clear blueprint of the grieving process. However, there are examples of when this grieving process is much shorter. For the Navajo, grieving was limited to four days. After that, the bereaved was expected to move on. [9] Even though an emotional disturbance is to be expected across the world, differences in culture and society can greatly affect expression and duration of said grief. [10]For example, among the Balinese, there is a lack of crying and a prevalence of smiling. This is not due to lack of emotions or feelings of grief, but an attempt to control and contain them. It is believed that grief is harmful to health. On the other hand, in Egypt, the bereaved “dwell profusely on their subjective pain in an atmosphere where…others also immerse themselves in tragic tales and expressed sorrow”. [11]

One aspect to consider when it comes to culture and grief is religion. In the United States, Christianity is the dominant religion that affects how many people understand and deal with death. There is not a generally accepted timeline for grieving in Christianity, but some other religions do have one. Sri Lankan Buddhists usually return to work after 3-4 days. [12]Orthodox Jews sit shiva for 7 days where the bereaved stays at home and loved ones visit. The mourning period after shiva depends on who has died. For a relative it is 30 days, for a parent it is one year, but prolonged mourning is not supported. [13]

Kubler-Ross touches on faith in her model in the bargaining stage, but there is not much discussed beyond pleading with whichever higher power one believes in. Psychologists and psychiatrists must know someone’s background in faith in order to help them grieve. Turkish Muslims, for example, use the five staged model, but there is also an emphasis on sabr—the Arabic word for patience. [14]Muslims believe that all of life and death and everything in between is all from God. They believe they can find strength in God, and that comfort aids in the grieving process. [15]Knowing that a higher power is in control lets people focus on grieving and reaching peace instead of putting energy into questioning God and the unknown.

The dominant religion in Turkey is Islam and many Turkish people rely on religious beliefs and traditions to death with the death of a loved one and the grief that comes along with it. In America, although many rely on religion and prayer to comfort them after the loss of a loved one, there are not nearly as many set rules or practices when it comes to mourning as Islam. [16] In Turkey, it is believed that burial shouldn’t be delayed so that the deceased can give accounts of their deeds in the Hereafter. [17] It is also considered normal to wrap the body in a shroud, and right side of the body is supposed to face Qibla, which is the direction Muslims face while praying. Qibla is the direction facing the Kaaba, the center of the holiest mosque, which is in Mecca. [18] Lights are kept on in the house and Helva (a sweet dessert) is cooked so that the deceased can see the house in light and enjoy the smell of the food. In Turkish beliefs, this is done so that the evil part of the dead doesn’t enter the house.The body is also washed with perfumed soap so that the body is clean and smells pleasant, allowing them to enter paradise. [19]

There is a 40-day restriction on haircuts and shaving during mourning if the person who died was young. You are also not supposed to watch TV, talk loudly or laugh. Talk about the dead person can only be positive, and there are no wedding ceremonies held during mourning. [21]All of these practices and traditions are an attempt to accept and understand the death of a loved one, as well as alleviate grief. There are no limitations on activities or events during mourning in the US. There are fewer guidelines for grief. Although it is common to keep the discussion of the deceased positive, there is no actual restriction on what people can talk about. Although both Christianity and Islam believe in an afterlife and that people either end up in Heaven or Hell based on their actions during their life on earth, there is less discussion of death in Christian communities. For Muslims, death is treated as a part of life, and thus discussed often. In Christian and overall American culture, death is mostly an avoided topic. [22]

The US and Turkey are both countries whose cultures are deeply affected by their religion. This results in some notable differences in expression of grief. Although there are universal aspects of grief, it is clear that culture, especially religion, has a huge impact on what beliefs and traditions are practiced after the death of a loved one.

The Turkish Neurological Society’s Diagnostic Guidelines for brain death and the Miller School of Medicine in Miami, Florida yield similarities in the determination of brain death. The Turkish definition of brain death is the, “loss of all activities of the parts of central nervous system that reside within the skull,” including the brain stem and cerebellum. [23] Under the Uniform Determination of Death Act, the legal definition of brain death is the, “irreversible cessation of all functions of the entire brain, including the brain stem.” [24].It is evident that both countries have a solid definition based on the foundation that the damage must be to the brain overall, but specifically brain stem too.

The three main signs of brain death for both countries that should be evaluated are coma, absence of brain stem reflexes, and apnea. [25][26]Both believe that a patient must lack any evidence of responsiveness. Turkey’s criteria holds that there must not be any response to painful stimulation of the temporomandibular joint located on the side of the jaw, or the supraorbital ridge—the brow bridge. It also states that activities such as blushing, sweating, and normal blood pressure sans medication do not imply that brain death should be thrown out. [27]There must be an absence of pupillary response to bright light, ocular movements, facial expressions, and corneal reflexes. [28][29]There should also not be any observable coughing or gagging. To address apnea, both sets of guidelines include the apnea test where in Turkey it is required by law for a specialist to conduct. [30] If the test is positive, and there is not a respiratory drive, then the patient is suggested to be brain dead. Another difference between the countries is the waiting period after the three main signs of brain death have been documented. In the United States, six hours is considered an acceptable duration, but in Turkey, the waiting period is twelve hours for children older one years old or older and adults. [31][32]

In a study of Turkish physicians, it was found that 32.7 % stated they did not regard brain death as “real death.” [33] If the highly educated physicians do not believe it to be, then why would the general population? If brain death is so clearly defined by their own guidelines, there should not be any confusion. They found the skepticism of the public came from lack of information, the media, and the similarities between a coma and brain death. In fact, the public believes that the term “brain death” was created to aid in organ procurement. [34] The uncertainty in Turkey amongst physicians and the general public regarding brain death only confuses those grieving the loss of a loved one, and ultimately makes it harder. The most prominent religion in Turkey is Islam, and some argue that because of religion, they do not accept brain death. [35] 84.5% of physicians stated that more effective education regarding the matter can aid those in grieving a loved one declared brain dead. Which is paradoxical in itself when physicians have so much education, yet some do not accept it themselves, but expect their patients’ relatives to.

The religiosity of American and Turkish peoples can create tensions and inequalities within contexts of grief because of the differences in social rules. Western society revolves around death-denial which, in turn, produces certain social roles that dictate who is exempt from responsibilities during periods of grief, the extent of discussion surrounding death, and who is publically grievable. [36]

The distribution of privileges among populations in Western societies has been historically unequal. Social roles in times of grief include favoring exemptions for those who have lost a child or spouse as opposed to a close friend, male strength, female weakness, as well as other elements of gender socialization. Forms of grief that lie outside of these social norms are subject to public scrutiny, which heightens the despair of those dealing with loss. These social schema act as a sort of injustice to those unable to operate within the confines of socially acceptable grief.

The acceptability of discussion of death and grief differs between the U.S. and Turkey. The U.S. favors stoicism and masking of grief over expression, internalizing oppressive social rules that determine proper forms of grief. The Islamic view of death as a continuation of life limits the need for social desirability and encourages open communication about loss.

American obituaries and Turkish death announcements exhibit the structural inequality present in available expressions of grief. Death announcements differ from obituaries in that they are formulaic and detached statements that serve more so to announce a death than to commemorate or honor the deceased. These very public expressions of grief are spaces of great inequity as the economically underprivileged are unable to express grief in their desired manner. [37] Minorities in Turkey are less equipped to achieve their desired deaths due to institutional inequalities including Turkish refusal to adhere to the Treaty of Lausanne. This treaty “grants not only non-Muslim minorities, but all citizensthe right to use ‘any language … in the press, or in publications of any kind.’” [38] Despite this legislation, Turkish authorities have never allowed minorities to exercise this right. This conflict revolved around native tongues and access to media, conflicts that also exist in the United States but on a lesser scale.

The primary ethical concerns surrounding American and Turkish cultural practices of grief lie in unequal access to full expressions of grief, but concerns of violations of autonomy are also raised in the preparation of bodies for burial and strict grief periods. The varying laws regarding advance directives and living wills among states within the U.S. can make it difficult to ensure that individuals receive the posthumous care they desire, particularly with religious and familial influence. These factors call into question the level of autonomy maintained by the deceased. It is also unclear to what extent Turkish individuals are able to or are comfortable in engaging in forms of burial other than shrouding. The combination of social roles and religiosity can stifle personal ideals of posthumous care. Strict social grief periods are prevalent in Turkey and require that individuals delay life events and abstain from daily activities. Policing of behavior and expressions of grief are forms of autonomy violation that are worsened depending on social and class status.

Both the United States and Turkey abide by the general “total brain death” definition of death. The principle requires individuals to be completely unresponsive in a state of coma, have no brainstem response, and to have an irreversible absence of respiratory or cardiac functioning in order to be declared legally dead. Ethical issues arise as a result of the great variability of execution of the total brain death principle across regions, and conflicting religious ideologies of the family in determining the death of a patient. [39]

Variance in the definition of brain death and its requirements are evident in the uncertainty of the definition among both physicians and the public. As stated, physicians in the United States observe a wait period of six hours after initial testing for brain death, while Turkey requires twelve hours. This variance in waiting periods reveals broader social and medical differences in the acceptability of total brain death as the definition of death. Physicians within the U.S. and Turkey disagree regionally on the merits of total brain death and whether it can be medically applied. Differing definitions and uncertainty of requirements of death leave the fate of patients to a physician’s discretion, without the legal requirement that the total brain death definition be observed. Public skepticism of medical death practices prohibits individuals from actively engaging in their death planning, resulting in a loss of autonomy. How can patients make informed decisions about what happens to them posthumously if the very definition of their death is up for debate? The lack of absolute protection against premature declaration of death leaves patients susceptible to premature organ procurement, a common concern among the U.S. and Turkey.

Arterial spin-labeling (ASL) and magnetic resonance angiography (MRA) imaging of a 46-year-old healthy woman (top row), a 75-year-old woman with brain death (middle row), and a 20-year-old woman with sudden cardiac arrest. . http://www.ajnr.org/content/36/5/909.

An additional concern that emerges from conflicting definitions of death in medical settings is the influence and level of consideration of conflicting religious beliefs. The majority of Turkish citizens practice Islam while adherence to a form of Judeo-Christian religion is most common in the U.S. [41]Freedom of religion is mandated by the Turkish government which cultivates strong reliance on religious virtues and familial support. In the U.S., a separation of church and state exists, which creates an increasingly secular climate. Within these sacred and secular contexts, a divergence in ethical principle occurs, particularly in the principle of autonomy. Turkish society includes paternalistic medical care in which the family and physician are solely responsible for the medical decisions of the patient. This combination of religious ideology and paternalistic care reduces patient autonomy. The definition of death is further muddied by the influence of familial religious ideals and physician power. In the U.S., there still exists a predisposition to reduced autonomy because of the variance in physician-patient relationship, allowing potential coercion of patients. The issue of conflicting religious values between the patient and caregivers exists in the U.S., but at a lesser extent due to the mandated separation of church and state. [42]

Consideration of the cultural, scientific, and ethical aspects of American and Turkish cultural death practices allows for a comprehensive comparison of the two cultures. The examination of two different cultures reveals the universal experience of death. While social rules, expressions of grief, and definitions of death present major differences between the two countries, the common thread of death and grief is prevalent.

Jenna Thornton

Natasja Brezenski

Siham Sherif

 

[1]Stroebe, Margaret, and Henk Schut. “Culture and Grief.” Bereavement Care 17, no. 1 (1998): 7-11. https://doi.org/10.1080/02682629808657425.

[2]Bowlby, John. Attachment and Loss. Vol 3: Loss: Sadness and Depression.London, UK: Hogarth, 1980.

https://www.abebe.org.br/files/John-Bowlby-Loss-Sadness-And-Depression-Attachment-and-Loss-1982.pdf.

[3]Stroebe, Margaret, and Henk Schut. “Culture and Grief.”1998.

[4]Mahmood, Kaiser. “Dr. Elisabeth Kübler-Ross Stages of Dying and Phenomenology of Grief.”  Annals of King Edward Medical University12, no. 2 (2006): 232-233. https://doi.org/10.21649/akemu.v12i2.882.

[5]Mahmood, Kaiser. “Dr. Elisabeth Kübler-Ross Stages of Dying and Phenomenology of Grief.” 2006.

[6]Bowlby, John. Attachment and Loss. 1980.

[7]Stroebe, Margaret, Henk Schut, and Kathrin Boerner. “Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief.” Omega- Journal of Death and Dying 74, no. 4 (2017): 455-473. https://doi.org/10.1177/0030222817691870.

[8]Stroebe, Margaret, et al. “Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief.” 2017.

[9]Miller, Sheldon I., and Lawrence Schoenfeld. “Grief in the Navajo: Psychodynamics and Culture.” International Journal of Social Psychiatry 19, no. 3-4 (1973): 187-91. https://doi.org/10.1177/002076407301900305.

[10]Stroebe, Margaret, and Henk Schut. “Culture and Grief.” 1998.

[11]Wikan, Unni. “Bereavement and Loss in Two Muslim Communities: Egypt and Bali Compared.” Social Science & Medicine27, no. 5 (1988): 451-60. https://doi.org/10.1016/0277-9536(88)90368-1.

[12]Bahar, Zuhal; Beser, Ayse; Ersin, Fatma; Kissal, Aygül; Aydogdu, Nihal G. “Traditional and Religious Death Practices in Western Turkey.” Asian Nursing Research 6, no. 3 (2012):107-114. https://doi.org/10.1016/j.anr.2012.08.003.

[13]Bahar, Zuhal, et al. “Traditional and Religious Death Practices in Western Turkey.” 2012.

[14]Mehraby, Nooria. “Psychotherapy with Islamic Clients Facing Loss and Grief.” Psychotherapy in Australia 9, no. 2 (2003): 1-8.

https://www.researchgate.net/publication/238102224_Psychotherapy_with_Islamic_Clients_Facing_Loss_and_Grief.

[15]Mehraby, Nooria. “Psychotherapy with Islamic Clients Facing Loss and Grief.” 2003.

[16]Beaty, Darla D. “Approaches to Death and Dying.” OMEGA – Journal of Death and Dying 70, no. 3 (2015): 301-16. https://doi:10.1177/0030222815568962.

[17]Bahar, Zuhal, et al. “Traditional and Religious Death Practices in Western Turkey.” 2012.

[18]Bahar, Zuhal, et al. “Traditional and Religious Death Practices in Western Turkey.” 2012.

[19]Bahar, Zuhal, et al. “Traditional and Religious Death Practices in Western Turkey.” 2012.

[20]Nabi. YouTube. March 19, 2013. Accessed April 09, 2019.

https://www.youtube.com/watch?v=NK7WW7Q5ylU.

[21]Nabi. YouTube. 2013.

[22]Nabi. YouTube. 2013.

[23]Turkish Neurological Society. “Diagnostic Guidelines for Brain Death.” Turkish Journal of Neurology 20, no. 3 (2014): 101-104. https://www.journalagent.com/tjn/pdfs/TJN_20_3_101_104%5BA%5D.pdf.

[24]Greer, David M., Hilary H. Wand, Jennifer D. Robinson, Panayiotis N. Varelas, Galen V. Henderson, Eelco F. M. Wijdicks. “Variability of Brain Death Policies in the United States.” JAMA Neurology73, no. 2 (2016): 213-218. https://doi.org/10.1001/jamaneurol.2015.3943.

[25]Turkish Neurological Society. “Diagnostic Guidelines for Brain Death.” 2014.

[26]University of Miami: Miller School of Medicine. “American Academy of Neurology Guidelines for Brain Death Determination.” Accessed March 25, 2019. http://surgery.med.miami.edu/laora/clinical-operations/brain-death-diagnosis.

[27]Turkish Neurological Society. “Diagnostic Guidelines for Brain Death.” 2014.

[28]Turkish Neurological Society. “Diagnostic Guidelines for Brain Death.” 2014.

[29]University of Miami: Miller School of Medicine. “American Academy of Neurology Guidelines for Brain Death Determination.”

[30]University of Miami: Miller School of Medicine. “American Academy of Neurology Guidelines for Brain Death Determination.”

[31]Greer, David M., et al. “Variability of Brain Death Policies in the United States.” 2016.

[32]Turkish Neurological Society. “Diagnostic Guidelines for Brain Death.” 2014.

[33]Hot, Inci, Elif Vatanoglu, Ahmet Dirican, and Hanzade Dogan. “Attitudes Toward Death and Brain Death Among Turkey’s Physicians: A Brief Research Report.” Omega 59, no.4 (2009): 339-349. https://doi.org/10.2190/OM.59.5.d.

[34]Hot, Inci, et al. “Attitudes Toward Death and Brain Death Among Turkey’s Physicians: A Brief Research Report.” 2009.

[35]Hot, Inci, et al.  “Attitudes Toward Death and Brain Death Among Turkey’s Physicians: A Brief Research Report.” 2009.

36]Harris, Darcy. “Oppression of the Bereaved: A Critical Analysis of Grief in Western Society.” OMEGA -Journal of Death and Dying60, no. 3 (2010): 241-253. https://doi.org/10.2190/OM.60.3.c.

[37]Ergin, Murat. “Religiosity and the Construction of Death in Turkish Death Announcements, 1970-2009.”Death Studies36, no. 3 (2012): 270-291. https://doi.org/10.1080/07481187.2011.553339.

[38]Kurban, Dilek. A Quest for Equality: Minorities in Turkey. Minority Rights Group International, 2007.

http://www.atour.com/government/pdf/MRG-TurkeyReport-MinorityQuestEquality-DeceMber207.pdf.

[39]Greer, David M., et al. “Variability of Brain Death Policies in the United States.” 2016.

[40] Kang, K.M., et. al. “Clinical Utility of Arterial Spin-Labeling as a Confirmatory Test for Suspected Brain Death.” American Journal of Neuroradiology36, no. 5 (2015): 909-914. https://doi.org/10.3174/ajnr.A4209.

[41]Beaty, Darla D. “Approaches to Death and Dying.” 2015.

[42]Beaty, Darla D. “Approaches to Death and Dying.” 2015.

 

 

Universal and Cross-Cultural Models of Grief

After the loss of a loved one, people often enter a period of bereavement filled with grief and mourning of the person they have just lost. Many people experience grief, but the scientific community is yet to make a universal model for grief. Grieve is experienced in different ways. In different cultures, the bereaved have different practices, ceremonies, and ways of coping with grief. Some forms of grief are controversial and others are seen as unhealthy. There is still much more to be known about grief. As research has been done on the topic, they have found more about how grief is similar and different between people. We argue that grief, although experienced in similar patterns, is not able to be put into a universal model. One’s experience of grief is unique to them and is influenced by many factors. Making a universal model for death is not what is needed in further research of this topic.

People experiencing bereavement often experience some form of emotional symptoms and physical symptoms including increased irritability, numbness, bitterness, detachment, preoccupation with loss, inability to show or experience joy, digestive problems, fatigue, headaches, chest pain, and sore muscles during their period of grief.[1] This raises the question, is there physical evidence of grief in the body?

Saavedra Pérez et al. showed that there may be a change in cognitive function during grief. However, they used a small sample of people that they classify as experiencing complicated grief (now classified as Prolonged Grief Disorder in the dsm-5). He studied how people experiencing “complicated grief” performed on cognitive testing (Mini-Mental State Examination, Letter–Digit Substitution Test, Stroop Test, Word Fluency Task, word learning test – immediate and delayed recall) while looking at total brain volume. His results showed that when people experience “complicated grief” they have lower cognitive ability and smaller overall brain volume.[2]

Other researchers including Peter Freed, Ted Yanagihara, Joy Hirsch, and John Mann have looked to see if there is a short term change in neural pathways to explain some symptoms of grief experienced. They had 20 recently bereaved subjects rate the amount of interfering thoughts related to their deceased loved one versus their ability to avoid those thoughts. During the experiment, subjects completed an Emotional Stroop (ES) task that contained words relating to the deceased and control words. The team of experimenters measured reaction time and used functional magnetic resonance imaging (fMRI). The second part of the experiment consisted of subjects visualizing the death of the deceased and rating the emotions elicited. Results of the study showed that there was an attentional bias toward words pertaining to the deceased that correlated with an increase in activity in the amygdala, insula, dorsolateral prefrontal cortex (FLPFC). The increase in brain activity in these regions corresponds with the sadness intensity, a double dissociation between grief style, intrusiveness, avoidance, and lower ability to complete tasks.[3]

Since there is some evidence to indicate that grief is in part a biological function, some might look to doctors as experts on what grief is and how to manage grief. However, Margaret Stroebe Henk Schut, and Kathrin Boerner criticize physicians aiding grieving patients and their use of the stages of grief model. They draw attention to the intent of Elisabeth Kübler-Ross’s model which was for the terminally ill. Elisabeth Kübler-Ross’s was adapted from Bowlby and Parkes’ theory which consisted of 4 stages of grief.

5 stages of grief model expanded

https://www.researchgate.net/publication/307949910_Emotionally_sustainable_change_two_frameworks_to_assist_with_transition [4]

Ross adapted this model to fit what she was seeing in her work with terminally ill patients in their process to cope with their own death. Somehow people accepted this model as a universal model for grief. Physicians explain grief as if it has time limits and universal patterns through the scope of this model.[5]The Cleveland Clinic even has a manual that is supposed to be a resource guide for children’s grief.[6] However, as Maciejewski et al. argue many people do not experience grief in the way Ross describes in her model. If they experience some form of these stages, they often do not present similarly among people and they are rarely chronologically similar.[7]As physicians push this model, it makes bereaving people more likely to feel that they are grieving incorrectly. This also opens up the possibility for the bereaved to think their grief may be abnormal. Because of their unwarranted concern, people out of the scope of Ross’s model may more likely be misdiagnosed with Prolonged Grief Disorder or Major Depressive Disorder.

The DSM was updated and removed the exclusion of people grieving from being diagnosed with Major Depressive Disorder. The change has raised the concerns of many researchers and clinicians in the field. The consensus among many in the field including Richard A. Friedman is that it is important that people that meet the criteria for MDD are treated and should not be excluded if they are experiencing grief.[8]However, moving forward the definition of grief and knowing more about the subject will be important as clinicians try to distinguish between symptoms of grief and depression. It will also be crucial for more studies to collect more diverse samples to get a greater understanding of grief in different cultures as well as learning more about various cultural practices on a broader scale.

As mourning practices and reactions to grief are increasingly researched in the scholarly world, these studies become increasingly aware of the inherent ethnocentrism in believing certain mourning and grieving practices are universal. As a response, more and more interest is being poured into the cross-cultural perspective that compiles accounts of different cultures and analyzes the universal patterns in human mourning and grieving. [9] An interesting subfield is in the study of the transformation of cultural norms and expectations that go along with mourning and grieving practices.

Within the U.S. itself there is already a melting pot of cultures from the diverse amount of ethnic and cultural groups residing in the country. This serves as a unique cultural context for these different groups to take in and transform Western mourning practices along with interaction with their own.This cultural appropriation serves as a way for residents to blend their own cultural ways of mourning and expressions of grief with the traditional Western ways that surround them. For example, when third or fourth generation assimilated ethnic groups like Jews or Italians that choose to identify as their ethnic group after bereavement. [10]

Another example of blending cultures is the cultural context that surrounds digital mourning practices. This includes clicking the ‘Like’ button when somebody posts in honor of a recent death and replying with positive messages about the person who died. Because of the rise of mediatization, specifically emotions, social media has become a place where friends and family can share recent deaths and mourn the social death of the person.[11]Anna J.M. Wagner points out the cultural norms and expectations for digital mourning practices, with an emphasis on the forms of mourning expression and reactions to such expressions on social media.[12]Social media, in turn, has become a digital space for mourning and grief.

A Facebook post of a wife announcing her husband’s death. Words such as “legacy” and “always” emphasize the prolonging of the husband’s social death, past his biological death.

https://www.dailymail.co.uk/news/article-3222086/Rest-beloved-love-forever-Wife-army-trooper-died-aged-36-dementia-caused-roadside-bomb-blast-Iraq-posts-loving-tribute-hero.html [13]

Despite the amount of groups and cultures invested in adopting other cultures and their mourning and grieving practices, there are many cultures that are relatively unbothered and choose to stay true to their roots. In Japanese culture for example, there is an emphasis of death being understood as a natural process and norm of respecting the bodies of the dead and by undergoing Buddhist practices.[14]

In investigating mourning and grieving practices using the cross cultural approach, a question that naturally rises is if there are “good” grief and “bad” grief, and what are the consequences of such definitions? Using the cross-cultural approach is challenging the inherent ethnocentrism present by only focusing on Western practices of bereavement. However, using this approach requires judging other cultures and discriminating what is “universal.”

The ethnocentrism in believing Western mourning practices are common throughout the world poses detrimental implications for medical practitioners and their patients. Medical practitioners that want to guide patients and loved ones through the mourning process should be aware of non-Western practices, as these can cause communication issues when applying Western models of grief and mourning.

Grieving takes many forms. Psychologist Ralph Rayback writes that grief “ can manifest itself in the form… of physical suffering, and we may experience anything from anger to denial…to despair.” [15]These grief stages have ethical consequences. The ethics of grief depend on a few factors: (1) one’s culture and how it views grief, whether it be as a healthy process or a sign of weakness (2) how you grieve and whether you commit unethical acts as a result of your grief (3) how grief affects others in the community. These factors make it difficult to prescribe a one size fits all view on the ethics of grief. Seemingly, no one has objectivity in the matter. In R. Bargo’s book The Ethics of Mourning, he writes “much of the limit placed upon mourning as an ethical act comes from those who stand outside of its perspective.” [16] What he means is that we cannot judge an act of grieving as ethical or unethical because of our limits in perspective. In my section, I will focus on the grieving process in the United States and contrasting it with Ilongot tribe in the Philippines and see if there are ethical dilemmas on the problem of grieving and propose that there is no universal answer for the ethics of grief.

There’s no universal answer on whether grieving is ethical because it brings up the question of who gets grieved and who does not. The United States culture of grief is ethically gray on grief. John Chuckman, a writer for Counterpunch, puts it as, “Death in America does not come easily…unless you are homeless or live on an Indian reservation or in one of the nation’s vast urban ghettos.” [17]This quote cleverly brings up the conundrum we face in the United States of grieving the death of those who the United States exemplifies, but we look the other way when oppressed people such as immigrants or poor people die.

A woman grieving at a traditional US military funeral.

https://www.politico.com/gallery/2014/08/funeral-for-u-s-army-maj-gen-harold-greene/001990-028297.html [18]
A practical example is the death of a member of the military. In the United States, we throw elaborate funerals for those who are killed in action, but when the US military kills a civilian, we look the other way. While we do treat the privileged with compassion and care, we ignore those who are not as valuable to our society. The act of grieving those who are close to us while ignoring the deaths of the oppressed appear to be unethical. Ethics of care states that beneficence and caring for relationships is imperative for human lives, but the US approach to grieving is ethically gray and does not follow this.

There are a variety of cross cultural grief rituals, and some would be considered unethical according to western moral standards, and the United States is not morally neutral in their process of grief. An example of a grieving process the west would deem unethical is the headhunting of the Ilongot tribe in the Philippines. Headhunting is the ritual of decapitating those who they kill. When members of the Ilongot tribe lose a loved one, they will go headhunting and kill other men as a way to process their rage, sadness, and anger. Anthropologist Renato Rosaldo lived with the tribe to understand their process of grief. At first he was dumbfounded by what seems such a heinous act, but as his time went on, he realized that as westerners, we cannot force other cultures to hold to our ethics on grief and death, and there is no universal consensus on the ethics of grief. He wrote, “This book argues that a sea change in cultural studies has eroded once-dominant conceptions of truth and objectivity. The truth of objectivism – absolute, universal, and timeless – has lost its monopoly status.” [19] Rosaldo found that no one can make a moral claim on another culture’s dealing with death in his time with the tribe, and that he had no objectivity over what his views on the ethics of grief were.

In conclusion, the ethics of grieving are morally gray. Not only for the United States and our process of selective grieving, but other cultures that commit what Western cultures would deem as unethical acts are also not in the right. Grieving will always be morally gray because grieving and many of the feelings that come from it are not logical, but they help humanity cope with loss and that should be enough. Dr. Randall Horton, a professor of medical humanities, writes about what all societies should agree on in regards to ethics of grief when he writes, “It is true that people grieve in their own way and their own time, but compassionate care, free from judgment, might help people reach acceptance of the reality of a world that often seems to lack moral order, fairness, and predictability.” [20]There is no one size fits all approach to grieving, and ethical questions come up no matter what culture one examines.

Even with the research from the scientific, cultural, and ethical angles compiled into this post, further research needs to be done in the field of mourning practices and reactions to grief to gain insight into how death affects the living, as well as the implications it poses for medical practitioners and patients.

In addition, when it comes to universal and cross-cultural models of grief there may not be a correct answer that will be able to generalize the majority population, as the vast amount of cultures provide many iterations of mourning and grieving practices. Furthermore, the act of grieving and mourning can be illogical and thus cast a fundamental moral gray ground onto models of grief.

Madelein Ngo

Jason Satterfield

Caroline Vincent

[1]”Grief Symptoms, Causes and Effects.” Psych Guides2019. Accessed April 07, 2019.       https://www.psychguides.com/guides/grief-symptoms-causes-and-effects/

[2] Saavedra Pérez, M. Ikram, N, Direk. H. Prigerson et al. “Cognition, Structural Brain Changes and Complicated Grief. A Population-Based Study.” Psychological Medicine45, no. 7 (05, 2015): 1389-1399. doi:http://dx.doi.org/10.1017/S0033291714002499. or http://libproxy.lib.unc.edu/login?url=https://search.proquest.com/docview/1672117893?accountid=14244.

[3] Peter J. Freed, Ted K. Yanagihara, Joy Hirsch, and John Mann. “Neural Mechanisms of Grief Regulation.” Biological Psychiatry66, no. 1 (2009): 33-40. doi:https://doi.org/10.1016/j.biopsych.2009.01.019. or http://www.sciencedirect.com/science/article/pii/S0006322309001000.

[4] Stephen Leybourne.“Emotionally Sustainable Change: Two Frameworks to Assist with Transition. International Journal of Strategic Change Management 7, no. 1 (2016): 23 doi:10.1504/IJSCM.2016.10000308. https://www.researchgate.net/publication/307949910_Emotionally_sustainable_change_two_frameworks_to_assist_with_transition.

[5] Margaret Stroebe, Henk Schut, and Kathrin Boerner. “Cautioning Health-Care Professionals.” OMEGA – Journal of Death and Dying74, no. 4 (2017): 455-73. doi:10.1177/0030222817691870. https://journals.sagepub.com/doi/10.1177/0030222817691870.

[6] “Understanding Death, Grief & Mourning.” Cleveland Clinic2008. Accessed April 07, 2019. https://my.clevelandclinic.org/ccf/media/Files/bereavement/understanding-death-grief-mourning-resources-manual.pdf?la=en

[7] Paul K. Maciejewski, Baohui Zhang, and Susan D. Block. “An Empirical Examination of the Stage Theory of Grief.” Jama297, no. 7 (2007): 716-23. doi:10.1001/jama.297.20.2200. https://jamanetwork.com/journals/jama/fullarticle/205661.

[8] Richard A. Friedman. “Grief, Depression, and the DSM-5.” The New England Journal of Medicine366, no. 20 (2012): 1855-1857. doi:http://dx.doi.org/10.1056/NEJMp1201794. https://www.nejm.org/doi/full/10.1056/NEJMp1201794?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

[9] Dennis Klass, “Developing a Cross-Cultural Model of Grief: The State of the Field.”OMEGA – Journal of Death and Dying 39, no. 3 (November 1, 1999): 155. doi:10.2190/bdtx-cye0-hl3u-nqqw. https://journals.sagepub.com/doi/pdf/10.2190/BDTX-CYE0-HL3U-NQQW

[10] Maurice Eisenbruch, “Cross-Cultural Aspects of Bereavement. II: Ethnic and Cultural Variations in the Development of Bereavement Practices.” Culture, Medicine and Psychiatry 8, no. 4 (December 1984): 325. doi:10.1007/bf00114661. https://www.ncbi.nlm.nih.gov/pubmed/6499505.

[11] Korina Giaxoglou, and Katrin Döveling. “Mediatization of Emotion on Social Media: Forms and Norms in Digital Mourning Practices.” Social Media Society 4, no. 1 (January 25, 2018):1. doi:10.1177/2056305117744393. https://journals.sagepub.com/doi/full/10.1177/2056305117744393.

[12] Anna J. M. Wagner, “Do Not Click “Like” When Somebody Has Died: The Role of Norms for Mourning Practices in Social Media.” Social Media Society 4, no. 1 (January 25, 2018):1. doi:10.1177/2056305117744392. https://journals.sagepub.com/doi/full/10.1177/2056305117744392.

[13] Teresa Millhouse, “Rest now my beloved. I love you more forever’: Wife of army trooper who died aged 36 from dementia caused by roadside bomb blast in Iraq posts loving tribute as hero is laid to rest,” Daily Mail.com,  (September 4, 2015). https://www.dailymail.co.uk/news/article-3222086/Rest-beloved-love-forever-Wife-army-trooper-died-aged-36-dementia-caused-roadside-bomb-blast-Iraq-posts-loving-tribute-hero.html

[14] Margaret Lock, “Contesting the Natural in Japan: Moral Dilemmas and Technologies of Dying.” Culture, Medicine and Psychiatry 19, no. 1 (March 19, 1995): 18. doi:10.1007/bf01388247. https://www.ncbi.nlm.nih.gov/pubmed/7671618.

[15] Ralph Rayback, “The Ways We Grieve.” Psychology Today. Accessed April 07, 2019. https://www.psychologytoday.com/us/blog/the-truisms-wellness/201702/the-ways-we-grieve

[16] Spargo, R. “The Ethics of Mourning.” The Ethics of Mourning | Johns Hopkins University Press Books. Accessed April 07, 2019. https://jhupbooks.press.jhu.edu/title/ethics-mourning.

[17] Chuckman, J. “America’s Culture of Grief and Dying.” Counter Punch. Accessed April 7, 2019. https://www.counterpunch.org/2002/02/03/america-s-culture-of-grief-and-dying/

[18] M, Mahaskey. Army 1st Lt. Matthew Greene comforts his mother, Dr. Susan Myers, as they prepare to bury Maj. Gen. Harold Greene at Arlington National Cemetery.,  2014. Politico, Arlington National Cemetery. Accessed April 07, 2019. https://www.politico.com/gallery/2014/08/funeral-for-u-s-army-maj-gen-harold-greene/001990-028297.html

[19] Mario D. Zamora and Renato Rosaldo. “Ilongot Headhunting 1883-1974.” Anthropological Quarterly 54, no. 3 (1981): 172. doi:10.2307/3317898. https://www.jstor.org/stable/i274755.

[20] Randal Horton,  “The Ethics of Grief.” Ethics Beyond Compliance. April 06, 2015. Accessed April 07, 2019.

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