A person who has been important in the field of Medical Anthropology is Sharon Kaufman. I had the pleasure of meeting her a few years ago at a workshop in Brussels, organised by some of my dear anthropology friends. We all had written and circulated papers beforehand and we spent two days discussing each other’s work and ideas. My kind of nerd-heaven. I remember Kaufman as a kind and generous person, and I was, and still am, envious of the way she was able to conduct long-term ethnography, something that becomes increasingly rare these days.
One of the reasons I am writing about her work at this point in time, is that it marks the one-year anniversary of Kaufman’s death. Kaufman died April 2022 aged 73, after a recent cancer diagnosis. I hope that, despite her physical death, Kaufman’s ideas will continue to live on, inspire and influence future generations of medical anthropologists. Kaufman was one of the people high on my list to interview for the Death Studies Podcast, but sadly death threw a spanner in the works. Dying is a natural phenomenon. Even great anthropologists can’t escape it.
Despite some people aspiring radical longevity, to date no one has found an answer to stop death. If you are interested in people who believe in and work towards immortality, a recent episode of the Death Studies Podcast featuring Jeremy Cohen from Talk Death might be of interest:
But while people have not yet found the answer to eternal live, there is a quest to extend and stretch out life beyond its current limits.
How societies deal with death and dying is not ‘natural’, but shaped by social norms and ideas. Where we are born and where we are raised has an impact on how we view death. Developments in medical technologies and understandings of what constitutes death, which has changed from being heart-focused to being brain-focused, have altered people’s attitudes towards death, as well as turned the entire notion of death on its head. As Lyn Lofland suggested in The Craft of Dying (1978, page 20)
“Between admission to the category dying and extinction, more and more persons are confronting -and doing so consciously- not minutes, or hours or days but weeks or months or even years”
In other words; dying can take a long time. I am not sure if Kaufman was familiar with Lofland’s work -there is no citation to it in the book we will discuss today- but I like to see …And a Time to Die: How American Hospitals Shape the end of life (2005) as a strong empirical account that exemplifies the prolonged dying that Lofland alludes to.
… A Time to Die explores how the face of death has changed in hospitals in the United States. The book is based on ethnographic fieldwork carried out in 1997 and between 1999-2000. While it has been 18 years since Kaufman published this book, many of the arguments still hold truth today. Indeed, much of what Kaufman wrote about hospital dying has exacerbated with the furthering of medical enhancements and the invention of new medical technology aiming to keep people alive for as long as possible.
“Instead of death, the hospital opens up an indefinite period of waiting during which patients do not cross that threshold until it is decided when it is time for them to die”
— …And a Time to Die (Kaufman, 2005 page 4)
Kaufman further develops her ideas in her book Ordinary Medicine: Extraordinary treatments, longer lives, and where to draw the line (2015). In this book she unpacks how ICDs, (implantable cardiac defibrillators) have become an ‘ordinary’ intervention implanted in many older people, with drastic effects on the dying process and experience. I might return to this book on a later day, but for now we will focus predominantly on her book …And a Time to Die.
Kaufman notes that the way people die in hospital is not inevitable and, importantly, despite popular opinion to the contrary, it is not always bad. But there is a lot of room for improvement, as American hospitals increasingly position death as a ‘problem’.
“Death today is medically and politically malleable and open to endless negotiation. This means that death can be timed, and timing has become the crux of the matter. While the primary task of medicine is to deny death, everybody knows that, ultimately, death cannot be denied”
— …And a Time to Die (Kaufman, 2005 page 3)
…And a Time to Die explores hospital deaths and hospital culture; how do nurses, doctors, patients and their families make sense of death and dying in this environment? How do their ideas of ‘good deaths’ differ or overlap? Kaufman suggests that all cultures contain contradictions, and hospital culture is no exception. Firstly, though patient autonomy and patient choice are important frontrunners in American medicine, medical professionals have great influence and power shaping the ‘choices’ patients and their families might face towards the end of life.
“Scenarios in which families are offered choice about the goals of medical treatment when death is near reveal the dark side of autonomy- full of anguish, guilt and above all the absence of knowledge about medical outcomes”
— …And A Time To Die (Kaufman, 2005 page 28)
Life choices are always difficult, but as people are living and dying for the first time, it is particularly difficult for patients to figure out what types of treatment they would want. Or not. Would you want ‘heroic’ measures, and if yes, what would that look like?
Despite death luring around the corner, Kaufman notes that the topic is rarely discussed or mentioned by medical professionals until shortly before death. There is also often a tension between curative and palliative care, two forms of care that co-exist but can clash in their potential outcomes and ethos. Lastly, Kaufman notes that ‘hospitals are not structured for the kinds of deaths that people claim to want’ (p. 29). She goes even further to say: ‘Simply put, at this point in history, dying people are not wanted in medical institutions, and it shows’ (p. 29). The cost-driven attitude towards care in American hospitals has caused the dying to be viewed as an unprofitable patient group that is often shipped out to other places.
…A Time to Die tells the stories of patients, their families and medical professionals and how they navigate the timing of death. Medical professionals are trained to keep people alive, and this prolongation can be supported by family members, who would like for their loved ones to live for as long as possible. Hospitals are able to let patients linger in a grey area between life and death. Nurses and doctors are in a bind between providing invasive medical treatment and means to reduce suffering. Knowing when to stop treatment, or when to do ‘nothing’ is difficult, for all parties involved.
…And a Time to Die will be of interested to anyone interested in the blurry boundaries between life and death. It offers lots of food for thought about how socio-cultural and medical environments shape the end of life. Kaufman shows how death is made and unmade in hospital environments, how patients try to get a version of a so-called ‘good death’ and how conflicting ideas around life and death move together inside these places. The bureaucracy of hospitals has great power over the types of death that occur inside American hospitals, and …And a Time to Die offers readers a critical lens to think through these issues.
‘Medical technology’ and ‘medical advancements’ are often mentioned as vectors that shape attitudes towards death and dying. However, this is phrase is painting with a broad brush and ignores the nuances and specific medical advancements that have occurred in particular decades and eras. As can be read in The Butchering Art, the surgeon Joseph Lister had a tremendous effect on medicine in the mid-1800s. In Mr Humble and Dr Butcher, Brandy Schillace explores how the development of the notion of brain death again caused practices to change in the 1970s. …And a Time to Die, similarly provides a time-capsule and explore the developments that occurred in the late 90s and early 00s. As developments are continuously occurring, with increasingly rapid frequency, these types of ethnographies and medical history books are important detailed accounts that capture socio-historical moments in time that consciously or unconsciously shape and change the face of death.
…And A Time to Die is published by the University of Chicago Press and you can order it directly from the publisher’s here. You can read an obituary written for Sharon Kaufman here.
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