Hospice Care and Culture

A Comparison of the Hospice Movement in the West and Japan

Teresa Chikako Maruyama

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138317482
• eBook ISBN: 9780429844072
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

First published in 1999, Maruyama explores some significant difficulties and differences in bringing the western hospice philosophy to the Japanese medical culture. Whilst not giving any definite answers, this study determines what some of the critical questions that need to be considered into Japanese medicine, as Mayuyama argues without defining these questions to begin with we cannot find appropriate solutions.

1    Introduction

An expression like ‘the West’, which is used in the title and will be used throughout this book, can easily be attacked for its over generalization and simplification. There are many different cultures inside the Western world. It may also seem wrong to use the term ‘the Western hospice movement’, since there are some Western countries which have not yet established any institution named a ‘hospice’. We would like to say, however, that it may be acceptable to use this phrase ‘the Western hospice’ in this study. Many Western countries have shared some general historical changes which have influenced the Western medical culture, for example, the doctor’s status, medical science, and also the Western perspective on life and death in relation to Christianity, the rise of individualism and the Enlightenment. The important thing is to look at how this common background, tendency, and change amongst different Western countries will relate to the care of the dying, particularly terminal cancer patients in Japan, when Japan imports the Western hospice movement. On the other hand, we should not bring the term ‘the East’ as an object for comparison with the West, because our primary interest is to consider what will be the issues in applying the Western hospice movement especially to Japanese medicine. This requires us to explore the details of the Japanese situation in regard to the care of cancer patients, attitudes to death and dying, and the doctor-patient relationship, and to distinguish them from those of other Eastern countries.

Another important question we have to raise at the very beginning of the book is whether one can make a cultural comparison or can understand both the Western and the Japanese culture in an objective way. We are not sure if it is possible for the writer of this book, I myself, to understand both the Western and the Japanese cultures. To some extent, I have been deeply influenced by Western culture; have an English name, TERESA; have been given a Catholic education since my childhood (though in Japan), and have lived in Great Britain for more than four years while studying at the University of Wales, Swansea. The way I think, look at things, and behave, whether consciously or unconsciously, may appear westernized in other Japanese people’s eyes.

On the other hand it may be also true that I have not been able completely to discard all my Japanese ways of thinking or behaving in only four years, because I have been brought up in a Japanese family and culture for the past twenty odd years. I may be acting, without awareness, in a very ‘typical Japanese way’ in Western people’s eyes, and will be treated as a Japanese or an Easterner by them no matter how many more years I live in this country. Thus I may be neither purely Japanese nor Western (British for example) and that means I have written this book, to some extent, as a ‘half outsider’ of both the Japanese as well as the Western culture. So I may be able truly to appreciate neither of the two cultures.

There is always the temptation of extreme cultural relativism in making a comparison between two cultures, by drawing too clear a line between them. But the experience of a person like myself could be a kind of evidence that the West and Japan share some basic moral values and that they cannot be totally separable, otherwise, I would not have been able to live in the West for four years, and make any sense of the experience. If there was no continuity between the two cultures at all, I would have needed ‘brainwashing’ in order completely to destroy my moral values as a Japanese person and change them into absolutely new ones so that I could adjust to life in the West. It is unrealistic to imagine that such ‘brainwashing’, which could create a ‘completely new identity’, can be done within four years. There is therefore no such a thing as perfect cultural relativism which determines that different cultures are unable to share moral values at all and in which ethical issues become merely a matter of culture. It is not of primary interest here to discuss the philosophical question of the existence of a universal innate moral awareness of humans beyond cultural differences, but to clarify the position taken in this study before going on to the main chapters so that we do not attempt to look at the two cultures as black-and-white. I may be a ‘half outsider’ but that means I am also a ‘half insider’ of the two cultures, and this may give me a positive advantage in getting a picture of both cultures and prevent the ‘temptation’ of extreme cultural relativism.

However, we will nevertheless discover some significant differences and difficulties in bringing the Western hospice philosophy to the Japanese medical culture. The main aim of this study is not to give any simple answer to these issues, but to determine some of the crucial questions that need to be considered, which have not yet been analyzed sufficiently in Japanese medicine. There will be no proper answers unless we find the right questions.

PART I

THE HOSPICE MOVEMENT IN THE WEST AND IN JAPAN

2 The Hospice Movement in the West

Introduction

It has become understood that hospice care is/will be one of the important alternative ways for the care of the terminally ill, especially, cancer patients. In this chapter, let us consider the nature of the Western hospice movement from several aspects, which will be a helpful basis for chapter 5, where we analyze how an attitude to death and dying and the doctor-patient relationship are reflected in the care of cancer patients in the West. We will tend to discuss the British hospice movement, since the modern hospice has its origin in Britain, and has more or less influence on hospices throughout the world, and we can see clearly and interestingly the crucial nature and underlying notions of the hospice there.

The History of the Hospice

First of all, let us consider how the term ‘hospice’ was born in the West and how it became a place particularly for cancer patients in the modern period. This historical analysis is necessary in order to understand the current problems raised by the modern hospice movement in the West, because such study reveals the process by which they have been created.

The Origin of the Word ‘Hospice’

The word ‘hospice’ came from the Latin ‘hospes’ which meant ‘guest’ but by late classical times, under the influence of Christianity, had changed to mean ‘a stranger’ not known personally to the host (Talbot, 1967, p.386; cited by Manning, 1984, p.33). Cicero (116–43 BC) said that ‘hospes’ implies a ‘host’ who welcomed an unexpected visitor and that ‘hospitalis’ meant ‘friendly’. A similar word for ‘hospitium’ in the Greek language was ‘xenodochion’ translated as a ‘place to receive the stranger’, in which ‘xenos’ meant ‘stranger’. In the Greek Bible, the term ‘xenos’ is used: ‘I was a stranger (xenos) and ye took me in’ (Matthew 25: 35). Jesus actually intended to say that we have to find Jesus (God) within each strange visitor, and to treat strangers lovingly as we do God. So ‘hospitium’ or pilgrims and strangers are called ‘xenodochia’. It is important to notice that in the classical era there was no idea of ‘the dying’ nor ‘cancer patients’, whether Latin or Greek, in relation to the term ‘hospice’, and the reason why ‘guest’ or ‘stranger’ has become replaced by ‘the dying’ or ‘cancer patients’ between the medieval and the modern age should be considered as one of the serious problems in the modern hospice movement, which we will discuss later in Section 3 (Manning, 1984, pp.33–34).

The Distinction between ‘Hospital’ and ‘Hospice’ in Medieval Times

There was no clear distinction between ‘hospice’ and ‘hospital’ in medieval times. The Latin word for ‘hospital’ is ‘hospitale’ or ‘hospitalia’. The former means ‘a large house, or place’ and the latter, ‘apartments for strangers’, which reminds us readily of the original concept of the word ‘hospice’ (An Etymological Dictionary of the English Language, p.272). Presumably, however, a ‘hospital’ tends to be bigger in scale than a ‘hospice’ as the Latin word ‘hospitale’ or ‘hospitalia’ implies ‘a large house’. Carlin tries to identify ‘hospice’ with one of the four classifications of hospital in the medieval period: ‘leper houses, almshouses, hospices for poor wayfayers and pilgrims, and institutions that cared for the sick poor’. None of the four supplied any professional medical care as modern hospitals do today. The inmates in leper houses and almshouses led ‘a semi-monastic life’. The fourth class identified by Carlin was uncommon and mainly cared for the non-leprous sick and poor (Carlin, 1989, pp.21–24). Taking the other three kinds of hospitals into consideration, let us now look at the more detailed history of the ‘hospital’ called a ‘hospice’ in Carlin’s third class.

The Emergence of the Distinction between ‘Hospital’ and ‘Hospice’

In the West, the hospice called a ‘hospitium’ already existed in Rome from the seventh or the eighth century, as a shelter for pilgrims visiting the tomb of St Peter. There was no evidence that the ‘hospitium’ gave any medical treatment except simply giving first aid for cuts and travel sores, nor that it was a place for the sick or the dying (Talbot, 1967; cited by Manning 1984, p.34). In the Middle Ages, the hospice flourished in Europe, and one of the typical hospices was located in Jerusalem, founded in 1100 AD by Brother Gerald, a member of the Knights Hospitallers of St John. The knights hospitallers expanded and established similar hospices in Italy, Germany, Malta, and England. The philosophy of these early hospices regarded the care of the soul to be as important as that of the body, so faith and love were considered to be more necessary than skill and science in the medieval hospice. Different religious foundations from the earliest times sheltered all comers especially Christian travellers and pilgrims and named themselves ‘hospices’ (Manning, 1984, pp.34–38).

At that time it was not easy to draw a line between a ‘hospice’ and the other three kinds of hospitals, where no professional medical care was given and the treatment of the inmate was care-centred. However it might be possible to say that hospices took a bigger part in caring for travellers and pilgrims than other hospitals did, though there seemed only a limited number of hospices dealing solely with people of this sort. Although the modern hospice movement emphasizes care-centred treatment for the dying, which challenges the modern hospitals’ cure-centred way, it was not necessary for the medieval hospice to be against the other three kinds of hospitals, since all of them were care-centred as much as the hospice was, and all lacked medical knowledge and facilities at that time. How have the ideas of hospice and hospital then come almost to oppose each other as the centuries have passed? To answer the question we need to see how the ‘hospice-like hospital’ in medieval times has been transformed into today’s hospital. Let us look at the process of the medicalization of medieval hospitals next.

The medicalization of hospitals began after the Black Death that occurred in the middle of the fourteenth century and ‘led to the immediate diversion of all charitable funds to medical hospitals’ (Henderson, 1989, p.70). As we will discuss in a later chapter on the history of the Western doctor’s status, however, it might be that the rise of the secular medical profession had already begun in the twelfth century. Before then, hospitals were under the order of the church, but from the twelfth century church councils forbade monks to go out from the monastery to give medical treatments to people outside so that monks would concentrate more on their religious work. This prohibition became the foundation of building secular medical schools and was the beginning of the separation of the medical profession from the church. Therefore, this change in the twelfth century should be considered as an important background against which the real medicalization arose from the time of the Black Death.

A real transformation of the hospitals from a ‘general refuge’ into a place only for the sick, and using medical technology, is linked to the Enlightenment in the late eighteenth century. An interesting phenomenon to notice is that the status of doctors in general became high in the social hierarchy from the time of the Enlightenment, because the development of science changed the image of the ‘intelligentsia’ and doctors although working in a practical field began to be recognised as part of this class, even though only a handful of doctors in theoretical fields had such a high standing in former ages. The doctor, on the whole, became able to earn prestige and economic power, and began to control the hospitals which were becoming reformed as institutions under professional authority. In relation to the improvement of the doctor’s status in line with the development of scientific technologies, in the middle of the late eighteenth century, medical surgery in Britain developed remarkably. In the early nineteenth century, surgeons became able to have their own college (see Chapter 4 for fuller details). The doctors and modern medicine since the Enlightenment have been concerned with the improvement of practical and scientific aspects of medicine in terms of the treatment of the patient, which made their status higher, while disregarding theoretical fields such as the philosophical as well as the ethical aspects of medicine. Consequently, hospitals were increasingly becoming ‘cure-centred’, and so there arose the clear distinction between the hospice as one form of the medieval care-centred hospital, and the modern cure-centred hospital. It was also the time when many special hospitals such as cancer hospitals were established. Through the doctor’s interest in the ‘cure’ of disease, ‘death’ tended to be understood merely as a defeat of medicine or science, which is unacceptable and disgraceful.

The Attitude to the Hospice in the Nineteenth Century

Although cancer hospitals in the nineteenth century tried to institute ‘hospices’ independent from any religious implication under the name of ‘Friedenheims’ which demonstrated a recognition of the needs of the dying, they came to nothing. This was because ‘the demands for the support of clinical research into cancer were given more priority, in the hope that discovery of a cure would remove the need for such places as ‘Friedenheims” (Murphy, 1989, p.221). To accept the hospice seemed to mean to admit the defeat of medicine and science, so cancer hospitals, ‘recognising that research would attract greater support than the care of the dying, shelved their Friedenheim plans and opened research laboratories’. Other cancer hospitals founded in various British cities tended to follow the pattern of paying attention to finding the medical cure for cancer. X rays were discovered at the end of 1895 and were first used in the treatment of cancer in 1896 (Murphy, 1989, pp.221–29). As hospices were replaced by hospitals, the holistic focus of the medieval hospice began to be neglected (Munley, 1983, p.29).

The Struggle in the Period of Modern Medicine

Herbert Snow, a consulting surgeon of the London Cancer Hospital, succeeded in using a mixture of opium and cocaine for cancer pain relief and published his research results in 1896 (Snow, 1896, p.718; cited by Murphy, 1989, p.227). Although this mixture became the basis of the Brompton cocktail, which would have an important role in the modern hospice care for the dying about seventy years later, no special notice was taken of this at the time (Murphy, 1989, pp.226–27).

In 1902, the Imperial Cancer Research Fund (ICRF) was established with a great expectation that ‘cancer would be cured as a result of the work of scientists in its laboratories’ (Murphy, 1989, p.227). During the Second World War, with the introduction of the medical treatment of cancer, aggressive treatments were reinforced even more by ‘new antibiotics and synthetic hormones aimed at cure’ (Infield, 1974; cited by Murphy, 1989, p.234). Consequently, by the 1960s, people were tending to die in hospital rather than in their homes (Murphy, 1989, p.234).

In the great progress of cancer treatment in the 1960s, patients and their families began to doubt whether aggressive treatment was really better than the disease itself. The question was raised about the worth of life prolongation if this was to mean continuous dramatic pain and suffering for a long time before death. Stoddard expresses his views of excessive life-prolongation at the university hospital in a dramatic way:

… The ICU is a supercomputer, a biochemical celebration, a sound-and-light show. It is also something like a launching pad. Disconnected from every familiar form of human contact and every ordinary support system, the patients lie one by one, espaliered, wired and turned like astronauts. (Stoddard, 1979, p.1; cited by Hill, 1989, p.4)

Against such inhuman treatment for the dying, the modern hospice movement started.

The Modern Hospice Movement

Hospice care survived through political as well as social changes by the effort of religious groups. During the seventeenth century in Britain, Sir Thomas Guy began a network of charitable hospitals, and Vincent de Paul (1581–1660) founded the hospice for galley slaves in France. Paul also founded an orphanage and established a Roman Catholic nursing order called ‘the Sisters of Charity’, dealing with nursing and teaching. By the eighteenth century the Sisters of Charity had founded hospices all over France, which revived the old philosophy of caring for the sick and dying with respect and compassion. Florence Nightingale was working with the Sisters of Charity in the nineteenth century. The actual idea of caring particularly for the dying in the hospice seemed to begin in the Dublin Hospice in the nineteenth century, where the old tradition of hospice care was transformed to a new understanding of the needs of the dying. In 1905 St Joseph’s Hospice was established by the Sisters of Charity from Ireland in response to the intolerable conditions in London’s East End, and the first patient was admitted in the same year (Manning, 1984, pp.40–42).

Without these Christian foundations which survived through the time of the Enlightenment and industrial revolution, the immediate development of the modern hospice movement from the 1960s might have been difficult. But on the other hand, the great hospice development since the 1960s until today is not imaginable either without the efforts of Cicely Saunders. Cicely Saunders was the first person who began to uni...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• 1 Introduction
• PART I: THE HOSPICE MOVEMENT IN THE WEST AND IN JAPAN
• PART II: ATTITUDES TO DEATH AND DYING AND THE HOSPICE MOVEMENT
• PART III: THE DOCTOR-PATIENT RELATIONSHIP AND THE HOSPICE MOVEMENT
• Bibliography
• Index