After Death

Social Engagements with Death and Dying

The “Great Equalizer”?

Racial Inequalities of the Post-Mortem

Abigail Goldman


It is often said that death is the “great equalizer.” From Shakespeare’s musings on the subject in “Hamlet” to the anonymous proverb that “six feet of dirt makes all men equal,” these considerations of popular culture often work themselves into the rhetoric of our daily lives to convince us that death does not discriminate. No matter our race, age, gender, social status, economic status or cultural inclinations, it is often collectively understood that all of the things that separate us from one another in life will dissipate as we all meet a common fate in death. However, if we take a closer look at this assumption, it becomes clear that a lot of the time, these elements that characterize an individual in life are still highly prevalent in the end-of-life process. Can one escape the forces of these differences, particularly when it comes to race? Where exactly are these discrepancies manifested, where do they come from, and how can we seek to eliminate them moving forward? In this segment of the Altman After Death podcast series, I will elaborate on just a few of the ways in which patterns of racial discrimination and inequality follow us into the grave through different steps of the end-of-life process. In other words, this podcast seeks to prove that death is, by no means, the “great equalizer” that we thought it was.

One of the most striking examples of racial differences in death occurs before the heart even stops beating. In the medical field, the series of possible procedures that can be instituted at the end of one’s life to either extend it or make the patient more comfortable in his/her final days is comprehensively known as “end-of-life care.” Although the act of dying itself is often shrouded in mystery, it becomes very clear very quickly after sifting through information from the National Institute on Aging and the Cleveland Clinic that, when it comes to planning our final moments, no stone is left unturned. For the purpose of time and relevance to the role of race in this extensive spectrum of options, I would like to zero in on two particular possibilities addressed in the end-of-life care process that shoulder the most significant amount of racial discrepancies…

A) Advanced directives, otherwise known as a living will, which outlines specifically what actions should be taken for the patient’s health should he/she become incapacitated and unable to make the decision on his/her own. Some of these actions to consider include life-extending procedures such as mechanical ventilation, feeding tubes and dialysis.

B) A DNR (“Do not resuscitate”), an order issued in cooperation with the patient’s physician indicating that should his/her heart or breathing stop, the physician must refrain from performing CPR.

In a study published in 2014 in the journal Cancer and featured by the Weill Medical College at Cornell University, it was revealed that black and Latino patients are universally more likely than white patients to prefer to receive more of these life-prolonging care measures near death. Out of a sample of 234 individuals with terminal cancer, the discrepancy between white patients and non-white patients who chose these measures is striking. While only 45% of white patients reported having signed a DNR order, the amount of black patients who stated this preference is miniscule by comparison at just 25%. The disparity does not stop there: out of all of the patients in the cohort who did not declare a DNR order, 46% of black patients indicated that they would prefer ventilation for one week if it kept them alive compared to only 30% of white patients who chose this preference. In an effort to recount and elucidate why these stark racial disparities exist, chief proponent of the study Dr. Holly Prigerson of the Center for Research on End of Life Care at Weill expounds upon the results of the study with the claim that the most significant explanation is their belief in God and miracles. According to Prigerson, the black patients liked and trusted their physicians, they, quote, “discounted all of the information being shared with them because they thought it was irrelevant” because of their religious beliefs. Although Dr. Prigerson’s allegation that the principal source of the black community’s preference for aggressive life-extending measures is due in large part to an inexpert sense of disavowal when it comes to medical opinion is certainly one explanation, I am inclined to say that this statement is a gross oversimplification. Instead of pointing fingers at a culprit as abstract as a collection of beliefs, it is ultimately more essential for us to take a look at some socio-cultural discrepancies between black and white patients that precede this study in order to better explain its results.

One valuable place to start is death anxiety. Although the term seems pretty self-explanatory, the phenomenon reveals much more than simply the feeling of dread and discomfort that we all tend to experience when it comes to thinking about our own demise. Rather, according to Kausar Suhail and Saima Akram in an article written for the journal Death Studies, the reduction of well-being and the will to live among patients with death anxiety is also inextricably linked to demographic and socio-economic factors: those situated at the lower end of the socio-economic ladder tend to exhibit higher levels of death anxiety because they tend to have more chronic medical conditions, more financial difficulties and less perceived control over their lives. African Americans are statistically proven to be among these populations: according to the American Psychological Association, the prosperity gap between black and white Americans is undeniably wide. Unemployment rates for African Americans are nearly double those of Caucasians, while three times as many black children live below the poverty line than white children and are more likely to attend low-income schools. When we consider these circumstances in trying to figure out why African Americans prefer life-prolonging measures, the results are more than logical. If this demographic of patients feels unprepared to face their own deaths for various reasons that are influence by socio-economic background, then it is only logical that the results of the study reveal that African Americans prefer these life-prolonging measures. Therefore, Prigerson’s assumption needs to be modified: the differences in the numbers do not reveal a simple and natural difference in attitude between black and white communities. Instead, we need to see the difference in the numbers as a reflection of differences in opportunity that also work their way into discussions on death.

Not only can we interpret these results by placing them in the context of racial discrimination both socially and economically, but we can also understand the finding as a result of discrimination in the health care field that ultimately lends a sense of distrust amongst black patients towards their physicians when making decisions regarding end of life care. This mistrust, however, is much more based in pragmatic experience than in a belief system as Prigerson suggests. In fact, a report published in The Journal of the American Medical Association revealed some striking instances of racial discrimination in medical procedures that would most definitely solidify a sense of distrust amongst black patients: although white and black patients had similar rates of hospitalization for chest pain in this study, whites were 33% more likely than African Americans to undergo a coronary angiography and were twice as likely to undergo a bypass surgery or angioplasty. In addition, black patients on Medicare received coronary bypass grafts only ¼ as often as white patients, and even less in the Deep South. Although this study was conducted in 1989, it seems as if not much has changed. In another peer-reviewed report released just this past summer for the Public Library of Science, researchers at the University of California San Francisco concluded that despite having identical symptoms, black patients are consistently less likely to be given opioid-based medication in emergency rooms for pain than white patients. These discrepancies reveal some astonishing prejudices that clearly still exist amongst medical professionals. In an article for a segment of the Daily Beast entitled “Black Pain Matters,” Keith Wailoo of Princeton University rehashes a study from the University of Virginia which revealed that out of a sample size of 222 white medical students and residents, half of them affirmed false stereotypes about biological differences between black and white patients. Some of these perceived differences include having “thicker skin,” having less nerve endings and having blood that clots more quickly than whites. Because of this inferior treatment, it is no mystery why African American patients also claim to exhibit more mistrust towards medical professionals. This mistrust, however, also gives way to a sense of distance between doctor and patient that greatly affects the end of life care process. As outlined by the American Association of Family Physicians, one of the most vital aspects to ensure an optimal decision for each patient as they navigate the end-of-life process is an open, honest and informative relationship with a trusted physician.  However, although black and white patients are reportedly having the same kind of EOL conversation with their physicians, it is clear that something has gone amiss when it comes to reaping the benefits of this communication as a recent survey concluded that more African American patients believe that doctors cannot be trusted to pronounce death correctly. Therefore, although the template of conversation, communication and treatment may be identical for both black patients and white patients, it is clear that racial inequalities through experiences in the medical field gives way to a vicious cycle of miscommunication that ultimately influences the outcomes of these patients as they face preparations for death.

In conclusion, it seems as if this stark discrepancy between black and white patients who prefer life-extending measures in their final moments is much more than a question of personal preference. Rather, it is an accumulation of pragmatic experiences of racial discrimination that give way to a collective consciousness of mistrust and trepidation that carry over from life when grappling with death. Perhaps the best hope of rectifying this situation would be an indictment of the racial ideas that frame the situation of black patients through a movement such as Black Lives Matter. Although this prolific organization has made great strides in closing the gap of injustice between black and white civilians most notably in the realm of police brutality, it is clear that it is not only in life that these structures of inequality persist. Instead, what is needed is a push for change to see these preferences in death as a reflection of discrimination in life so that we will no longer be in need of a “great equalizer.”

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