CHAPTER 5

Applications of Terror Management

Theory

As medical students are enculturated into the attitude of detached concern

and adopt the medical gaze commensurate with linear perspective vision,
they tend to demonstrate precipitous declines in empathy (Neumann
et al., 2011). Consequently, the decline in empathy increases the risk
that patients will be dehumanized (Haque & Waytz, 2012). Even while
students may thrive when it comes to objective examinations of medical
knowledge (e.g., Medical College Admissions Test), the decline in empa-
thy, not surprisingly, is found to be associated with diminished clinical
competence (Hojat et al., 2002).
Again, we witness here a theme of sacrifice. With linear perspective
vision, the culture gains a scientific project that serves, through exper-
imentation, to better predict and control the materiality of our world.
But these gains are granted at the expense of an appreciation for the
richness and complexity of lived experience. As Becker (1973) put it,
“Manipulative, utopian science, by deadening human sensitivity, would
also deprive men of the heroic in their urge to victory” (p. 284).
Similarly, within medical education and clinical training, young physi-
cians adopt a mastery of an objective, detached knowledge of the body,
disease, and death, which is meant to be in the service of enhancing the
health of the patients they serve. But the attitude within which such
mastery is made possible is, at the very same time, a distinct threat to
the kind of empathic engagement necessary for building relational rap-
port with patients. Ironically, the detached attitude required for mas-
tery of analyzing and dissecting the medicalized body of the cadaver

© The Author(s) 2018 85

B. D. Robbins, The Medicalized Body and Anesthetic Culture,
https://doi.org/10.1057/978-1-349-95356-1_5
86  B. D. Robbins

sets up the very conditions in which a loss of empathic engagement with

patients entails a threat to the health and well-being, not only of the
patients served by such physicians, but the physicians themselves. Indeed,
research has shown overwhelmingly that patient health is critically under-
mined when treated by physicians who lack empathy for them (Neuman
et al., 2011). And, in addition, physicians with a diminished empathic
engagement with patients are especially at risk of burnout, emotional
exhaustion, and/or depression (Thomas et al., 2007).
Medical students begin their education with empathic capacities that
exceed their peers (Thomas et al., 2007). The diminution of empa-
thy among medical students typically reaches its peak when students
first encounter actual, living patients in their medical residency (Bellini,
Baime, & Shea, 2002; Bellini & Shea, 2005; Chen, Lew, Hershman,
& Orlander, 2007; Hojat et al., 2004; Rosen, Gimott, Shea, & Bellini,
2006). While the loss of empathic engagement can be partly explained
by high workloads, lack of social support, and problematic relationships
with mentors, research evidence supports the intuition that a numbing
of empathic connection with patients also, and perhaps even primar-
ily, results from the distress medical students experience in the wake
of confronting patients who are faced with suffering, death, and dying
(Neumann et al., 2011).
Confrontation with the mortality of real patients likely triggers com-
pensatory, defensive processes identified by terror management theory.
First, the medical culture provides cover in the form of advanced tech-
nologies, a technical vocabulary that serves as euphemistic and de-po-
tentiated linguistic devices for talking about suffering and mortality, and
protection in the form of an emphasis on a detached attitude considered
superior for its objectivity in the face of possible emotional decompensa-
tion (Chen et al., 2007; Hojat et al., 2004). Here, within the technolog-
ical world of medical practice, the body of the patient, viewed through
the lens of the objectified, mechanistic cadaver, is able to provide shelter
and cover for the living body of the suffering and the memorial bodies of
the deceased. To view the body in this fashion, from the detached gaze
of linear perspective vision, is to distance one’s self from the catastrophic
realization of one’s own potential for suffering and death.
A student is also capable of finding some relief in a sense of profes-
sional achievement (Thomas et al., 2007). However, while this preserves
a better capacity for intimacy with living patients, it nevertheless creates
a new temptation to distance oneself from the suffering and dying by
 5  APPLICATIONS OF TERROR MANAGEMENT THEORY  87

adopting an elite attitude of superiority based on one’s professional role

(Marcus, 1999; Thomas et al., 2007; van Ryn et al., 2014). In either
case, the young medical professional, through institutionalized practices,
is tempted into making a trade-off in which empathy is exchanged for a
sense of security in the face of unbearable suffering and loss.

Terror Management Theory and Medical Coping

Both of these strategies of the medical professional recollect the basic
principles of terror management theory, based on the work of Ernest
Becker (1973). The strategy which emphasizes pride in one’s achieve-
ment, and the potential dark side of elitism that may arrive with it, is
an example of the use of self-esteem as a buffer against death anxiety.
The danger of maladaptation, in this case, is the dehumanization of the
other who threatens one’s self-conceit, and who therefore comes to bear
the brunt of the aggression that results from the unconscious desire to
destroy those who remind us of our finitude. For Becker, self-esteem is
a result of a person’s self-assessment that he or she measures up to his or
her cultural values. To measure up to one’s cultural values is to find one-
self a champion of the cultural hero-project. And to be a cultural hero,
in a certain sense, is to possess a fantasy that one may be immortalized as
a hero, forever identified with something much larger and more endur-
ing than oneself. When the self-esteem is particularly vulnerable, such
as in cases where the idea of death is made salient, the ego protects its
pride, typically, through aggressive, exclusionary tactics aimed at those
who threaten one’s worldview. Identification with the role of the physi-
cian is to identify with a highly prized and rewarded identity. A danger
resides in a potential elitism by which the physician may protect his or
her self-esteem by taking on an attitude of superiority.
When self-esteem is threatened due to exposure to thoughts of death,
as is typical in medical settings, additional stress and depletion of coping
resources raise the risk that the self-esteem defense mechanism will falter.
This is especially a risk as the physician encounters situations where his
or her expertise or knowledge is met with limits or defeat. Terror man-
agement theory predicts, in such situations, the individual will be faced
by increased anxiety and amplification of defensive means of protect-
ing the self against the terror of mortality. The result in these cases may
be increased burnout, cynicism, debilitating anxiety, and/or feelings of
despair and depression.
88  B. D. Robbins

Empirical research in terror management theory lends abundant

evidence to support these observations. Understanding the basic prin-
ciples of terror management theory, and relevant research, provides a
hermeneutic key to understanding the physician’s socialization into
detached concern and its consequences. This excursion will prove
to be especially important for a subsequent analysis of the physician’s
response to death anxiety through the objectification of the body and
its relevance to the modern worldview described in previous chapters.
The physician’s response to death anxiety through the objectification
of the body has, quite literally, become a ubiquitous and generalized
theme of the modern worldview. It should be abundantly clear at the
close of this analysis that the denial of death in modern medicine is at
the heart of the project of modernity and its symptoms.

Self-Esteem and Cultural Worldview

as Buffers Against Death Anxiety

According to terror management theory, self-esteem plays a key role

in buffering general anxiety and anxiety regarding one’s mortality
(Solomon, Greenberg, & Pyszczynski, 1991). In childhood, the individ-
ual is socialized by the parents into the adoption of prized social values,
and the child learns to avoid what are perceived to be behaviors and atti-
tudes frowned upon by the parental unit. The child discovers self-value
through the “nourishing, fondling, and admiring” of the parent, whose
affirmation provides the child with a deep, ontological sense of security in
the face of anxiety and uncertainty (Becker, 1962, p. 79; 1964, p. 440).
Disapproval of the parent threatens these feelings of security and provides
an incentive to adopt the values of the parent to maintain intimacy and
a sense of well-being provided by the parent’s perceived omnipotence.
“The previously clung-to, inseparable mother object stands menacingly
aloof, now imposing conditions. The child has to ‘earn’ the affection
which was heretofore unquestioningly his” (Becker, 1962, p. 59).
Through this process of striving for the parent’s approval, the child
builds an ego, which protects the self against anxiety. The ego emerges
through the incorporation of an identity that situates itself and evalu-
ates itself in relation to the ideals of the symbolic matrix of the culture,
handed down through parental approval and disapproval. When the child
matures to the extent that the parents are recognized also to be mor-
tal and fallible, the child transfers his or her source of self-esteem from
the parent to a more expansive self-system linked to cultural systems of
 5  APPLICATIONS OF TERROR MANAGEMENT THEORY  89

meaning beyond the domestic sphere. “Children respond to the realiza-

tion of their parents’ limitations and their own mortality in two ways:
ambivalence toward the parents and a shift in the basis of self-esteem
from the parents to the culture” (Solomon et al., 1991, p. 24). From
this point on, self-esteem is gauged in relation to the values embedded
within the worldview of one’s culture.
One’s cultural worldview is therefore closely linked to self-esteem.
The worldview serves a number of important functions. First, the world-
view provides the individual with a sense of stability and meaning, as well
as a system of values through which an implicit ethics provides a guide
to appropriate and inappropriate behavior. The worldview also gives the
person the promise of value, or self-esteem, to the extent that he or she
lives up to these cultural values, and typically upholding these values is
incentivized by the promise of reward in the form of security and even
immortality (Solomon et al., 1991, p. 25).
Psychological studies support the hypothesis that self-esteem serves
the function of protecting the self from impinging anxiety. Experiments
have shown that individuals who watch a video about death are less
anxious when they are given positive feedback about their personality
(Greenberg et al., 1992). When participants in an experiment anticipated
painful, electric shocks, the enhancement of self-esteem helped to dimin-
ish anxiety (Greenberg et al., 1992).
The anxiety-buffering function of self-esteem has been shown to also
operate in conditions of anxiety triggered by fear of mortality. For exam-
ple, people were found to be less likely to deny vulnerability to an early
death when they received positive feedback on their personality, and indi-
viduals high in trait anxiety were found to be more prone to a cognitive
bias in which the individual denies his or her vulnerability to a foreshort-
ened life span (Greenberg et al., 1993). Moreover, when individuals
with high self-esteem, as compared to those with lower ­self-esteem, were
exposed to death-related stimuli, they were less likely to respond with
compensatory defenses of their worldview (Harmon-Jones et al., 1997).
Those with high self-esteem appear to have a superior ability to sup-
press death-related thoughts (Harmon-Jones et al., 1997). This capacity
to manage death-related anxiety among those with self-esteem is linked
to ego-strength, a reflection of one’s ability to manage emotion, moti-
vation, drives, and one’s environment (Davis, Bremer, Anderson, &
Tramill, 1983). The negative relationship between self-esteem and state
anxiety has been found not only to apply to the general population, but
also to medical professionals (Suliman & Habili, 2007).
90  B. D. Robbins

Neuroscientific Evidence:
The Role of the Insula
Research in neuroscience has identified brain mechanisms that may account
for the role of self-esteem as a protective defense against thoughts of mor-
tality. When participants were exposed to death-related stimuli, as com-
pared to unpleasant stimuli unrelated to death, brain imaging revealed
less activation in the bilateral insula (Klackl, Jonas, & Kronbichler, 2014).
Those participants with high self-esteem were found to have greater deacti-
vation of the bilateral insula. In contrast, those with low self-esteem, when
exposed to death-related stimuli, showed greater activation in the bilat-
eral ventrolateral prefrontal and medial orbitofrontal cortex (Klackl et al.,
2014). Activation of these latter regions of the brain implies more explicit
and effortful cognitive processing, something along the lines of rumination.
The bilateral insula serves a variety of important functions, includ-
ing interoception of bodily sensations, such as pain and emotion (Craig,
2009), not only in oneself but in response to the pain and suffering of
others (Jackson, Brunet, Meltzoff, & Decety, 2006; Jackson, Meltzoff,
& Decety, 2005; Lamm, Decety, & Singer, 2011; Singer et al., 2004).
That is, the bilateral insula seems to play a key role in empathy, espe-
cially empathy relevant to the pain and suffering of other people. And
this empathic capacity seems to be linked to bodily awareness.
Interestingly, those individuals who are prone to anxiety tend also to
have hyperactivity in the insular region (Simmons, Strigo, Mathews,
Paulus, & Stein, 2006). When exposed to emotional faces, individuals
who are prone to anxiety show higher activation in the insular region as
well as in the bilateral amygdala (Stein, Simmons, Feinstein, & Paulus,
2007). Individuals with generalized anxiety disorder have also been
found to have higher activation in the insula and amygdala when exposed
to emotional images (Sha, Klumpp, Angstadt, Pradep, & Phan, 2009).
Increased insula activation in those with anxiety—including panic disor-
der, obsessive-compulsive disorder, and generalized anxiety disorder—
seems to be linked with the intolerance of uncertainty in the face of
ambiguous affective stimuli (Simmons, Matthews, Paulus, & Stein, 2008).
In fact, anti-anxiety medications seem to work by operating on precisely
these brain mechanisms. The anti-anxiety drug lorazepam, for example,
causes dose-dependent decreases in the activation of both bilateral amyg-
dala and insula during the process of emotions (Paulus, Feinstein, Castillo,
Simmons, & Stein, 2005). Remarkably, both self-esteem and anti-anxiety
 5  APPLICATIONS OF TERROR MANAGEMENT THEORY  91

medications appear to serve the same mediating function of reducing

bodily awareness of pain and suffering—and thus ameliorating anxiety—
however, at the risk of diminishing empathy. States of mind that cultivate
bodily awareness, such as mindful attention, on the other hand, are linked
to both high self-esteem and lower anxiety (Rasmussen & Pidgeon, 2010).
When high self-esteem is paired with insensitivity to others, the result
is a narcissistic personality; whereas, those with socially adaptive varia-
tions of self-esteem maintain a communal orientation, which is invested
in the well-being of others (Campbell, Rudich, & Sedikides, 2002). The
narcissistic individual, in contrast, manages relationships and interper-
sonal distress primarily through anti-social channels, including hostility,
grandiosity, and dominance (Raskin, Novacek, & Hogan, 1991).
Neuroscientific research on narcissistic personality has demonstrated
that subclinical narcissistic traits are linked to deactivation of the insula of
the brain (Fan, Wonneberger, Enzi, & de Greck, 2011). The researchers
found that individuals high in narcissism deactivated the part of the brain
linked to empathy more often than those with low scores in narcissism.
These same individuals with high narcissism also scored high on a meas-
ure of alexithymia, a construct related to difficulty understanding and
managing emotions in one’s self and in others. This brain imaging study
corroborates clinical and empirical observations that individuals with nar-
cissistic traits have difficulty with self-regulation of their cognitive and
affective processes, especially within social contexts.
The narcissistic type is one whose grandiosity and yet vulnerable sense
of self motivate the individual to find affirmation and esteem from other
people. However, due to the narcissist’s insensitivity to other people and
beliefs regarding the inferiority of other people, their attempts at affirma-
tion backfire and, in the end, only re-affirm their underlying feelings of
inadequacy (Morf & Rhodenwalt, 2001). In turn, once again, the under-
lying sense of inferiority and vulnerability sets up the need for the narcis-
sistic defensive reactions, the counterproductive strategies of grandiosity
and contempt for others. Underneath it all, the narcissist is in search of
valid, healthy self-esteem, as a means to manage uncertainty and anxiety,
but the attempt to live up to the existential hero project is met over and
over again with self-defeat. Management of underlying anxiety through
suppression of empathy, via the brain mechanism of deactivation of the
insula, and diminishment of sensorimotor awareness temporarily numbs
the narcissist’s pain and frustration, but at the cost of minimizing the
very capacity most needed to escape the vicious cycle: healthy self-esteem
marked by humility and empathy for others.
92  B. D. Robbins

The deactivation of the insula in those with anxiety and among nar-
cissistic types leads to a lowering of bodily awareness and the suppression
of empathic engagement with others. The defense of the ego, in these
cases, has been shown not only to be linked to internalizing behaviors,
such as anxiety and depression, but also to externalizing behaviors of vio-
lence and aggression (Baumeister, Smart, & Bolden, 1996).
We have seen how important the hero project is to the maintenance
of anxiety about mortality. When another person criticizes, attacks or
demeans a highly valued aspect of one’s self, no matter how deserved that
criticism may be, the individual with an inflated sense of self will com-
monly react with hostility and even, at times, with violence. When beliefs
about one’s value are based upon a sense of superiority that rests upon
shaky ground due to inflation, instability, or beliefs that are tentative, the
individual can avoid adjusting their self-evaluations in a downward direc-
tion by channeling anger and hostility, instead, toward the agent who
called those beliefs into question (Baumeister et al., 1996, p. 5). In con-
trast, a person with a more stable sense of self-worth is able to tolerate
negative evaluations of the self, and, consequently, extraordinary means of
managing self-esteem by attacking others is rendered unnecessary. When
communal, prosocial values rank high in an individual’s worldview, the
person with high self-esteem is also especially motivated to protect and
repair relationships when they are confronted with disgruntled but valued
family, friends, and colleagues. These values provide additional incentive
to avoid reliance on hostile and aggressive defenses to manage self-worth.
The findings reviewed thus far corroborate terror management theory’s
understanding of the role of self-esteem in adaptation, whereby adaptation
is conceptualized “as the minimizing of anxiety through the perception
that one is a valued member of a meaningful universe” (Solomon et al.,
1991, p. 26). This process of adaptation consists of two central motiva-
tions, one of which is a search for validation of one’s self-worth and the
worldview that gives meaning to self-worth, and another that consists of
efforts to minimize or avoid threats to self-worth, especially those which
undermine one’s sense of value and meaning.

Management of Threats to Self-Worth

Threats to self-worth can be parceled out into two types. On the one
hand, those within our own culture, and who by virtue of a shared
worldview have adopted the same values, hold the potential to threaten
one’s personal sense of value. Because others within our culture share
 5  APPLICATIONS OF TERROR MANAGEMENT THEORY  93

our values, we depend upon these compatriots to affirm our hero project,
or to recognize our achievement in upholding the values of the culture. If
and when a person challenges our foundational beliefs or puts our value
into question, that person constitutes a threat to our self-worth. On the
other hand, there are those who reside outside of our culture, and who
thereby do not share with us a common worldview. These strangers to
our cultural horizon threaten the meaning of our worldview merely by
virtue of the fact that they exist. The person who testifies to a worldview
different than one’s own, by default, stands as direct proof that other
worldviews exist. The existence of other, incompatible worldviews give
rise to the implication that perhaps the worldview I hold may not be valid.
So, we have threats to value internal to our culture, and threats to mean-
ing that come from outside of the culture. Threats to value and meaning
represent different kinds of threats that are managed in different ways.
In the case of threats to one’s value, we possess a variety of cognitive
strategies for managing self-esteem. For example, when participants are
exposed to thoughts about death, they tend to use more s­elf-serving
attributions. By managing anxiety, self-serving attributions allow for
maintenance of performance at various functional tasks (Mikulincer &
Florian, 2002). Self-serving attributions protect self-esteem when an
individual attributes positive outcomes to their own efforts, yet percep-
tions of failure are attributed to circumstances beyond one’s control.
By assuming credit for success and deflecting blame for failure, personal
value is preserved, thus protecting the self-esteem needed to buffer death
anxiety. This tendency among those with high-esteem is linked with
­decision-making processes. Due to the protection of self-serving attribu-
tions, high self-esteem individuals, when faced with the salience of mor-
tality, are more willing to take risks in order to achieve outcomes even
when failure remains a distinct possibility (Landau & Greenberg, 2006).
This motivation is amplified in the case of conditions where the high
self-esteem individual is faced with thoughts of mortality.
Protection of personal value can appeal to other, similar defensive,
cognitive processes. For example, individuals can identify more closely
with a group that represents success and distance themselves from
groups that have become associated with failure (Snyder, Lassegard, &
ford, 1986). By “basking” in the glory of a successful group, the per-
son is able to enjoy some of the after-glow of the group’s success, which
serves the function of enhancing personal value. By cutting themselves
off from association with groups associated with failure, the individual
protects him- or herself from the blow to self-esteem that would come
94  B. D. Robbins

with identifying too closely with the perceived “losers.” For this reason,
sports fans are more likely to identify with a team when they are win-
ning, but may refrain from fandom activities when the same team is on a
losing streak (Dechesne, Greenberg, Arndt, & Schimel, 2000). In these
ways, social affiliation serves a self-esteem maintenance function.
Affiliation with others in order to maintain self-esteem can also take
the form of social comparisons. When people feel threatened, they tend
to evaluate themselves in comparison with those who are worse off. This
downward social comparison serves the function of improving self-esteem,
because, in comparison with those who fair worse than us, we typically feel
more fortunate (Taylor & Bolel, 1989). However, in cases where informa-
tion about a threat is more important than enhancement of self-esteem,
we may choose instead to seek out those who are doing quite well in the
face of a threat. Through our affiliation with those who are more fortu-
nate, we stand to gain more information that might help us cope with
the threat. Modeling our own behavior on those who are doing well also
provides us with increased motivation and hope that we too can survive
the threat. Nevertheless, in cases where the comparison to others is down-
ward, in relation to one who is worse off, the comparison primarily serves
the purpose of maintaining personal value.
Another social mechanism for self-esteem management is the
false-uniqueness phenomenon (Suls & Wan, 1987). When it comes to
our negative qualities, we have a tendency to believe that other people
share our faults. In other words, we overestimate consensus. On the
other hand, when it comes to our desirable qualities, we tend to believe,
falsely, that these desirable qualities make us special because we are
unique compared to other people. In fact, in most cases, we underesti-
mate the extent to which other people share our positive attributes. This
is rather convenient since having a sense of being special serves the func-
tion of bolstering one’s sense of value and self-esteem.
One last example: Another way our minds protect our self-esteem is
through the information we seek, or do not seek, for that matter. When
participants in an experiment were exposed to thoughts about death, and
when faced with making a decision, people showed an increased prefer-
ence for information that validated their decision rather than information
that conflicted with it (Jones, Greenberg, & Frey, 2003). This evidence
shows that a very common cognitive bias, called the confirmation bias, is
influenced by our thoughts about death and dying. To bolster our self-esteem
and manage death anxiety, we tend to seek information in a way that is
 5  APPLICATIONS OF TERROR MANAGEMENT THEORY  95

biased toward information that makes us feel good about ourselves. The
glow of self-esteem that results from the cognitive bias does serve to pro-
tect us from death anxiety, but at a substantial cost. Because our search
for information is biased by an irrational desire to feel good about our-
selves and forget about death, we seem to be quite willing, at least sub-
consciously, to forgo the truth.
In Becker’s (1973) theory, the development of character, or the ego,
requires some element of self-deception, which he calls “the lie of char-
acter” (p. 72). The person who is relatively healthy or adaptive will pos-
sess a character that is “ego-controlled and self-confident” and engages in
appraisals of the world that are “open more easily to experience” (p. 72).
Even in the cases of high-functioning people, however, the onset of threats
to self-esteem, especially when coupled with anxiety about mortality, has
a tendency to mobilize cognitive and physiological mechanisms to pro-
tect self-esteem and, as a consequence, restrict access to experience. The
range of experience can become limited as a device to protect the ego dur-
ing times of vulnerability. We can become cutoff from our bodily aware-
ness, severed from empathic understanding of other people, and distorted
in our judgments about our culpability and responsibility for outcomes.
Yet, for the most part, the person with an underlying secure self-esteem
manages to maintain a relatively open access to the wide range of experi-
ence, and, while biased in self-serving ways, judgments tend less often to
devolve into self-defeating patterns.
However, in many cases, the development of character armor can
be maladaptive to the extent that it results in “too much blockage, too
much anxiety, too much effort to face up to experience by an organism
that has been overburdened and weakened by its own controls: it means,
therefore, more automatic repression by an essentially closed personality”
(p. 72). As we have seen, contemporary psychology provides a compel-
ling body of evidence that supports Becker’s observations. Those with
healthy self-esteem seem to maintain healthy patterns of self-regulation
of emotion and intrapersonal relationships, and death anxiety remains
relatively under control without overly restricting access to bodily
awareness and empathic engagement with other people. However,
with debilitating levels of distress and anxiety, and when coupled with
underlying feelings of insecurity and vulnerability due to low or unsta-
ble self-esteem, individual experience becomes overly restricted. These
restrictions paradoxically amplify the problem, because in the long
run they increase anxiety, impair relationships necessary to build and
96  B. D. Robbins

maintain a secure sense of self and interfere with judgment to the extent
that a person’s achievements are often self-handicapped. At least two
extreme forms of maladaptation in this context include trait anxiety and
narcissism. Whereas the anxious person lacks sufficient cognitive, emo-
tional, and social resources to manage mortality threats, the narcissist
relies upon counterproductive strategies that involve inflating the self by
cutting off empathy and through the dehumanization or diminishment
of others, even to the extent of overt hostility and violence when the
self-system is especially threatened.

Threats to Meaning
So far, we have examined threats to value. In these cases, the threats
to self-worth occur among other people who share our worldview.
Due to their own achievements, or their criticism, judgement, or social
rejection, we can feel existential threat that mobilizes us to bolster a
self-esteem under assault. However, we have not yet touched upon
threats to meaning. Whereas threats to value come from encounters with
others who share our worldview, threats to meaning involve encounters
with others who do not share our worldview. Terror management the-
ory predicts that simply the presentation of other people with differing
worldviews is sufficient enough to produce a threat to meaning. These
threats to meaning, in turn, will heighten anxiety and mobilize defenses
to respond to the threat.
Threats to a religious worldview have been studied and support these
predictions of terror management theory. When people are presented
with evidence that contradicts their religious faith, we find that, paradox-
ically, the faithful compensate for this threat through an increase in their
faith (Batson, 1975). An experiment found that when the faithful are
presented with cognitively dissonant information about their faith, they
experience less negative affect when they are able to appeal to transcend-
ent explanations—i.e., explanations that appeal to realities beyond the
material world—and they also feel better when they are given opportuni-
ties to bolster their threatened beliefs (Burris, Harmon-Jones, & Tarpley,
2010). People feel shame and guilt when they are confronted with their
own religious hypocrisy, a discrepancy between their beliefs and their
behavior (Yousaf & Goet, 2013). However, these feelings of guilt and
shame can be eliminated through the implied recovery of self-esteem,
when participants engage in tasks that affirm their religious faith.
 5  APPLICATIONS OF TERROR MANAGEMENT THEORY  97

Terror management research has also shown how death anxiety can
trigger biases toward members of our in-group and increase hostility or
prejudice toward those who do not share our worldview. Christian par-
ticipants, for example, were more likely to evaluate fellow Christians
more favorably and to evaluate Jewish people more negatively, when they
were exposed to thoughts about death (Greenberg et al., 1990). Also,
again under conditions of death salience, participants were found to eval-
uate more positively those who favor their worldview, yet held increased
negativity toward those who criticized their worldview. These types of
effects were virtually eliminated, however, when participants were primed
to think about the value of tolerance (Greenberg, Simon, Pyszczynski,
Solomon, & Chatel, 1992). Since mortality salience amplifies adherence
to closely held cultural values, those values that are especially salient, in
this case tolerance, are the values that will tend to influence how defen-
sive cognitions intervene to protect self-esteem.
These types of defenses in response to worldview threat are not lim-
ited to religious worldviews. For example, studies have shown that
judges in the court of law are subject to similar defensive reactions in
response to alleged criminals whose crimes threaten the meaning of the
judge’s moral universe (Rosenblatt, Greenberg, Solomon, Pyszczynski,
& Lyon, 1989). In an experimental setting, judges were presented with
the case of a prostitute and were asked to recommend a price for bond.
When the judges were exposed to thoughts about death, they demon-
strated an increased tendency to pronounce much higher bonds for the
prostitute, presumably as a means to bolster the perceived threat to cul-
tural values embodied by the criminal behavior of the prostitute. The
same effect occurred with students, but only with students who shared
with the judges a negative attitude toward prostitution (Rosenblatt et al.,
1989). In contrast, when experimental subjects were presented with a
person represented as a hero who upheld cultural values, the awareness
of mortality led to the recommendation of larger rewards for the hero’s
behavior. These findings demonstrate how individuals perceive and react
to others who either threaten or uphold cultural values that are dearly
held—values that, if undermined, represent a threat to meaning and, by
implication and indirectly, a threat to self-esteem.
The theory also extends to political ideologies. In an experimental
paradigm, participants were asked to write about either their own death
or a topic unrelated to death. After the writing exercise, the participants
were exposed to one of the two targets—either a person who criticized
98  B. D. Robbins

their political perspective or one who did not. Next, the participants
were asked to participate in a taste test exercise, in which they would
select the amount of hot sauce the target would receive. When the par-
ticipants had been exposed to writing about death, and when presented
with a target with a differing political perspective, the participants (as
compared to participants in the other conditions) opted to give their tar-
get a much higher proportion of hot sauce (McGregor et al., 1998). The
allocation of a larger amount of hot sauce represents a form of aggression
toward the target. Participants who were given an opportunity to der-
ogate their target by expressing a negative attitude, on the other hand,
were less aggressive toward the target, an indication that derogation of a
person who represents a worldview threat may serve the same defensive
function as aggression.
The pattern of increased aggression as a result of mortality salience
and threat to one’s worldview has also been found to apply to attitudes
about military interventions in foreign nations (Pyszczynski, 2006).
Under conditions in which Iranian students were exposed to thoughts
about death, they were likely to endorse martyrdom as a military tac-
tic. American students under the same conditions were more likely to
endorse military interventions even at the cost of killing many civilians.
Right-wing authoritarianism has been found to be especially associated
with endorsement of military interventions (Motyl, Hart, & Pyszczynski,
2010). However, the influence of mortality salience on right-wing
authoritarian attitudes toward military interventions can be eliminated
when war and violence are associated with animal-like behaviors. The
motivation to deny creatureliness and, by implication, one’s mortality
appears so strong as to override the influence of political ideology on
aggressive attitudes. In any case, overall, mortality salience has a very
robust influence on bolstering political attitudes and, in some cases, may
especially influence attitudinal shifts toward more conservative, or cultur-
ally stable, worldviews (Burke, Kosloff, & Landau, 2013).

Social Prejudice, Stereotyping

and Intergroup Conflict

The social psychological effects of terror management help us to under-

stand dynamics that lead to social prejudice, stereotyping, and intergroup
conflict. When individuals are exposed to others who are perceived to
belong to an out-group with a differing worldview, and especially when
 5  APPLICATIONS OF TERROR MANAGEMENT THEORY  99

mortality is brought to one’s awareness, the tendency for maladaptive

attitudes of prejudice and stereotyping is substantially increased, and this
exposes minorities and out-group members to derogation or victimiza-
tion (Greenberg & Kosloff, 2008). Even minorities who are targets of
prejudice and stereotyping are at risk of distancing themselves from their
in-group and endorsing group stereotypes under conditions of death
salience. In general, the management of self-esteem enlists the defense
of one’s worldview, especially moral codes highly favored by one’s cul-
ture, as a way to manage underlying feelings of vulnerability triggered by
awareness of mortality (Kesebir & Pyszczynski, 2011).
The empirical evidence in support of terror management theory is
compelling and testifies to the validity of Ernest Becker’s (1973) theory
that much of our behavior, at a level mostly beneath our awareness, is
motivated by the management of anxiety related to our mortality. With
the empirical validity of terror management theory established, we can
now return to the physician, and better understand how ongoing expo-
sure to cues related to death and dying naturally expose the medical
­professional to ongoing thoughts of his or her own mortality. We should,
therefore, expect defensive, compensatory mechanisms to operate among
physicians, just as they do with the general population.

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