4—
Ritual and The Death Certificate
Case Histories
Medical school is supposed to prepare you for your internship. During those four years you study, therefore, considerable amounts of biology, pathology, neurology and urology, gynecology, pharmacology, physiology and radiology, anatomy, surgery, biochemistry, psychiatry, orthopedics, genetics, pediatrics, and obstetrics. You are also taught a number of essential clinical skills. But you are never taught—at least I was never taught—how to pronounce a person dead. That does not really matter when you are a medical student because by law only a physician can pronounce a person dead. Interns (or other M.D.'s) thus are the ones who have to fill out death certificates. But then you become an intern.
An Obolus for Charon
My intemship began the last week of June 1977. Somehow I managed to survive my first week—and so did all of my patients. Then,
sometime during my second week, I was sleeping in the on-call room when I was awakened by the telephone at 2:00 or 3:00 A.M.
"Dr Peschel? Come to the medical floor immediately. We need you to pronounce someone dead."
When you are an intern and have been working for some thirty hours with no sleep, or barely any, you find it disheartening to be awakened to tend to any patient. But how much more disheartening it is to be startled out of your slumber to pronounce a patient dead.
The hospital routine for handling a death is this: as soon as a patient is discovered dead, he must be pronounced dead so that his body can be sent down to the morgue. The morgue will not—legally, cannot—accept a corpse until a doctor has pronounced it dead and has signed the death certificate. Sometimes, of course, the physician has seen a patient die, but often he has not since deaths occur in different ways on the different floors or units of the hospital. In private rooms or in rooms of two, three, or four beds, patients are neither monitored nor observed constantly. Thus, if it is late at night, when there are no visitors or routine hospital personnel around, a patient on one of the regular medical floors may die quietly, alone, and unobserved. In fact, his death may not be discovered until minutes or hours after it has occurred. Then, a nurse making rounds to take her patients' vital signs may find him. If it is clear that the patient has been dead for some time or if it had been decided by the patient, his family, and physicians not to attempt any heroic measures, no one will try to resuscitate him. Often, therefore, when an intern is summoned to the regular medical floor to pronounce a patient dead, he is not being asked to do something to help the patient. All he is being asked to do is pronounce the patient dead.
It is not a great role for the physician.
It was 2:00 or 3:00 A.M., then, when I was summoned to the medical floor to testify to my first death and fill out my first death certificate. Trying to clear my thoughts, I suddenly realized that during all my years of medical school there had never been any sort of formal discussion about how you are supposed to pronounce a person dead. Were there any rules, any required procedures? I tried to think. But all that came to mind was that from a medical, legal, and even religious point of view, what I was being called on to do was a highly significant act. From the legal viewpoint, this was probably the most important thing that happened
in life—except, perhaps, for birth. And yet I, who had to officiate, did not have the slightest idea what specific, formal, or legal acts I was expected to perform. When I reached the medical floor, I had to ask the nurses on duty what I was supposed to do. They gave me instructions, in a general way.
I went into the patient's room. Because the body was very cold, it was clear to me that this man had been dead for some time. Coldness is, in fact, one of the best ways of determining if a person is dead. That this man was dead, I had no doubt. Still, just to be formal, I slipped my stethoscope into my ears and listened for a heartbeat. Next, I listened for some sounds of breathing. After that, I stood around for a while so it would appear that I had spent a respectable amount of time determining that the patient was dead.
When I emerged, I had to ask the nurses what to do next. They handed me the death certificate. At that point, it struck me more deeply than before that this was one of the most monumental events in life: the final rite de passage. And although I could see that everyone dealt respectfully with the dead body, I knew that the highest priority, for the nurses at any rate, was to get the body off the unit and down to the morgue. I also realized, with some guilt, that that was my priority as well, although for a different reason (I wanted to get back to bed). Thus, I saw that except in very unusual cases (e.g., a death that is unexpected or cannot be explained easily), there is very little reflection about a human life having just ended. Sitting there, holding that first death certificate in my hand, I felt somehow disappointed in the whole thing.
I took out my blue pen and started to fill out the death certificate. Since this was my first and the form is rather long, it took me some time to finish it. It was especially difficult because this patient had been admitted by another intern, and I knew his medical history only vaguely. The medical information I needed could be gleaned from his chart. But there were many other questions I could not possibly have answered. Had the deceased ever served in the armed forces? What were the names of his parents? In response to these questions and others I had to write "unknown."
As I filled out the death certificate, I thought about what an important legal document it was. After all, once it was signed the body could be laid to rest, and, potentially, the transfer of tremendous sums of money, property, and titles could begin. For a moment I felt awed by my role.
Two questions troubled me: cause of death and contributory causes. You would not think these would pose a problem for a physician, but they do. Of course, the cause of death is always attributed to the fact that the patient's heart stopped or he ceased breathing or some such elementary explanation. But when you really think about it, the cause of death is a curious question because there might be all sorts of actual causes and contributory causes: a possible drinking problem, smoking, poor medical care, lack of medical care or too much medical care, perhaps a nagging wife. Who knows? The real possible causes are endless.
Years ago, before the World Health Organization established strict rules for filling out death certificates, some physicians answered these questions quite colorfully. One old certificate read, "'Cause of death: blow on the head with an ax. Contributory cause: another man's wife.'" Now, however, the "'blow on the head with an ax' . . . would be certified as 'skull fracture with laceration of brain' . . . and as 'homicide."[1] How much less revealing! Or consider what another old-time doctor wrote in response to the question about the cause of death of a person who had died suddenly: "Don't know. Died without the aid of a physician."[2]
When I finally finished filling out the death certificate, I handed it to the ward secretary and began thinking about getting back to sleep. But the secretary scowled at me. "You can't use your own pen," she said. "You have to use the Brady Pen." (Brady was the name of the morgue.) Then and there, I was introduced to the Brady, or Death, Pen: a special pen with black indelible ink which was always set aside in a special place and used for filling out death certificates.
Instead of feeling angry, I actually felt relieved. Until the moment I learned about the Death Pen, filling out the death certificate had seemed like filling out just one more form—as an intern you fill out scores of forms every day. Now, this form would be decidedly, indelibly different. As the months passed and I filled out more death certificates, I began to discern in the Death Pen a wonderful symbolism. Just because that pen was obligatory and set apart, it became in my eyes an object that could guarantee, upon every signing of every death certificate, something of the solemnity and sanctity of a ritual. Such a ritual is, at a time like that, at once calming, soothing, and healing.
I do not know if the nurses sensed the symbolic significance of that pen, that it linked, in a way, the physical with the tran-
scendent. They did know, however, that the morgue would not accept a corpse unless the death certificate had been filled out correctly: with that pen . And so they made sure each time that the proper ritual was carried out.
Eventually I developed a routine, very formal and very ritualistic, for pronouncing a patient dead. I would spend a certain amount of time listening for a heartbeat and breath sounds, then I would move to the death certificate. Somehow, however it was always the use of the Death Pen that gave the entire procedure added meaning and moment.
As soon as a death certificate was completed, an attendant was called to take the body to the morgue. But he would absolutely refuse to accept a body unless it could present its proper coin of passage: the death certificate filled out with the Death Pen. Once the attendant had received that—like Charon receiving his obolus —he would ferry the body from the land of the living to the land of the dead. Only in that way could a corpse gain entrance to the Underworld of our hospital, the morgue.
Halloween
Over the next three years, I completed numerous death certificates and grew comfortable with my ritual. But one time I could not perform it, and the memory of that breach stays with me still.
For several months I had been treating Mr. Q, a sixty-fouryear-old laborer, for a very advanced cancer of the tongue. He had done well for a while after his radiation treatments but then had begun to deteriorate rapidly. We admitted him to the hospital to give him nutritional support. Further tests revealed that his cancer had metastasized to his bones and lungs.
When we had done everything we could in the hospital, Mr. Q said that he wanted to leave. He knew he was dying, and he wanted to die in his own home. Because his wife also wanted that, we discharged him. Every day a visiting nurse went to Mr. Q's house to make sure he had enough pain medication. From time to time I also went there to see how he was doing and if he needed anything.
The sickbed was in the living room. Mrs. Q had made the couch into a bed so that her husband would not have to climb the stairs.
On one of my visits it was clear to me that Mr. Q would not live much longer. I told Mrs. Q, and she asked me what she would
have to do when her husband died. She said she did not want to have to take his body to the hospital just so that a doctor could pronounce him dead. Because I knew Mr. Q very well and knew what his wishes were, I said I would go to his home to pronounce him dead, whenever he died.
On the morning of October 31, Mrs. Q called me at the hospital to say that her husband was doing very badly I promised I would stop by on my way home. When I arrived, I saw that it was just a matter of hours. I told Mrs. Q to call me when the time came.
That night, colorfully clad trick-or-treaters streamed to our house. Every time I opened the door, cold winds, along with greedy little goblins, ghosts, and ghouls, rushed in. Amid all that merriment, mischief, and mystery, the telephone rang. It was Mrs. Q. Mr. Q had just died.
I got into my car quickly and drove to Mr. Q's house. Although it was dark outside, here and there streetlights and lights from houses illuminated straggling processions of trick-or-treaters making their rounds. Mr. Q was stretched out on the sofa, and like the masquerading goblins I had just seen outside, he too wore a sheet over his head.
I pronounced him dead in his living room. I quickly took out the death certificate because I was actually looking forward to the calming, healing effect of my little ritual. Suddenly, however, I realized that I did not have the proper pen with me. I had no choice then but to fill out Mr. Q's death certificate with my own pen. Luckily, it had black ink. But was it indelible?
I felt almost guilty as I filled out the form. for aside from my very first death certificate—the one I had filled out with my blueinked pen and then had had to discard immediately—Mr Q's death certificate was the only one I had ever filled out with anything but the Death Pen. Did Mrs. Q notice? I do not think so, because she called the undertakers as soon as I had finished and they accepted the corpse without hesitation. (Of course, I did not tell them what I had done.)
Now, when Halloween comes, I find myself thinking about that night. In fact, I have always felt there is something unfinished about that death certificate, something as yet unsettled, some loose end dangling.
Anthropology and Ritual
Why did the doctor find so much comfort in his little ritual? And why did he still feel disturbed because he had failed to perform it one time? Anthropology offers some insights into the role of ritual in primitive cultures—and our own.
Anthropologists frequently write about the anxiety-reducing effects of ritual for a primitive people and, by extension, for ourselves. "There is . . . evidence from our own society that when ritual tradition is weak, men will invent ritual when they feel anxiety," wrote George C. Homans.[3]
The origin of the word is illuminating. Related to "rite" and to the Latin ritus (a religious custom, usage, ceremony, or rite), ritual is a formal system of solemn acts, religious or otherwise, established by rule or by custom. Because it is formalized as well as solemn and/or sacred, ritual symbolically links man with something beyond himself: with other men or times or with certain ideas or with the transcendent. Ritual is probably understood best in terms of what anthropologists call the "symbolic principle."
Those realms of behavior and of experience which man finds beyond rational and technological control he feels are capable of manipulation through symbols. Both myth and ritual are symbolical procedures. . . . [While] myth is a system of word symbols,. . . ritual is a system of object and act symbols. Both are symbolic processes for dealing with the same type of situation in the same affective mode.[4]
Ritual seeks to manipulate and therefore to protect a person from what is threatening or unknown. In other words, ritual is a powerful defense against what cannot be seen, controlled, or foretold.
Because rituals are repeated, they make certain behavior and events predictable and expectable. In that way, they seem to protect one: they grant to the person practicing them a sense of security, familiarity, and control. Like myths, rituals "supply . . . fixed points in a world of
bewildering change and disappointment," wrote Clyde Kluckhohn.
People can count upon the repetitive nature of the phenomena. For example, in Zuni society (where rituals are highly calendrical), a man whose wife has left him or whose crops have been ruined by a torrential downpour can yet look forward to the Shalako ceremonial as something which is fixed and immutable. Similarly, the personal sorrow of the devout Christian is in some measure mitigated by anticipation of the great feast of Christmas and Easter.[5]
Besides offering the reward of repetition, ritual defends against anxiety in at least two other ways: it gives a person something to do , and it eliminates the dilemma of thought or choice. Not only does ritual tell a person what he should do, how he should do it, and when, but also tells him that it is the right thing to do; to perform the ritual is right, not to perform it is wrong.
But a problem arises here. Since not performing a ritual is regarded as "wrong," it is clear that anxiety is produced when a ritual is not performed or is not performed properly. Literature offers insights into the anxiety-reducing—and/or anxiety-producing—aspects of ritual.
Literary Parallels
The ritual of prayer can, of course, be powerful, calming, and healing. "To Mercy, Pity, Peace, and Love, / All pray in their distress; / And to these virtues of delight / Return their thankfulness," intoned William Blake in his Songs of Innocence .[6] "You pray in your distress and in your need. . . . / And . . . it is for your comfort," wrote the Lebanese mystic poet and artist Kahlil Gibran.[7] At times—as in John Donne's Devotions upon Emergent Occasions (1624)—literature actually demonstrates the soothing power of prayer in action.
John Donne
In late November 1623, Donne (1573–1631); who was Dean of St. Paul's (London) and already famous for his poems and sermons, fell gravely ill with what modern specialists have diagnosed as relapsing fever.[8] During his illness and convalescence, he wrote his Devotions , those impassioned outpourings about body and soul, sin and sickness, fear and hope, man and God, death and Eternal Life. The book contains twenty-three chapters, which Donne called "The Stations of the Sickness," an evident reference to the Stations of the Cross. Just as those pictorial representations of Jesus' sufferings are offered as objects for meditation and prayer, so are Donne's sufferings.
Each chapter has three parts: a "Meditation" on the human condition, an "Expostulation to God," and a "Prayer." In what has become the most famous Meditation (it inspired Hemingway's title For Whom the Bell Tolls ), Donne found that a bell tolling for another person became for him a memento mori, warning him, with its sad and funereal sound, "Thou must die."
No man is an island, entire of itself; every man is a piece of the continent, a part of the main. . . . [A]ny man's death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.[9]
The Prayer following this Meditation is at once an expression of anguish and a realization and illustration of the soothing power of the ritual itself. In it, Donne both vents and negates his anxiety. He depicts death as the price men must pay for original sin, and he portrays himself as a sick man and a sinner. Yet he says he "cannot be afraid." In fact, Donne believes that because of his prayer, his contrition for his sins, and his submission to God's will, he has received God's pardon. Therefore, unburdened and reassured, he is able to reach out and pray for the soul of the man for whom the bell was tolling.
PRAYER
O Eternal and most gracious God, . . I humbly accept thy voice in the sound of this sad and funeral bell. . . . As death is the wages of sin it is due to me; as death is the end of sickness it belongs to me; and though so disobedient a servant as I may be afraid to die, yet to so merciful a master as thou I cannot be afraid to come; and therefore into thy hands, 0 my God, I commend my spirit. . . . And being thus, 0 my God, prepared by thy correction, mellowed by thy chastisement, and conformed to thy will by thy Spirit, having received thy pardon for my soul, . . I am bold, 0 Lord, to bend my prayers to thee for this assistance, the voice of whose bell hath called me to this devotion.[10]
Donne's ritual of prayer has carried him from an expression of personal fear to expansive feelings of relief, confidence, compassion, and love. His Meditation and Prayer are dramatic examples of the healing power of a ritual in action.
But what if a ritual is not performed or is not performed properly? Another poem by Donne, "Holy Sonnet XIX," illustrates how the poet feels anxiety because he has not been constant in prayer. This poem is particularly interesting for two reasons: it describes emotional and spiritual distress in terms of physical illness, and it contains two expressions related to seventeenth-century medicine. "Humorous" (line 5), derived from the old physiological notion of the four bodily humors, means changeable; "ague" (line 13) is the archaic term for malarial fever.
Donne conveys his anxiety in this poem by lamenting that to "vex" (i.e., trouble) him, his inconstancy in prayer has become a habit. Even his contrition, he says, is as "humorous" and as soon forgotten as his worldly loves: he is no more faithful to God than he is to women or to any earthly thing. To illustrate his infidelity, the poet says that a day ago he dared not look at heaven, but today he offers prayers and even tries to flatter God, and tomorrow he will quake with fear that God will punish him. Finally, he compares his sudden bursts of prayer—his "devout fits," as he
disparagingly calls them—to a "fantastic [i.e., capricious] ague."
Oh, to vex me, contraries meet in one:
Inconstancy unnaturally hath begot
A constant habit; that when I would not
I change in vows, and in devotion.
As humorous is my contrition
As my profane love, and as soon forgot:
I durst not view heaven yesterday; and today
In prayers, and flattering speeches I court God:
Tomorrow I quake with true fear of his rod.
So my devout fits come and go away
Like a fantastic ague: save that here
Those are my best days, when I shake with fear.[11]
The only difference, Donne says, between his anxiety-induced ague and a genuine malarial fever is that with malaria the worst days are those on which one shakes with fever, whereas for him the best days are those on which he shakes "with fear" of God's wrath. For on those days he thinks wholly and contritely about God and prayer, which he has neglected.
Reflections
Anthropology helps to explain the symbolic nature of ritual. Because anthropologists have shown that rituals exist in all cultures everywhere, both literate and nonliterate, they have been able to point out that the fundamental purpose of ritual is similar everywhere: to dispel anxiety in the face of what is unnerving, threatening, or unknown. In literature, for example, in the words of Blake, Gibran, and Donne, we hear—and feel—the anxiety-reducing and/or anxiety-producing powers of ritual. These powers can be seen in the doctor's ritual of the Death Pen. Faced with the need not only to see but also to palpate and certify to man's inevi-
table fate, that doctor could look forward to his ritual as the devout believer might look forward to a prayer: something that is above and beyond the universe of death and disintegration, something that is always right and always there.
Yet that nagging problem remains. What about the guilt and anxiety generated when a ritual is not performed or is not performed properly? When a ritual is not performed, the "anxiety . . . has been displaced from the original situation."[12] Thus, in the case of Mr. Q, the doctor was anxious not so much because of what occasioned his ritual in the first place—the corpse or death itself—but because he had failed to perform the ritual associated with that death. And Donne experienced a malariallike malaise not because of any physical disease but because he felt he had been delinquent in his devotion to prayer.
Can one allay this anxiety? According to Homans, this kind of "secondary or displaced anxiety" can be alleviated by what he calls a "secondary ritual" —a "ritual of purification and expiation."[13] Donne's guilt-ridden sonnet, in which he seeks atonement through suffering, is such a ritual. Perhaps, too, by this act of writing and telling, the doctor who found relief in the ritual of the death certificate is performing a ritual of purification and expiation, that is, a kind of confession and a quest for healing. And is not the quest for healing—of the patient but also, in a sense, of the physician—at the heart of the art of medicine?