Cultural Issues in Death and Dying Kathryn L. Braun DrPH*, Rhea Nichols MSW Although all of us experience death, not all of us think about death show generational differences in response to death, with issei (first or respond to death the same way. This study begins to explore how generation) respondents more likely to practice customs and tradi cultural traditions, education, and tenure in Hawaii impact views of tions of Japan compared to sansei (third generation) and yonsei organ suicide, and euthanasia. This 4-5 Students of traditional Chinese culture have advanced directives, donation, (fourth generation). information is useful to physicians who need to engage patients and reported that Chinese are often hesitant to talk about death, as this families in discussions about death and end-of-life decision making. 6 describe the importance of is considered bad luck. Other reports funeral rituals in Chinese culture, from determining the right day of Introduction burial, to burning paper money to send with the deceased on his/her will, experience death. But not all people 6-7 If a person is buried without strict adherence to proper All people have, and journey. our 8 The view death or respond to death in the same way. As we increase funeral rites, a hungry ghost may return to plague the living. life expectancy’ and our ability to prolong life artificially, issues carrying-out of traditional death rituals is considered the most surrounding death and dying become more controversial. How do important act of filial piety among Vietnamese, from the rite of different cultures look at death? What factors, besides culture, feeding the deceased to the rite of reburial, where bones of the impact one’s perceptions of issues like advanced directives, organ deceased are collected, washed and preserved in a sacred jar for These questions were asked in a 9 Ancestor worship is also important, and many Vietnam donation, suicide, euthanasia? reburial. among five Asian 9’° Very little literature qualitative study of death and dying in Honolulu ese Americans tend ancestral altars at home. and Pacific Islander (API) groups—Chinese, Filipinos, Japanese, appears about Filipino Americans. Several cross-cultural studies of Native Hawaiians, and Vietnamese. suicide, however, suggest that suicide rates among Chinese, Japa Expanding knowledge of cultural issues in death and dying is nese, Filipino, and Vietnamese Americans are lower than suicide important for two major reasons. First, as health care professionals, rates of Caucasian Americans and lower than those of their compa differences if we hope to 12 we need to understand and respect cultural triots at home.’’- provide care that is relevant and acceptable to our clients. Second, In summary, while some information is available about traditional as educators, we need to encourage individuals to share their death rituals, literature on how these traditions are practiced in the differences with each other as our society develops policies and U.S. and on views of suicide, euthanasia, advanced directives, and social structures related to end-of-life decision making. This is organ donation is limited. This study begins to fill the gap by especially crucial given the recent decisions by the 2nd and 9th presenting information from interviews on death and dying prac Circuit Courts supporting the right to physician-assisted suicide. tices with five Asian American and Pacific Islander groups in Although the Supreme Court has issued a stay on these decisions, Hawaii—Chinese, Filipinos, Japanese, Native Hawaiians, and Viet many feel it is only2-3a matter of time before assisted dying is legalized namese. in the United States. Method Literature Review Data were gathered from July 1995 to February 1996 through in- Literature and educational materials on cultural-specific responses depth interviews with individuals of Chinese, Filipino, Japanese, to death and dying among API Americans are scarce. Even where Native Hawaiian, and Vietnamese descent. From each of the ethnic literature exists, it most often focuses on Japanese Americans and groups studied, two key informants (a religious leader and a bilin gual health/social service professional) and five to eight focus group participants were interviewed. Key informants were selected be cause of their level of knowledge about their community’s practices in this area; they were generally older adults who were well educated, bilingual, and respected by their communities as experts. Focus group members were identified by key informants and were affiliated with the religious and/or social service groups represented by the key informants. Because focus group members in the Chi nese, Filipino, and Vietnamese groups were first-generation immi grants to the U.S., many were interviewed with the assistance of Address repdnt requests to: bilingual students. * Kathryn L. Braun, DrPH The study’s interview questions explored six broad areas includ Associate Professor of Public Health and Director ing: 1) the underlying philosophy/religion influencing death and Center on Aging dying in the culture; 2) burial, memorial services, and bereavement; University of Hawaii dona 1960 East-West Road 3) suicide and euthanasia; 4) advanced directives and organ Honolulu, HI 96822 tion; 5) how beliefs/practices have changed over time; and 6) advice (808) 956-5768 for health care professionals working with dying patients from the Fax (808) 956-9582 email [email protected] culture. Transcripts of the interviews were analyzed for common HAWAII MEDICALJOURNAL, VOL 55, DECEMBER 1996 260 and differentiating themes. An initial draft of the summary of 1965, Filipino immigration accelerated and, in 1990, Filipinos findings for each group was sent to one or more of the key comprised about 15% of the state’s population.’4’ 19-20 informants, who were asked to provide corrections and/or to vali The Vietnamese are among our most recent immigrant groups, date that the information contained therein was accurate to the best first arriving in the U.S. after the fall of Saigon to the Vietnamese of their knowledge. Communists in 1975. A second group, called “boat people,” are The study identified a number of differences among and within those who fled Communist rule on foot or boat, often spending time the ethnic groups, a full description of which is provided else in refugee camps before relocation. Established in the early 1980s, 3 information the study that Departure where.’ The current paper presents from Vietnam’s Orderly Program allowed controlled immi is relevant to the more controversial aspects of death and dying— gration directly from Vietnam for political prisoners, Amer-Asians, advanced directives (e.g., will, living wills, and documents giving and those whose family members were already U.S. citizens. The power of attorney for health care decisions), organ donation, sui 1990 Census estimated the Vietnamese population in the U.S. at cide, and euthanasia (e.g., withholding treatment, withdrawing 614,547, a 134% increase4’2over 1980. Vietnamese comprise less treatment, and aiding death). than 1% of the Hawaii’s population.’ Findings Traditional Beliefs about Death Historical Background of the Five Ethnic Groups Native Hawaiian beliefs about death and dying are influenced by The Native Hawaiian people (orkanaka maoli) are indigenous to both Native Hawaiian traditions and Christianity. A focus group the islands of Hawaii, establishing their arrival as early as 100 A.D. member explained that death is accepted as a part of life by most They are of Polynesian extraction, sharing a common ancestry with Native Hawaiians, who see an “openness” between this life and the the indigenous people across the South Pacific. Following contact next. For example, a participant explained that when we complete with the West, the native population was reduced drastically as our tasks on earth, it is time to die and “move on to the next realm.” Native Hawaiians contracted and died from newly imported infec Others believed that, upon death, people are reunited with loved tious diseases. This loss of cheap labor led to the “importation” of ones who have died before. We heard several stories about commu labor from Asia and this, in turn, helped contribute to the erosion of nication between realms, e.g., either dreaming about or seeing signs Native Hawaiian traditions and customs. Since the 1960s, the state about the deceased. We also heard that touching a dead body may has seen an increased appreciation of Hawaiian heritage and a make you sick, as the dead body is “empty and can take the living resurgence of the traditional language and cultural traditions. In person’s mana.” 1990, Native Hawaiians comprised about 19 percent of the state’s Chinese participants reported that their traditions are influenced population.’4”5 by three religions—Confucianism, Taoism, and Buddhism. In Con The Chinese were the first of the Asian groups to immigrate to fucianism, it is believed that the body should be preserved in order Hawaii in significant numbers, arriving in the mid-to-late-I 800s to to respect one’s parents, and that ancestor worship is very important. work on sugar plantations. Fears about loss ofjobs for Caucasians In Taoism, longevity is emphasized and stimulates discussions stimulated a series of laws that substantially reduced Chinese about the right foods to eat in order to maintain health and obtain immigration, including the Chinese Exclusion Act of 1882 and the long life. The Buddhist religion teaches that one must be good in the Oriental Exclusion Act of 1924. Immigration restrictions began to present life in order to be reincarnated on a higher level in the next relax in the 1 940s, in part to recognize China’s position as a U.S. ally life. A premature death is considered bad luck, as this is thought to in World War II. Since the Immigration Act of 1965, which allowed mean that someone has done something bad and is being punished.