STAGES OF DYING?

Gabriel Moran

Kubler-Ross is famous for elaborating five stages of dying - denial, anger, bargaining, depression, acceptance. She did not provide a scientific argument for this pattern, despite the fact of using the language of developmental stage theory. Each chapter simply recounts conversations with the dying which she interprets and classifies. At the least, one would have expected a few cases discussed longitudinally, that is, one person exemplifying all five stages, but the book reports no such cases. The names of the five stages are borrowed from ordinary speech, each of the terms having a wide range of ambiguity.

When the theory has been challenged by critics, Kubler-Ross and her defenders have been quick to admit that variations in the scheme are possible. The defenders grant that one or more stages can be omitted or that the stages may overlap or that the order of stages may be different or that a patient may regress. If one has enunciated a pattern and then admits innumerable qualifications, at some point there simply is no pattern.

Over the years I have come to understand Kubler-Ross=s pattern in a way that not only saves some of its meaning but can suggest a greater significance than it is usually thought to have. Her stages may seem to be a case of Adevelopmental theory@ with pretensions to scientific objectivity. But parallel to what I said in a previous chapter about Areligious development,@ Kubler-Ross=s stages are not just one more dimension of development. Instead, they challenge the modern idea of development itself. Not surprisingly, what Kubler-Ross found in listening to the dying bears a much closer relation to medieval mystical journeys than to social science theories in the modern age.

Modern developmental theory began as a protest against a closed world; it claims to maintain openness and to let loose creativity. As a theory of human history or economic progress, development may be sustainable in the face of ambiguous data. But what about the individual person? Does the certainty of a wonderful economy in the distant future keep the life of today=s individual Aopen@?

Most works in psychology talk glowingly about the future and the need to grow, to be creative, to be open to new experiences. Not far below the surface, however, every person knows that the future holds only one certainty: I die. Ernst Bloch put it bluntly: AThe axe of annihilation is the most stringent of non-utopias.@ William James put it more imaginatively: Athe skull will grin at the banquet.@

The simple fact of dying is what Kubler-Ross placed on the table before psychology which seldom speaks candidly of death. Freud=s attempt to introduce a Adeath drive@ into his psychology was largely unsuccessful. I think that theories of development are like instructions on how to get to the roof of a high rise building; what they fail to note is that when you get there you get pushed off the roof. With all the wizardry of modern medicine, the death rate is still one hundred percent.

Kubler-Ross=s stages make sense both as stages of dying and stages of living, or better, as stages of living that include dying. What she found from interviewing a few hundred people in a modern hospital is that people keep struggling near the end of life to find some sense in their lives. She also found that most people, given some help, do come to a peaceful resolution about their imminent deaths, that is, about a life that now includes dying. Religions have always been concerned about what is in a person=s mind at the moment of death. And even a secular audience can respond to the efforts of a Helen Prejean trying to get a condemned prisoner to die with an attitude of love and repentance.

The Afive stages@ of dying do admit of great variation but there is nonetheless a definite pattern at stake. Practically everyone begins by denying that death is imminent. This is a healthy reaction which sustains a person=s resistance. The alternative is to collapse on the spot and give up all fight.

In her chapter on denial, Kubler-Ross says that denial is usually replaced by Apartial acceptance.@ What happened to the in-between stages? And is not acceptance something you either have or do not have? What I think her words suggest is that the whole of life is a dialectic of denial/acceptance. Total denial of death would exclude acceptance of life as well as death; total acceptance of death means that the person is leaving the land of the living. Thus, in the ordinary course of life, there is partial denial/partial acceptance.

Strong denial at the diagnosis that one is terminally ill is followed by a series of Astages@ in which emphasis on denial or acceptance varies. The direction is not necessarily in a straight line; it would be surprising if it were. Rather, there is a circling movement that includes not only present possibilities but past actualities. Eventually this circling back through the past reaches the beginning of life. In this way, birth and death (rebirth) tend to converge. Each stage of this movement can be given a name, such as anger, bargaining and depression; or hope, submission, resistance, resentment, rebellion, resignation, and so forth.

There can be an indefinite number of such stages but I think that (as in most mystical writing) there is always an odd number of stages. A series that splits evenly between yes and no is followed by a conclusion that is a yes inclusive of no. What can be called a last stage is actually an attitude underlying the stages and eventually embracing all of them. The first no to death (which is a yes to life) is followed by a yes to death (which is a no to life). It is in this way that anger follows denial or that depression follows bargaining. A similar pattern of yes and no can be repeated any number of times until a crucial degree of acceptance of one=s entire life has been reached.

Reaching the final condition of acceptance is clearly what Kubler-Ross advocates. She wants patients to reach this stage and says that a majority of her patients do. In calling this stage Aacceptance,@ I think she chooses the right term ; it is a word connoting an attitude of receptiveness to reality. Freedom is present in acceptance not as a choice among alternatives but in the deeper freedom to say yes or no to what life offers.

Acceptance is what human beings practice every day until the moment when death is near and they must accept that Athis is the whole of my life, this is who I am and have been.@ If the fact of death were the only thing at issue, we would speak of acknowledgment or recognition of a fact rather than acceptance; we do not accept the fact of death, we accept our life including the fact of our own dying.

Kubler-Ross chose the right word but I think that she failed to provide an adequate description. More important, her description carries a bias that made her vulnerable to criticism. While her intention was to humanize death, to insist on the need for a caring community that would surround the dying person, her description of acceptance as the need to be left alone can be read as inviting isolation, of leaving the dying person to his or her solitariness.

I think she was unwittingly led into this description because of an assumed choice between the mechanizing and medicalizing of death over against its biological naturalness. A community context gets lost in that contrast. The assumed choice between a natural death and a dehumanized death is unfortunately becoming the common way to look at death.