Trans-Atlantic Death Methods:

Disciplinarity shared and challenged by a common language1

Abstract

The different countries that death and dying researchers reside within often shape not only

research agendas but also research methodologies. The United Kingdom and the United States

are two examples of countries that share a common language and intellectual history but their

discourses on death have been very different. These differences are partly explained through

cultural practices, but also government funding of research, definitions of death and end-of-life

planning education. In this article, we argue that early death scholarship in the United States

impacted death research and outcomes in both the U.S. and the U.K., but that recent scholarship

in both countries has caused the two countries to diverge in two major areas: 1) the

methodological approaches to death studies and 2) the educational training of medical and

hospice personnel in direct contact with the dying. We argue that in order for death studies to

fully benefit from trans-Atlantic dialogue on death, both countries need to move towards a more

integrated trans-disciplinary model.

Key Words: death, United Kingdom, United States, death education, culture, dying

Word Count 9,317 (excluding title, abstract, keywords, acknowledgements)

Introduction

This article focuses on the field of death and dying research in both the United Kingdom

and the United States, positing that though these two countries may both speak and write in

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English, hence etymologically sharing a common language, approaches to death studies, and the

ways in which scholars examine, research and teach about the intersection of medicine and

culture, vary greatly across the Atlantic. We posit that though early death scholarship in the

United States impacted death research and outcomes in both the U.S. and the U.K., recent

scholarship reveals key differences in two major areas: 1) the methodological approaches to

death studies and 2) the educational training of medical and hospice personnel in direct contact

with the dying. In a brief comparative analysis below, we posit that the British model, which

centres its death studies in the field of social sciences and culture, is a better model for fostering

trans-disciplinary dialogue, creating studies of death that result in fruitful policies regarding

death. We also position methodologies as a series of concepts, as well as practices, that articulate

different conditions of possibility that encompass death and dying in the modern First World.

These conditions of possibility transform methodologies from mere analytic tools to productive

meaning makers in both countries. Finally, we argue that in order for death studies to fully

benefit from trans-Atlantic dialogue on death, both countries need to move towards a more

integrated trans-disciplinary model.

Transdisciplinary, Interdisciplinary, and Multidisciplinary

We distinguish “trans-disciplinary” from “inter-disciplinary” or “multi-disciplinary,” in

that transdisciplinary approaches not only involve multiple disciplines (multi) and conversation

between the disciplines (inter), but also utilise methodologies that impact, change, and transform

each of the various disciplines involved.2 Specifically in this example, having sociology,

medicine, and cultural studies involved in a transdisciplinary examination of death has resulted

in research outcomes that have impacted the way death is examined, studied, taught, and

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practiced in each sub-field. We posit that death education in the U.K. is largely transdisciplinary,

while death education in the U.S. largely remains inter- or multi-disciplinary. While disciplinary

specialisation might result in a depth of knowledge over breadth, it also has a limited value,

when specialists are not able to disseminate their research outcomes across disciplines. The

emphasis on transdisciplinary death education in the U.K. has also led to better and more

effective policy-making surrounding end of life (EOL) care, while the safeguarding of

disciplinary expertise in the U.S. has led to fractured, less effective, and poorly implemented

policy.3

Trans-Atlantic Divides: A very brief history of “Death Education” in “Death Studies”

Building on the history of death education between both countries, end-of-life based

pedagogy has prospered through the work of many individuals including, but not limited to,

individuals such as Cicely Saunders, Tony Walter, George Dickinson, and Glennys Howarth.

Most death scholars trace the origins of death studies (our umbrella term for all scholarly activity

regarding death) to a shared research history of scholarship on death in the United States, citing

sources such as Herman Feifel’s death and dying courses and his studies of death in the United

States (Feifel, 1959; 1977; 1982), Kübler-Ross’s studies of dying (Kübler-Ross, 1969; 2009),

Weisman’s study of the impact of death from a psychological and psychiatric perspective

(Weisman, 1961; 1972), Kalish and Sudnow’s examinations of death and its social impact

(Kalish, 1976; Sudnow, 1967) , or even Glaser and Strauss’s studies of death in the medical field

(Glaser & Strauss, 1966; 1968). These early American studies on death, dying, and its social and

psychological implications were formative in their impact not only on death and dying as a field

of study, in general, but also on the current generation of scholars in both the U.S. and the U.K.

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What must be noted, however, is that this influence on death scholarship (at least until the

seventies and eighties) was largely unilateral, with American scholarship heavily influencing

British understandings of death and dying. Even cultural critiques of death and dying, such as

Ernest Becker’s seminal work (1973), The Denial of Death, emerged from the American

experience during the Vietnam War years. An important exception, to this trend, however, was

the English doctor Dame Cicely Saunders, whose hospice work was foundational to the

examination of dying, and who established not only the first hospice, but in many ways, also

sparked the study of the dying process, when she responded to the invitation to give a series of

lectures at Yale University in 1965.

What is significant and interesting about the fifty-plus years of death studies on both

sides of the Atlantic, is how death studies has been bifurcated across the Atlantic—in the United

States, most death scholars study and emphasise the psychological and psychiatric effects of

dying and death, while in the United Kingdom, there is much more interest in the study of death

from a sociological, historical, anthropological, and cultural point of view.4 This assertion bears

itself out when one examines the dominant professional associations and think-tanks associated

with the study of death in the two countries. The primary association that studies death in the

United Kingdom is the Association for the Study of Death and Society (ASDS). The membership

of ASDS runs the biennial international conference on Death, Dying, and Disposal (DDD) and

consists mostly of social scientists and humanities scholars that examine death in cultural and

societal contexts (e.g., art, religion, medicine, the law, etc.) and is affiliated with Mortality.5

Conversely, the primary association in the United States is the Association of Death Education

and Counselling (ADEC), whose membership is mainly filled with grief counsellors, social

workers, hospice personnel and clergy whose work deals primarily in bereavement and

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counselling. Apart from ADEC, the only interdisciplinary conference or organisation centred on

the study of death in the United States is Columbia University’s long-running Death Seminar,

which operates out of the Narrative Medicine department in Columbia, and meets monthly for a

dinner featuring a speaker who discusses some aspect of death studies. Though the various

academic disciplines in the United States do have sub-committees featuring particular topics,

such as the “Death, Dying, and Beyond” subgroup in the American Academy of Religion, or the

“Medical Anthropology” sub-group in Anthropology, there is no umbrella organisation that

studies death from a largely social sciences perspective, as one finds in the United Kingdom.6

These different organisations illustrate and underscore the contemporary emphases placed in

each respective country in regards to death studies—the United Kingdom tends to be rich in

social scientists who examine death and dying from a cultural and sociological perspective, while

in the United States, death and dying seem to be taught and examined primarily from a

psychological and psychiatric perspective, with occasional exceptions.

Underscoring this difference is the fact that in the United Kingdom, Medical Sociology is

the top sub-discipline within Sociology, whereas in the United States, this is far from the case.7

In fact, the discipline of social sciences (if it exists at all), is rarely found in American medical

schools, as they tend to focus on behavioural rather than social sciences.8 This, of course follows

the trend to privilege psychological/psychiatric interpretations of death over and above socio-

cultural ones. These differences—in both the historical influences, and in methodological

approaches to the examination of death, have subsequently influenced the way death is currently

studied, researched, defined, taught in medical school, and then implemented in government

policy. While we do not intend this analysis to be an exhaustive study of these differences and

their implications, we do offer this article as an important signpost to the ways in which death

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and dying as a field is thought about and implemented in the United States and the United

Kingdom. In other words, these methodological differences in approaching death studies are

important in that they may ultimately influence the way we understand death to function, and

ultimately impact death itself.

In the U.K., we argue, academics and practitioners are not only more collaborative but

also more inter/transdisciplinary, and have a comprehensive perspective on death care, that takes

into account both academic understandings of death, and the ways these academic perspectives

shape and influence policy. Additionally, while U.K. death researchers and practitioners are

often more likely to respond to the research directives and aims of the U.K. government and

healthcare system, they are also more likely to affect current policy and make proactive and

positive changes to end-of-life care. These impacts arrive on many levels, from hospital care for

patients, to hospice care for the terminally ill, to the dignified final disposition of human remains

after a funeral (Cooper, Hedges & Valentine, 2009). U.S. death studies academics and deathcare

workers in hospitals (for example and by contrast) are often specialists with little overlap or

conversation between themselves. In a U.S. healthcare market economy driven by medical

specialisation and private market forces, the incentives to improve end-of-life care through

public collaboration are not nearly as numerous as in the U.K.

In the United Kingdom, research is often initiated, funded, and stimulated by government

backed agencies and research councils. These collaborative research projects often present

transdisciplinary9 research outcomes (i.e., transcending disciplinary expectations) that encourage

a dialogue between death and dying practitioners (e.g., medical staff, hospice workers, funeral

directors) and academics and policy makers wanting to improve current end-of-life practices.

Conversely, in the United States the field of death and dying is largely academically

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interdisciplinary with little conversation or overlap between practitioners, academics, and policy

makers. This is a result of medicine and death care being mostly privately funded, particularly

and especially for the elite sectors of society. Additionally, the disciplines of medicine, social

science, and the humanities rarely intersect, and interdisciplinary departments (and the research

they produce) still suffer from the stigma of scholarship that seeks breadth over depth.10 On a

certain level this situation is slowly changing in a few U.S. academic institutions through the

introduction of fields of study such as medical humanities, bioethics programs, and narrative

medicine. Unlike the U.K., popular interest and/or non-profit grant funding largely drive research

directives in the U.S., while government grant money tends towards issues of public healthcare

that often exclude questions around death and dying. We argue that the key differences in

medical culture, death education, and legislation surrounding death and dying influence and

shape the way death is viewed and studied in both the U.K. and the U.S. These differences

manifest themselves in vastly different approaches to death education, resulting in widely

disparate cost differentials for end of life care and attitudes toward hospice training. It is our

hope that by bringing awareness to these differences in studying death we can open up a new

discussion around methodological approaches that benefit both countries.

Medicine and Culture

Now that we have examined the death education and death studies methodological

relationships in the U.K. and U.S., we want to examine the role of medicine and culture, as this

relationship is integral to the way sickness, dying, and ultimately, death, is understood (Lupton,

2012). Though death can largely be understood in the Global North (and increasingly the rest of

the world) as the cessation of bodily and neurological processes, there is varying cultural

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interpretation over how and when death occurs, who is authorised to verify a death, and whether

or not death is viewed as an organic or a disruptive process. Cultural understandings of death

differ, and are often rooted in conceptions of illness and vary according to perceptions of bodily

functions. Annas and Miller (1994), for example, discuss the cultural variants at work in the

diagnosis of illness, illustrated in such factors as normative body temperatures or blood pressure

diagnosis and treatment.11 Payer (1996) discusses the function of the heart as both organ and

centre of identity in different countries, and how different cultural views regarding the heart’s

function inform many kinds of diagnoses, e.g., in the United States, the heart is classified as a

muscle or a pump, and thus the valves leading to the heart are examined in order to make the

heart pump more effectively. The heart as strictly an organ pump is not viewed the same way in

other countries (e.g., Israel), and thus the diagnosis and treatment might vary. Payer’s work on

medicine and culture notes how these differences then translate to systemic divergences in

healthcare.

The English, for example, have less money to spend on health, but

they are nevertheless spending what they do have quite differently

than we do in America. There are only one hundred cardiologists

in the whole of England [in 1996] —but also one hundred geriatric

psychiatrists. If the English had more money, they might as well

spend it on the training of more geriatric psychiatrists, because to

them the quality of life in old age takes precedence over preventing

heart attacks. (Payer, 1996, p. 20)

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Payer also links the tendency in the U.S. medical system to favour aggressive medical treatment

to the American frontier spirit, arguing that death is often viewed as failure, and hospice

sometimes treated as “giving up.” In the American context, aggressive action is valued in the

face of adversity, even when it leads to exorbitant healthcare costs. This view of prolonging life

at any expense is one reason why hospice has not experienced the same kind of success in the

U.S. as in the U.K., and helps explain why the task of palliative care is often handed off to social

workers, hospice volunteers, and privately run facilities rather than medical personnel as in the

U.K. Dickinson and Field, in their comparative analysis of hospice education as a part of medical

school training, found that 94% of medical students in the U.K. were given hospice exposure,

while that number was nearly halved in the U.S., with only 50% of students receiving hospice

training (Dickinson and Field, 2002, p.184).12 Additionally, American hospice care workers are

given an overall lower market value in comparison to American medical personnel, often

receiving low pay or volunteering without pay, and Dickinson and Field point to the lower

education standards required in the U.S. to be a hospice provider as justification for the

discrepancy in wages. In the United States, the cultural emphasis placed on prolonging life over

dying well is then methodologically reflected in the following cultural practices: lack of training

for medical personnel, the separation and compartmentalisation of end-of-life care from standard

medical care, end-of-life care costs and expenses, and legal directives and laws. This

dramatically differs from the U.K., where hospice and end-of-life care are integrated into both

the medical school training and the actual healthcare system, e.g., National Health Service

(NHS) end-of-life care planning programs.13

The systemic differences in the American and British health care regimes and

methodologies also point to widely different cultural interpretations of death and the role death

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and dying play in determining levels of intervention, and patient consent. Annas and Miller

(1994) argue that American individualism has been instrumental in emphasising patient choice

and autonomy in choosing one’s medical provider and the degree of medical care one decides to

pursue. In the private provider American system, the patient develops a “collaborative” treatment

plan with their doctor, and doctors are expected to provide information to his/her patient

regarding a prognosis. Providing this information is regarded as a contractual part of the

agreement between patient and doctor. This stands in contrast to the U.K.’s NHS system, in

which the physician acts as gatekeeper to other specialists, and a patient must receive a referral

to a specialist in order to pursue further healthcare. In the U.K., the doctor is not under the same

“contractual” duty to inform the patient, as the healthcare system is viewed as a public service

provided to its people, rather than part of the market system (though the shift from public good to

private healthcare marketplace in the U.K. is slowly changing) (Annas and Miller, 1994;

Heyward, 2015).14 Thus, the classic societal perception between the U.S. and the U.K. is that the

American patient operates as a consumer poised to manage their own care within a market

system, while the British patient seeks healthcare in a system that favours medical paternalism

over patient autonomy. That being said, however, patient autonomy is not without cost.

Obviously, the long-term effects (and costs) of the U.S.’s continually evolving Affordable Care

Act (2010) (a.k.a. Obamacare) and recent U.K. patient choice campaigns will continue to affect

these outcomes, but our fundamental point is that culture plays an important role in these

systemic healthcare differences. Systemic healthcare differences also then play a key role in how

articulating the end-of-life is methodologically pursued given core differences in the delivery of

care. These differences emerge not only with gatekeepers protecting patients but also in national

perceptions of what end of life death care should and could involve.

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Finally, it is difficult to confront these cultural differences in medical contexts that often

describe themselves as “objective” and “lacking culture” (Taylor, 2003). We would explicitly

argue that medical cultures themselves are being deployed and represented within national

healthcare regimes, thus changing and influencing the multitude of ways the dying person

understands “treatments for dying.” The aggressive treatment of dying patients and the enormous

costs associated with such treatment in the American context, and the emphasis on palliative

treatment and training of medical personnel along with the availability of hospice education in

the U.K. context are clear cultural worldviews being exported alongside medical treatments. In a

sense, medicine has become a new kind of missionary field populated by evangelists for both

market-based healthcare and nationalised care, and attitudes toward death and dying are central

to both diagnosis and treatment in either system.

The Cost of Dying

Another major difference between the U.K. and U.S influencing methodological

considerations can be found in per capita healthcare costs. While this may not be seen to have a

direct immediate correlation, the fact remains that in the United States, 30% of overall healthcare

expenditures for a person’s lifetime are in the last year of life. This means that the understanding

and attitudes of both death and dying are central to healthcare expenditures. According to the

Worldbank, the United States is the third most expensive country in the world in terms of

healthcare expenditures per capita, with costs increasing annually. The U.K. per capita cost for

healthcare is less than half of the American cost, and unlike the U.S., the costs sometimes decline

as well as rise. In 1994 the American per capita spending on healthcare was $3,788, while in the

United Kingdom, it was $1,994; in 2014 per capita spending in the U.S. had risen to $9,403,

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while the U.K. had risen to $3,935.15 With the exception of Switzerland (at $4,308 and $9,674)

and Norway ($2,698 and $9,522), the U.S. spends more for healthcare than any other country in

the world. Aggressive life-prolonging treatments play a key role in this per capita expenditure

and illustrate how by spending more money, the U.S. does not always guarantee higher quality

end-of-life care; an argument clearly illustrated in Dr. Atul Gawande’s last book Being Mortal

(2014).

We also argue that the differences in dying costs are related to methodological

differences within interdisciplinary and transdisciplinary medicine. The American healthcare

market economy makes being a medical specialist far more profitable and therefore reinforces

disciplinary differences, especially when factoring the cost of dying. End-of-life care provisions

reflect a medical education system that hypothetically supports multi-disciplinary initiatives but

through specialisation, often leaves dying as an afterthought. U.S. doctors that specialise in

Palliative Care Medicine mitigate this dilemma, in part, but this is a further specialisation that

then also reinforces disciplinary boundaries. In the U.K. and through the educational

opportunities described by Dickinson and Field (2002), medicine can become a more

collaborative, interdisciplinary method that works across healthcare methodologies in an end-of-

life transdisciplinary method. These shifts in methods are not without controversy or problems,

as well established medical experts may suddenly need to collaborate instead of simply dictating

care. Our point is that medical care costs, and the costs of dying more specifically, can be read as

an indicator of how easily end-of-life methodologies collaborate across medical disciplines.

Medical Schools and Nursing Programs in the U.S. and U.K.

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A closer examination of death and dying courses for medical personnel in both the United

States and the United Kingdom illustrates precisely this pedagogic disparity between countries.

In Dickinson and Field’s (2002) survey of medical schools and nursing programs in the two

countries, they found that death and dying course offerings were frequently integrated into

curriculum, rather than offered as special courses covering the subject of death alone. In

addition, over 90% of death and dying courses in the U.K. were taught by medical personnel,

with a majority of courses actually taught by palliative and hospice care specialists. Conversely,

a survey of death education in the United States revealed that while many U.S. specialists

acknowledged that a hospice curriculum was already integrated into the U.K.’s medical

curriculum, the different U.S. medical school curricula did not make the same kind of offer.

Overall, however, Dickinson and Field found that palliative care and treatment courses were

taken by all U.K. medical students, while American medical students were still lagging behind

the U.K. with 94% of all American medical schools offering some form of palliative care

education (Dickinson, 2006). Though by 2000, 100% of all American medical schools offered

some course on death and dying (Dickinson, 2006), the U.K. achieved this goal in death

education and palliative care training much earlier.16 Ultimately, Dickinson and Field concluded

that the United Kingdom emphasise holistic death education more than the United States.

Dickinson (2007) did a further study on United States’ medical schools and nursing programs a

few years later and found that strong majorities of the respondents received some kind of end-of-

life and/or palliative care education but in a limited fashion. The total number of hours dedicated

to death and dying was generally less than fifteen per academic semester.17 The need for death

education is evident. If death is only taught from the point of view of something to be prevented

at all costs, and not from the “good death” perspective, the dying patient will need to be

13

responsible for procuring a good death on his/her terms, rather than through the facilitation of

medical personnel. Adding a further wrinkle to how U.S. death education methodologies are

used, Wass (2004) found differences in how health professionals (medical personnel and grief

counsellors) received some kind of minimal training but that death industry workers (e.g., funeral

directors) received even less, if any, education. While it is true that most death industry workers

require some form of education and accreditation in the United States, the actual pedagogy is far

more about technical skill than end-of-life concerns around dying.18

Finding Points of Convergence

What does unite both the U.S. and U.K. in some senses is a shared history of scholarship

and research exchange on death related topics (Noppe, 2007; Seale, 1998; 2000; Davies, 2008). What

makes this situation even more methodologically complex is how this shared historiography of

death has largely been forgotten. Indeed, both the U.K. and U.S. suffer from profound historical

amnesia when it comes to knowing the history of post-WWII death research before the advent of

mid-1990s internet communication. One of the larger methodological issues confronting death

studies is the failure to fully understand the intellectual and practical genealogy of ideas that

created today’s death scholarship. The proliferation of trans-Atlantic death discourse surrounding

hospice care during the 1970s is one significant example of work that appears largely missing

from today’s research projects (Overy and Tansey, 2012; Buck, 2011). Without an understanding

of what has been written before, it can be very difficult to see what will come. This significant

epistemological gap represents a core issue for any methodological analysis and requires the

creation of new tools for researching death.

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This article presents a series of critical interpretations on how these educational and

methodological conditions of possibility can be differently understood in their respective

countries. What is fundamentally required is a new kind of methodological approach for a trans-

Atlantic conversation on death, death education, and policy-making regarding death and end-of-

life issues. This new kind of approach requires not only the institutionally supported academic

researcher but also a more ‘on-the-ground’ community-based approach that appreciates the

vastly important cultural differences between groups. An important step in this process is to

understand how the relative economic affluence, middle-to-upper social class standing, and

generally white-Anglo positioning of death education impacts the work being done. We posit

that that next step in death studies influenced pedagogy will be the dismantling of dominant

models of elite constructions of dying, death and grief, and the acceptance of richer, more

diverse understandings of dying, death, and grief that account for racial, gender, and class

diversity. Only by first understanding how the dominant models came to be so dominant, largely

through educational practices, can the shift towards a different “kind of death” and the research

surrounding it be achieved in both countries.

Conclusion

The question of how best to methodologically approach death studies in the U.S. and

U.K. is replete with shared history, forgotten collaborations, and a somewhat fractious common

language. We view the possibilities for the development of a new kind of death research between

the United States and the United Kingdom with much optimism. While it is true that recent

challenges to how the U.K. defines itself internationally have created a potentially years long re-

think on what exactly it is to be “British,” the United States is also (seemingly always) in the

15

middle of a very similar conversation about being “American.”19 What remains constant, of

course, is that no matter how these identities are defined, citizens and residents of both countries

will continue to die. This persistent death is, for us, the core issue that envelops human mortality

and makes new kinds of death work possible. From our analysis, it seems clear that the United

Kingdom has done more to instil and utilise death education for individuals and professions

working around end-of-life care. Methodologically speaking, the United States appears on this

same trajectory but could most certainly speed up the process. It is also clear, based on how the

different countries regard the input of academic research, that end-of-life social policy, laws, and

care are more easily influenced in the U.K. by respected authorities. What both countries offer

each other is an opportunity (that should resist being momentary) to rethink how the dominant

death discourses are established and reinforced through methodological blind spots. By coming

to terms with the socio-economic and cultural homogeneity of so much death discourse,

education, and methodological model making since the post-war period and specifically since the

1970s, these two countries separated by a common language may yet find new kinds of common

ground. This will not be a utopian death language, but a conversation between cousins

rediscovering what came before and how this shared genealogical death discourse represents a

new kind of transdisciplinary methodological future. A future, it should be added, that will only

come about by first accepting that all new death-focused methodologies will inevitably be

replaced by yet unknown generations of scholars, professionals, and workers all trying to

understand what it means to live and die in both countries.

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Acknowledgements

Since this piece is methodological, we want to acknowledge and give thanks to our

methodological mentors in the field. Candi gives special thanks to George E. Dickinson and

Donald Joralemon, and John gratefully acknowledges Michal Kobialka, Professor of Theatre

History at the University of Minnesota, who introduced John to “The Order of Things” by

Key Points

We posit that in order to improve death studies and improve trans-Atlantic research

surrounding dying, death and grief, the following should be observed and put into practice. We

call for scholars and practitioners to observe and implement the following:

Re-evaluate the dominant discourses and histories that have framed and shaped death

studies

Recognise that current policies on death (including the medical definition of death and

dying, current legislature regarding bodily disposal, etc.) are in part shaped by our shared

thantalogical history

Rewrite the current narratives in death studies, examining from a critical discourse any

implicit biases that have shaped our assumptions and conclusions on dying, death, and

grief

Reframe policy models so that they more accurately serve their populations

Realise trans-disciplinary dialogue and reduce interdisciplinary entrenchment.

We believe that if these five measures are taken, death studies in both the U.S. and U.K. will

emerge as more collaborative, better informed, and more holistic.

17

Michel Foucault in 1995. You are our thanatological and scholarly pioneers, and we are

especially grateful for your guidance and mentorship in our work.

Notes

18

1 Our title is an ironic refiguring of the potentially apocryphal quote attributed to Irish writer George Bernard Shaw, “England and America are two countries divided by a common language.” The quote was originally attributed to Shaw in The Christian Science Monitor in 1942, though the quote is possibly a reworking of Oscar Wilde’s original quote from his 1887 short story, “The Canterville Ghost,” which Shaw then paraphrased.

2 For distinctions between transdisciplinary, interdisciplinary and multidisciplinary, see Kessel F, Rosenfield PL. Toward transdisciplinary research: historical and contemporary perspectives. American Journal of Preventive Medicine. 2008 Aug 31; 35(2):S225-34, and Rosenfield, Patricia L. "The potential of transdisciplinary research for sustaining and extending linkages between the health and social sciences." Social science & medicine 35, no. 11 (1992): 1343-1357.

3 We believe that the UK’s National Health Service (NHS) End of Life Care Guide (http://www.nhs.uk/planners/end-of-life-care/Pages/End-of-life-care.aspx) is an example of productive policy making that is next to impossible to achieve in the United States. The NHS guidance is far from perfect but at least recognises the need for policy making on end-of-life, while US policymakers can’t even agree on whether or not Doctors should speak with their patients about end-of-life wishes.

4 We are grateful to Reviewer 2 for pointing out this difference in the fields of death studies in the U.S. vis-à-vis the U.K.

5 Full disclosure of interest: Article co-author John Troyer is a founding member of ASDS and sits on the ASDS Council as the Website Manager. 6 See: American Academy of Religion (AAR) “Death, Dying and Beyond” subgroup, (http://deathandafterlife.com), American Anthropological Association Medical Anthropology section (http://www.medanthro.net), American Sociological Association, medical sociology section (http://www.asanet.org/communities/sections/sites/medical-sociology ), Columbia University Seminar on Death (http://www.columbia.edu/cu/seminars/death).

7 We are indebted to Reviewer 1’s comments pointing out the difference in Medical Sociology as a sub-discipline.

8 Many American medical schools have behavioral science departments, but not social science departments, though this is hopefully going to change, as there is more evidence that Social Science courses make better doctors who practice more effective medicine. For more on these changes see, Institute of Medicine (US) Committee on Behavioral and Social Sciences in Medical School Curricula; Cuff PA, Vanselow NA, editors. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington (DC): National Academies Press (US); 2004. 3, The Behavioral and Social Sciences in Medical School Curricula. Available from: http://www.ncbi.nlm.nih.gov/books/NBK10239/

9 See Rosenfield, Patricia L. "The potential of transdisciplinary research for sustaining and extending linkages between the health and social sciences." Social science & medicine 35, no. 11 (1992): 1343-1357.

10 For more on this, see Klein, J. T. (2008). Evaluation of interdisciplinary and transdisciplinary research: a literature review. American journal of preventive medicine, 35(2), S116-S123, and Boix Mansilla, V., Miller, W. C., & Gardner, H. (2000). On disciplinary lenses and interdisciplinary work. Interdisciplinary curriculum: Challenges to implementation, 17-38.

11 For example, standard body temperature is set at 98.4 in the U.K. while 98.6 in the U.S.; this may have more to do with Celsius conversion, however, than actual temperature differences between Brits and Americans.

12 Dickinson and Field note, however, that at the time of their survey, about two-thirds of the American medical schools that did not offer exposure to hospice or hospice training, did have plans to incorporate it into their future curriculums (Dickinson and Field, 2002, p.184).

13 See NHS End-of-Life Care Planning http://www.nhs.uk/planners/end-of-life-care/Pages/End-of-life-care.aspx.

14 Annas and Miller point to the Arato v. Avendon legal case to make this claim in the American system, arguing that this case places healthcare and doctor services firmly in the market, meaning that doctors are required under law to fully inform their clients of their prognosis as a way to make better informed decisions regarding healthcare. This case still stands today as a key decision in informed consent decisions. Annas and Miller use Sidaway v. Bethlem Royal Hospital Governors (1985) AC871 to illustrate that the opposite is true in the U.K. However, in Chester v. Ashfar (2004), the House of Lords ruled in a 3-2 ruling that the patient should give informed consent to their doctor, and Rob Heyward argues that in Montgomery v. Lanarkshire Health Board (2014) the Chester v. Ashfar case accelerated changes initiatives, emphasising patient rights to consent. This will be an important development to continue watching as it will also help shape the future doctor-patient relationship in the United Kingdom. 15 World Bank, Health Expenditure per Capita, http://data.worldbank.org/indicator/SH.XPD.PCAP

16 Dickinson (and various colleagues-- Mermann, Field) conducted surveys of American medical schools in 1975, 1980, 1985, 1990, 1995, and 2000, so in some ways, he has been instrumental in educating the medical schools themselves in their lacking curriculums. When he started, only 80% of all medical schools taught courses on death and dying. 17 Dickinson (2007) used a mail survey to evaluate the depth of teaching on end-of-life issues. Of those who responded to the survey, Dickinson found that majorities received some kind of death education but generally less than fifteen hours per semester. He also found that less than one-fifth of U.S. medical and nursing schools offer a semester length course on death and dying. The medical schools that do offer courses generally have to invite outside experts since few on staff faculty cover end-of-life or palliative care medicine. See Dickinson, G. E. (2007). End-of-life and palliative care issues in medical and nursing schools in the United States. Death Studies, 31(8), 713-726.

18 Wass (2004) also summarises that “death” is being replaced by euphemisms such as end-of-life care, palliative care, etc., and that not directly addressing death is a methodological problem. Wass notes that many U.S. medical schools still lack comprehensive courses and training for death professionals and that quick dying continues to be favored over slow dying in terms of compassion and cost. There is a shift towards death education for health professionals (e.g., medical personnel and grief counselors), but no mention of professional death workers, such as funeral directors. As a result, a strong divide between medical personnel, social workers/grief counselors and death industry workers has opened up and that while many U.S. academics work with the medical/social work/grief professionals, they don’t generally work with death industry workers. See Wass, H. (2004). A perspective on the current state of death education. Death studies, 28(4), 289-308.

19 See Matthew d’Anconca “Brexit: How a Fringe Idea Took Hold of the Tory Party” in The Guardian Long Read (June 15, 2016) https://www.theguardian.com/politics/2016/jun/15/brexit-how-a-fringe-idea-took-hold-tory-party and Jelani Cobb “Donald Trump and the Death of American Exceptionalism” in The New Yorker (November 4, 2016) http://www.newyorker.com/news/news-desk/donald-trump-and-the-death-of-american-exceptionalism

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