© Copyright Irish Journal of Sociology ISSN 0791 6035

Vol. 17.2, 2009, pp. 41–55

A figurational approach: views of communication and

­awareness of death and dying in Ireland

una macconville
Centre for Death and Society, University of Bath
regina mcquillan
St Francis Hospice, Dublin

Abstract
Open awareness and communication in death and dying have become important
aspects in caring for people who are terminally ill. This change began in the
1960s and has been driven by social and ideological factors, especially in highly
individualistic societies such as the US and the UK. While this is the preferred
interaction within palliative care, open awareness and communication about
death and dying can be resisted in some societies where families seek to protect
their relative from the truth of a terminal illness. This article considers some
attitudes to open awareness and communication in Ireland from recent research
and a popular radio talk programme. This suggests that while there is openness
about issues of mortality in Ireland, there can be resistance when terminal ill-
ness becomes a reality within a family. Elias’s figurational approach is utilised
to understand these differing responses.
Key words: open awareness, death, dying, palliative care, Ireland

Introduction
Elias (1985) observed that ‘never before in the history of humanity have the
dying been removed so hygienically behind the scenes of social life’ (1985: 23).
He considered changes in attitudes to death as part of long-term social proc-
esses, akin to other civilising social processes and his observation refers to the
increased medicalisation of society, of which the experiences of death and dying
clearly form a part. In the USA, sociologists Glaser and Strauss (1965) were in-
fluential in the debate on communication and awareness about dying in modern
western societies. Their study, Awareness of Dying, researched the organisa-
tion of dying in hospitals in the San Francisco Bay area and was concerned
with the way in which awareness about death was managed and communicated.
They identified four ‘awareness contexts’ – closed awareness, where staff kept

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p­ atients ignorant of their impending death; suspicion awareness, where patients

suspected that they were dying and tried to get staff and relatives to confirm this
suspicion; mutual pretence, where all parties knew that the patient was dying
but did not acknowledge this, pretending that ‘everything was normal’; and
open awareness, where all parties knew about, and acknowledged the fact that
the patient was dying and were therefore able to talk about it.
While open awareness about death and dying was not a common practice for
much of the twentieth century, a shift toward this began in the mid-1960s par-
ticularly in the United States. For example, a study published in 1961, ‘What to
tell cancer patients’ (Oken 1961), showed that 88 per cent of doctors would not
normally tell cancer patients their diagnosis yet when this study was later rep-
licated in the 1970s, Novak et al. (1979) found that 98 per cent of respondents
would usually tell their patients the diagnosis.
There are a number of reasons why this shift occurred; improved healthcare,
and in particular improvements in the treatment of cancer, meant that many peo-
ple spend a longer time living with incurable illness. As a result, it can be more
difficult to hide the truth about a terminal illness, or at least more difficult to
manage non-disclosure (Walter 1994: 32). In the USA, a change in the legisla-
tion enforcing the patient’s right to informed consent also ensures that patients
are informed about why treatment is needed, and consequently there can be
open discussion about the illness and prognosis (Field and Copp 1999).

The modern hospice movement

The 1960s also saw the emergence of the modern hospice movement. While
hospices, as places to care for the dying, have a long history and can be docu-
mented from the fourth century (Small 1998), ‘hospice’ in contemporary socie-
ties is a term that describes both a place and a philosophy of care that takes place
in a wide range of care settings. The term ‘palliative care’ rather than hospice is
now more widely used. Open awareness and communication in death and dying
are important aspects of palliative care, which is the active, total care of patients
whose disease is no longer responsive to curative treatment. Control of pain and
symptoms and of psychological, social and spiritual problems is paramount and
the goal of this model of care is the achievement of the best possible quality of
life for patients and their families (WHO 1990).
In the UK the current model of hospice care is one that has developed from
the work of Dame Cicely Saunders who, with other medical professionals be-
came disillusioned with the care of dying patients in hospitals and established
St Christopher’s Hospice in London (Small 1998: 170). The ideal of the hos-
pice movement was to provide a form of extended family which sought to give
patients a more personal form of care and which stressed the importance of
including the family as well as the dying person within the remit of care (Du
Bois 1980). St Christopher’s quickly became a model for future developments,

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inspiring other groups of people across the UK to set up their own services
(Lunt 1985: 753).
In the USA Elisabeth Kübler-Ross was another key influence in the area of
death and dying, promoting holistic care for dying people (Small 1998: 175)
and like Saunders in the UK, observed the isolation of dying patients and a
lack of attention to their needs. She developed a stage theory of dying, based
on studies of over 200 dying patients, and observed that, in coming to terms
with a terminal illness, many patients went through the stages of denial, anger,
bargaining, depression and acceptance (Kübler-Ross 1970). While stage theory
was highly influential in shaping understandings of the experiences and needs
of dying people, particularly in nurse training (Walter 1994: 72) where it filled
a void in healthcare theory (Copp 1998), questions have been raised about its
adequacy and validity (Weisman 1974; Charmaz 1980; Kastenbaum 1985).
Lawton (2000) has argued that the modern hospice movement formed part of
a broader cluster of social movements that shared a number of features. There is,
according to Lawton, a distinct parallel between the hospice and the alternative
health movement as both advocate that the patient should be seen as a ‘whole
person’ (Lawton 2000: 14). There are also parallels with the women’s health
movement, which challenged the technological focus of modern medicine, par-
ticularly in relation to childbirth. The natural death movement, established in
the early 1990s (Albery, Elliot and Elliot 1993), is based loosely on the natural
birth movement and while not advocating that people die without any kind of
pain relief or intervention, encourages the dying person to take control of their
dying and to reject a passive ‘patient’ role (Bradbury 1999: 155). McNamara,
Waddell and Colvin (1994) contend that while formalised hospice objectives
do not state disclosure norms regarding impending death, open communication
concerning death seems to be the ‘preferred interaction’.

Palliative care in Ireland

With the growth of the hospice movement in the UK from the 1960s, simi-
lar developments and initiatives took place in Ireland. Hospice care in Ireland
originated in the late nineteenth century with the establishment of St Patrick’s
Hospital in Cork and Our Lady’s Hospice in Dublin by the Sisters of Charity,
who have played a crucial role in the development of palliative care in Ireland
(O’Brien 1995; Butler 1980). The Irish Hospice Foundation (IHF), established
in 1986, supported the development and improvement of hospice services. The
Irish Association of Palliative Care (IAPC) was established in the early 1990s
to support professionals working in palliative care and to promote the develop-
ment of palliative care throughout Ireland. The Irish Medical Council recog-
nised palliative medicine as a speciality in 1995.
Local and voluntary organisations played a large part in the initial develop-
ment of hospice services in Ireland, as has also been the case in the UK. Pal-
liative care services were initially established around the country largely owing

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to the ‘strong and concerted efforts of various voluntary organisations’ (Report

of the National Advisory Committee on Palliative Care 2001). While the role
of voluntary organisations in the establishment of ­ palliative care services is
­acknowledged, this led to an ad hoc establishment of services nationwide, with
a number of different and independent organisations.
The National Advisory Committee on Palliative Care report (RNACPC 2001)
provided a comprehensive overview of palliative care services and set out a
number of key recommendations for the future development of services. For
instance, the committee recommended that palliative care should be structured
in three levels of ascending specialisation: palliative care approach, general pal-
liative care and specialist palliative care (ibid.: 32). The demand for palliative
care services is expected to rise in the coming years, in line with population
growth and the anticipated extension of palliative care services to other patient
groups (Addington-Hall and Higginson 2001).
The hospice movement and palliative care is predicated on the recognition
that not all illnesses are curable and that patients will die. Although palliative
care is ‘active’ care it is not active curative or disease-modifying care. Hospice
care or palliative care acknowledges for its practitioners and patients and their
families that an illness is fatal.

Fluctuating responses to death and dying

A preference for open awareness of dying is now, according to Seale, ­Addington-
Hall and McCarthy (1997) ‘well established in terminal care settings and
amongst the general populations in the UK, USA and other Anglophone coun-
tries’. However, there is not a uniform acceptance either within cultures or
across cultures. For example, Hinton (1999) found individual and fluctuating
responses to awareness of dying in a study of progression of awareness and
acceptance of dying in cancer patients and their relatives. Young and Cullen
(1996: 112) consider the situation in the UK as one of transition and describe
situations of ‘benevolent paternalism’, where some doctors are willing to tell
patients that they have suffered a heart attack or heart failure but are reluctant to
disclose information about cancer. Some doctors assume that if patients do not
ask they do not want to be told, ‘especially so if patients were elderly, working
class and poorly educated’. Field and Copp (1999) have suggested that in spite
of an ideological commitment to open awareness and a wish for full informa-
tion, there seems to have been a progression from closed to open awareness and
then partially back to ‘conditional awareness’. While there is now recognition
that patients and family have a right to full information and may wish to have
this, they may be unwilling to be continually reminded that they are dying even
though they know this is the case (1999: 466).
There are also cultural differences with regard to the appropriateness of open
awareness about death and dying. Seale (1998) argues that the Anglo-­American

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culture of individualism is at the heart of the growth of the patient-centred

­approach to relationships between health professionals and patients. However,
in other cultures there is not necessarily the same individualism. In Japan, for
instance, there is an expectation that doctors will make decisions on behalf of
patients without sharing the thinking behind the decision, and family members
often make decisions on behalf of another family member (1998: 111).
A study conducted in Italy (Surbone 1992) argues that this idea of patient
autonomy is, in an Italian context, considered as patient and social isolation. In
this context the protection of the patient by the family, considered negatively
as collusion or denial in awareness contexts (Faulkner, Maguire and Regnard
1994), is understood as protection and as shouldering the burden of knowledge
for the patient (Seale 1998: 112).

Perspectives on death and dying in Ireland

The shift toward open communication and awareness in death and dying have
taken place in highly individualistic societies such as the UK and the USA,
although even within these societies there are conditional and fluctuating re-
sponses. Less individualistic societies, as the research in Italy and Japan has
shown, display a resistance to this ideal of open awareness.
Ireland has been characterised as a society that incorporates rather than de-
nies death. Studies that focus on cultural attitudes and beliefs in Ireland suggest
that there is considerable open awareness and acceptance of death. For example,
there are many documented traditions surrounding death and dying in Ireland
(O’Suilleabháin 1967; Lysaght 1995, 1996; Donnelly 1999) and although some
traditions have died out, many traditions are valued and continue, albeit in a
modified and constantly changing form (Keegan and van Doorslaer 2001). As
these authors state, traditions and customs are not static; they change, some die
and some become revived, such as the practice of bringing the deceased home
or laying them out at home (2001: 54). New rituals are also established, such as
that of personalising a religious service. As rituals are a way of ‘talking about’
important issues for a culture (Sheehy 1994: 494), the continuation of traditional
rituals and the development of new ones illustrate the centrality of death within
Irish culture. A centrality, which the State Pathologist, Professor Marie Cassidy,
considers, is ‘an obsession with death in Ireland’ (MacCormaic 2006).
Other commentators, such as Witoszek and Sheeran (1994), also argue that
there is a preoccupation with death in Ireland. The authors consider the funerary
rituals and practices as a ‘Theatrum Mortis’, a theatre of the dead. Considering
the various traditions in this way, as a performance by the living (the actors)
for the dead (the audience), reveals an underlying cosmology that, according
to Witoszek and Sheeran, is ‘an acute awareness of a powerful realm bordering
on the world of the living’ (1994: 7). The authors also consider that this view of
the dead, one that sees the dead as occupying an almost tangible existence, is so

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 46 Irish Journal of Sociology

embedded in cultural practice in Ireland that it goes unnoticed.

The late poet and philosopher John O’Donoghue echoes the observations of
Witoszek and Sheeran. Drawing on the traditions surrounding death and ­dying,
O’Donoghue states that these traditions recognise that the eternal and tran-
sient worlds are ‘woven in and through each other’ (O’Donoghue 1999: 256).
O’Donoghue also talks about the visions of deceased mothers, grandmothers
and other relations, and states that ‘when a person is close to death, the veil
between this world and the eternal world is very thin, in some cases the veil is
removed for a moment’ (ibid.: 256).
The cultural values and beliefs highlighted by these commentators suggest
a certain level of ease about death and dying in Ireland. Studies undertaken
specifically about views on issues of mortality, within and outside health serv-
ice settings, suggest that in general terms there is an openness about death and
dying and a willingness to talk about it. However, studies with people directly
exposed to these experiences show a more mixed response, with many relatives
wishing to protect family members when it comes to breaking bad news and
awareness of terminal illness.
A nationwide survey undertaken by TNS MRBI on behalf of the Irish Hos-
pice Foundation in 2004 contacted one thousand people. Of these, 51 per cent
thought there was not enough discussion about death and dying in the commu-
nity. Most people (79 per cent) were comfortable personally discussing death
and dying, and 66 per cent of those surveyed said they were comfortable talking
with the recently bereaved.
The Irish Council of Bioethics published an opinion paper about advanced
directives in 2007. (www.bioethics.ie). Of those who took part in the survey,
90 per cent considered advance care directives important in relation to lifelong
treatment if they were terminally ill, and 79 per cent stated they wished to be
informed of their diagnosis and prognosis.
In a hospital based Irish study, ‘Telling the truth about cancer: Views of eld-
erly patients and their relatives’ (O’Keefe, Noone and Pillay 2000), 83 per cent
of 120 patients wanted to be told the truth but only 55 per cent of relatives
wanted the patient informed. The usual reason given by relatives for not want-
ing the patient to know was that it would cause worry or depression.
Research undertaken by Van Doorsler and Keegan in 2001 involving focus
group discussion and semi-structured interviews with healthcare professionals
including palliative care specialists, community workers, funeral directors and
members of the general public covered issues such as how Ireland as a society
dealt with death, the process of dying and bereavement. Talking about death
was seen as positive, therapeutic and should be encouraged. However, silence
around grief and bereavement was most often mentioned. Participants found
it awkward, not knowing what to say. The setting up of formal bereavement
support structures was seen as a reflection of the inability of society to offer ap-
propriate support to those who are grieving because of the reluctance to discuss

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a bereavement.
The Keegan, McGee, Brady et al., (1999) study, Care for the Dying –
­Experiences and Challenges: A Study of Quality of Health Service Care ­during
the Last Year of Life of Patients at St James’s Hospital, Dublin, from their
Relatives’ Perspective is based on the Addington-Hall and McCarthy (1995)
‘Regional study of care for the dying’. The research focused on the care of pa-
tients and their families in an acute hospital, with and without the involvement
of the palliative care team, and conducted structured qualitative interviews with
155 relatives.
One aspect of the research focused on aspects of palliative care such as com-
munication and breaking bad news, and suggests that when palliative care prin-
ciples were adhered to – in relation to good communication, spending time,
breaking bad news gently but clearly – relatives appreciated this approach. The
research also documented many instances where patients were told bad news
alone with no family or social support; in corridors, and over the telephone
(Keegan, McGee, Brady et al. 1999: 13) and frequently relatives were told by
the doctor while the patient may not have been. Some relatives found this stress-
ful as there was uncertainty concerning awareness of the prognosis by the pa-
tient. This difficulty also meant that any talk about death between relatives and
patients was unlikely. At the same time most relatives did not talk to their family
member about the possibility of death and remained glad of this fact. Patients
who received palliative care were more likely to have been informed directly of
their diagnosis (ibid.: 62).
An Irish study which explored both lay and professional understandings of
a ‘good death’ in a palliative care setting (MacConville 2010) found that while
ideologically there is a commitment to open awareness within the model of pal-
liative care, in some circumstances this is not possible. For example, healthcare
professionals working within the home care service frequently encounter fami-
lies whose culture of communication is at considerable variance with those of
the service. In these cases, family members viewed their position as protecting
the family member and shouldering the burden for the patient, similar to views
expressed in the Italian study already mentioned.

Unpicking truth telling and breaking bad news

A discussion of truth telling and breaking bad news on a daily Irish radio pro-
gramme in November 2003 provided an opportunity to further explore views
about these issues.
A daily early afternoon radio show on the national radio station, hosted since
1999 by Joe Duffy, reflects a mix of topics from serious social issues such as
homelessness and suicide to more mundane matters of recycling charges and
the price of groceries. In November 2003 the programme featured a discussion,
over four days, of the issue of ‘truth telling’ and breaking bad news. While

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 48 Irish Journal of Sociology

respondents to a radio programme such as Liveline are not representative of

the general population, and radio shows may tend to broadcast callers whom
they consider more interesting and possibly more controversial, media content
can provide a valid form of data for analysis (Blumer and Katz 1974; McQuail
1994). This data provides insights into social and cultural issues at a particular
time and place and ‘can tell us about the aspirations and intentions of the period
to which they refer’ (May 1993).
The central discussion on the programme concerned the issue of whether
people should be told they had a terminal illness and in what way they should be
told. The subject was raised by one caller to the programme who wanted to talk
about, ‘the whole issue of how to tell people, how and when to deliver bad news
and to whom to deliver it’ (Joe Duffy, Liveline, 10 November 2003).
Over four days, there were 19 callers (3 male and 16 female) relating a total
of 23 stories. A variety of relationships were represented – seven were parents
of children who had either died or were terminally ill, five were adult children
of terminally ill or deceased parents, five spoke of family members without
disclosing the relationship, a wife spoke about her, now deceased, husband, a
sister spoke about her brother’s experience and four callers were themselves
patients.
Callers expressed their views based on their own experiences and those of
family members and related a mixture of good and bad experiences, express-
ing opposing views concerning whether patients should be told bad news. Not
all callers addressed the issue directly; some callers related stories which were
based on hearsay and others spoke of experiences which were not always di-
rectly related to the topic. Two main issues emerged: the perceived benefit and
harm of giving bad news and the issue of how news was communicated by doc-
tors to patients and families.

Breaking bad news

Three callers strongly expressed the view that patients should not be told; two
of these callers were adult children of now deceased parents. For these callers
giving bad news was harmful because it removed hope.
Everybody would like to have a wish, or like to have a hope that with new medi-
cine and new technology and what-have-you that we’d all have a hope, but for a
doctor to turn around and say ‘Look, you have no hope.’ I certainly wouldn’t like
to be told that, I would always like to think there was some hope, but if a doctor is
going to tell you, you know, you’re going to be gone in three months, it’s too final.
(Caller 1, 10 November 2003).
I feel that cancer patients or any patient that has a terminal illness, they have to
have hope, they have to have something to live with, something to make them go
on. (Caller 2, 10 November 2003)
I think that, you know, that they should take more care in telling people, to make

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sure at least that family are there and also to ask the person if they did want to
know, if they wanted a full consultation, that maybe they wouldn’t want to know
all the ins and outs of it. Because as lots of people pointed, how do you get up in
the morning and have some sort of reason to get out of bed and you know, what are
you living for if you know there is no hope, you know? (Caller 7, 10 November
2003)

For these callers, a further aspect of potential harm for patients in being told bad
news was related to the question of who knows the patients best. These callers
clearly felt that only they really knew the patients, no matter the length of the
relationship with health professionals; callers felt that they knew whether the
patient ‘was able for it’ or not and therefore family members should have a say
in the decision about whether to tell the patient:
Any doctor can decide to walk in and say to the patient ‘I’m sorry, I’ve bad news’
without first consulting the family, or even asking the family ‘will the man be able
for it?’ or the person be able for it. (Caller 1, 10 November 2003)
No matter how well a doctor knows a patient, you know, and if they have them for
years they get to know them very, very well … but they still do not know a patient
as well as a family knows them. And I think that a mother, father, sisters, anybody
can judge better whether a person is able to carry this, able to take it and I think
that they should be consulted. (Caller 2, 10 November 2003)

Trust and autonomy

While some callers felt that telling bad news would have a negative impact, oth-
ers spoke of the pressure of non-disclosure. This problem was discussed by one
caller whose 17-year-old son had a terminal illness. As the caller related, one
doctor felt there was a benefit at times in ‘false hope’ but that the news can be
given when the person is ready. The caller described the pressure of non-disclo-
sure and the impact on trust between herself and her son.
But we were now at a stage where I was running around like a headless chicken
trying to control everything that everybody said to him and then he was in a place
where he was losing trust in me and I mean I was going to have to look after him
down the road and he needed that, you know we needed to have that trust back.
(Caller 13, 12 November 2003)

Once everyone was aware of the prognosis:

When he was finally told that you know he was not going to get better and it
seems to have, it seems to have grounded him in the sense that he now you know,
has trust in me again, he seems to have trust in the system again. (Caller 13, 12
November 2003)

One caller – a cancer patient – felt strongly that patients should be told. Re-
sponding to previous calls about protecting patients, the caller also talked about
the feelings of family members but from a different perspective.
If my family had been with me they would have been devastated and … so not

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 50 Irish Journal of Sociology

only would you have to cope with your own feelings in moments of crisis but you
have to reach out to your own family and to help them cope and that would have
been an additional pressure. (Caller 5, 10 November 2003)

For this caller not telling a patient takes away a person’s dignity.
If my family were told and I was not I would hugely resent that. That would take
away my dignity. You know it would be like people were talking behind your back
about you and they would take away your power to decide what you want to do.
(Caller 5, 10 November 2003)

Responding to comments made by adult children regarding withholding infor-

mation from their parents, this caller talked about taking away the autonomy of
the patient.
Often, as adult children we feel that we know best for our ageing parents and
I think that’s being unfair to our ageing parents. You know, to take away your
autonomy as an adult is to reduce you to the level of child again and I don’t think
that that is right. (Caller 5, 10 November 2003)

Communication: doctors, patients and families

The way in which bad news is communicated can have considerable impact.
Callers spoke of learning of bad news such as reading ‘prostate cancer?’ on an
appointment card (Caller 3, 10 November 2003), or hearing over the phone that
her son had died of cot death (Caller 14, 13 November 2003). An additional
aspect of communicating bad news is the impact of the news.
A number of callers commented that doctors were often good at their job but
sometimes they were poor at communicating bad news: (‘he is very good at his
job but just doesn’t have the manner for breaking bad news’ (Caller 12)). Some
callers had very positive experiences about being told bad news. One caller was
able to relate the various stages of communicating bad news and how this can
be an incremental process.
They always answered the questions he asked. You know, they didn’t volunteer
the information but they answered the questions so the doctor said ‘I really think
he needs to know, or he wants to know maybe’. So he said ‘I’m going to ask, you
know I always answer the specific questions’, which is what he did. And over
about three days she broke it to him and the registrar broke it first and then the
oncologist from the hospice came in and she sat down and she broke it to him
himself. (Caller 13, 12 November 2003)

Discussion: A figurational approach

Open awareness and communication about death and dying is a key aspect of
the palliative care model and progression from closed to open awareness has
increased since the 1960s, particularly in the UK, the USA and Anglophone

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 A figurational approach: views of communication, death and dying 51

c­ ountries. In spite of this progression, a shift toward full and open awareness is
not uniform with suggestions that the position in the UK is transitional (Young
and Cullen 1996) or conditional (Field and Copp 1999). Likewise there are
cultural differences, as already outlined, noted in Italy and Japan where fam-
ily members frequently act to protect their relative from bad news and see this
positively as shouldering the burden for their family member.
Ireland is a less individualistic society than either the UK or the USA and
probably closer to Italy in terms of family and kinship relationships. However,
in Ireland there is a broad cultural emphasis on rituals and beliefs surrounding
death and dying, a sense of continuing relationships and the presence of the de-
ceased. There also appears to be, in a general sense, an ease with talking about
issues of mortality. However, when the reality of terminal illness becomes close,
desires to protect family members from this reality become apparent.
Examining the responses of callers to the radio show provided a useful way
to unpick some of the issues that people struggle with when trying to resolve
whether open awareness and communication is appropriate. Callers related ex-
periences that had happened in acute or general hospital settings and there ap-
peared to be considerable differences in the level of skill on the part of healthcare
professionals in breaking bad news, although it must be borne in mind that what
people perceive they have heard is not always what has actually been said.
While some callers to the programme had a negative view of open aware-
ness, feeling that it would remove the possibility of hope and as a result have
a detrimental impact on the patient, others felt that having full information en-
hanced trust and patient autonomy. Some callers recounted clearly negative ex-
periences of being told bad news, however when bad news was communicated
carefully callers considered this experience more positively. This was also the
case in the Keegan, McGee, Brady et al. study, but this is not always the case
as the MacConville (forthcoming 2009) study makes apparent. In this study
when families were in a position to control levels of information, such as when
the dying person was being cared for at home, open awareness was frequently
resisted notwithstanding the high level of expertise of healthcare professionals
in communicating bad news.
The ideal of open awareness within the palliative model of care may be re-
sisted not only by family members but also healthcare professionals working
outside of this model thus making it difficult to neatly assign these responses
to positions such as lay and professional perspectives. The grouping together of
social actors under two headings – a lay and a professional perspective – dis-
guises complex interactions and that these perspectives are informed by some-
times conflicting sets of information, knowledge and beliefs. The perspective of
professionals is shaped and informed by specific technical knowledge, expertise
and experience. The social actors incorporated within the lay perspectives, com-
prise not just the patient but also their relatives, friends and wider community
(Kellehear 2002), who also have their own previous experience of healthcare

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 52 Irish Journal of Sociology

professionals and medical science. Lupton (1997) in exploring ideas of consum-

erism, reflexivity and the doctor–patient relationship, found that representations
of the patient as the ‘reflexive, autonomous consumer’ fail to recognise that
‘knowledges are constructed via embodied and affective experiences which are
both accumulative and dynamic over a person’s lifetime’ (ibid.: 380), suggest-
ing that the boundaries surrounding a lay perspective on health and illness are
far from fixed but rather are better characterised by their constantly shifting
nature.
Elias’s (1987) ‘figurational’ or ‘sociogenetic’ approach may offer some way
in which to understand these shifting boundaries and the patterns of social inter-
action and interdependence that are rarely static and unchanging (Mennell 1996:
15). In considering social processes at work in long-term social development,
Elias believed that the stage of development attained by society can be identi-
fied and measured in relation to a ‘triad of basic controls’ (Elias 1978: 156–7).
These controls are firstly the extent of society’s capacity to exert control over
non-human forces and events or ‘forces of nature’; secondly the extent of its
control over interpersonal relationships and events or ‘social forces’; and thirdly
the extent to which each of the members of a society has control over him or
herself as an individual (Mennell 1992). These three types of control develop
and function in interdependence with each other and with the development of
knowledge, but Elias contends that this interdependence is not to be understood
as simple parallel increases of three types in step with each other. Rather these
controls interact with each other in a more paradoxical way; as the capacity
for taking a more detached view and control over natural forces increases, this
tends to increase the difficulties in extending control over social relationships
and the feelings in thinking about them (ibid.: 169).
Elias (1987) argues that when people are in positions of vulnerability and in-
security it is more difficult to control strong feelings about events that deeply af-
fect their lives, and more difficult to approach those events with detachment as
long as they have little ability to control the course of events. On the other hand,
Elias argues, it is also difficult to extend understanding and control of these
events if they are not approached with a greater detachment. This produces a
kind of double bind that can obstruct the growth of knowledge in respect of all
three levels of the triad – the ‘always interconnected levels of the technological,
the social and the psychological’. The interconnection between the three levels
may serve not only to impede growth of knowledge but to put the process into
reverse gear (Mennell 1992: 170). While impediments and reversals of change
occur, over the very long term these social processes produce developmental
change of and within societies and individuals.
Elias’s figurational approach can be utilised to understand how, in terms of
a continuum of social development in very broad terms, the shift toward open
awareness and communication in death and dying has both progressed and
also been resisted. The developmental processes involved in the emergence of

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 A figurational approach: views of communication, death and dying 53

p­ alliative care and the key aspects of communication and open awareness, for
instance, illustrate the different stages of development at each of the three levels
suggested by Elias: the technological – developments in cancer care which, as
already stated, mean that more people are living longer with cancer and there-
fore full disclosure of the prognosis becomes necessary; the social – the devel-
opment of palliative care as a model of care that manages the social relationship
between the increasing technological information and expertise and the disclo-
sure and mechanism of living with that information; and the psychological – the
individual response to the implications of that information.
The broad cultural acceptance of death and dying and the ease with which
issues of mortality can be discussed in Irish society can come under pressure
when, as Elias asserts, people are in positions of vulnerability and insecurity
as seen in the varied responses of callers to the radio programme. Some of the
callers were positive about open awareness when this had been handled ap-
propriately by health service practitioners. There were also difficulties between
professionals working in the healthcare services who do not have the same level
of commitment to open awareness and communication and palliative care, and
the healthcare services (for example in the Keegan, McGee, Brady et al. 1999
study) and the shift from full to conditional awareness (Field and Copp 1999)
demonstrate that these stages do not necessarily work smoothly with each other
and illustrate the kind of ‘double bind’ referred to by Elias.

Conclusion
Open awareness and communication about death and dying is the preferred in-
teraction within highly individualistic societies and within the palliative care
model, although there can be fluctuating levels of acceptance. Irish society has
strong cultural practices around death and dying and research has shown that,
in general, people are open to talking about issues of mortality. However, this
openness can change when the reality of a terminal illness comes close to home
and people may seek to protect their relative from receiving bad news. Elias’s
figurational approach is concerned with levels of involvement and detachment
and how this impacts on social processes. This approach aids in understand-
ing that while in theory, or from a detached perspective, people may state their
preference for openness about terminal illness, when there is a high level of
involvement or when people are in positions of vulnerability, this stance can
shift and even go into reverse.

References
Addington-Hall, J. and M. McCarthy 1995. ‘Regional study of care for the dying:
­Methods and sample characteristics’, Palliative Medicine 9: 27–35.
Addington-Hall, J. and A. Higginson (eds) 2001. Palliative Care for Non-Cancer

3 Mcconville.indd 53 24/03/2010 17:02:51

 54 Irish Journal of Sociology

­Patients. Oxford: Oxford University Press.

Albery, N., G. Elliot and J. Elliot (eds) 1993. The Natural Death Handbook. London:
Virgin.
Bradbury, M. 1999. Representations of Death: A Social Psychological Perspective.
­London: Routledge.
Butler, H. 1980. We Help Them Home: A History of Our Lady’s Hospice, Harold’s Cross.
Dublin: Caritas Press.
Blumer, J.G. and E. Katz (eds) 1974. The Use of Mass Communications. London: Sage.
Charmaz, K. 1980. The Social Reality of Death: Death in Contemporary America.
­Reading, MA: Addison-Wesley.
Copp, G. 1998. ‘A review of current theories of death and dying’, Journal of Advanced
Nursing 28(2): 382–90.
Donnelly, S. 1999. ‘Folklore associated with dying in the west of Ireland’, Palliative
Medicine 13: 57–62.
DuBois, P. 1980. The Hospice Way of Death. New York: Human Sciences Press.
Elias, N. 1985. The Loneliness of the Dying. Oxford: Basil Blackwell.
Elias, N. 1987. Involvement and Detachment. Oxford: Basil Blackwell.
Faulkner, A., P. Maguire and C. Regnard 1994. ‘Breaking bad news – a flow diagram’,
Palliative Medicine 8:145–51.
Field, D. and G. Copp 1999. ‘Communication and Awareness about Dying in the 1990s’,
Palliative Medicine 13: 459–68.
Glaser, B. and A. Strauss 1965. Awareness of Dying. Chicago: Aldine.
Hinton, J. 1999. ‘The progress of awareness and acceptance of dying assessed in cancer
patients and their caring relatives’, Palliative Medicine 13: 19–25.
Irish Council for Bioethics 2007. Is it Time for Advanced Health Directives? Opinion.
Dublin: Irish Council for Bioethics.
Kastenbaum, R. 1985. ‘Do we die in stages?’, pp. 154–73 in N. Datan and L. Ginsberg
(eds), Life Span Developmental Psychology: Normative Life Crises. New York: Aca-
demic Press.
Keegan, O., H. McGee, T. Brady, M. Hogan, S. O’Brien and L. O’Siorain 1999. Care for
the Dying – Experiences and Challenges: A Study of Quality of Health Service Care
during the Last Year of Life of Patients at St James’s Hospital, Dublin, from their
Relatives’ Perspective. Dublin: Irish Hospice Foundation.
Keegan, O. and O. van Doorslaer 2001. Contemporary Irish Attitudes Towards Death,
Dying and Bereavement. Dublin. Health Services Research Centre, Royal College
of Surgeons.
Kellehear, A. 2002. ‘Spiritual care in palliative care: whose job is it?’, pp. 166–77 in B.
Rumbold (ed.), Spirituality and Palliative Care: Social and Pastoral Perspective.
Melbourne. Oxford University Press.
Kübler-Ross, E. 1970. On Death and Dying. London: Tavistoock
Lawton, J. 2000. The Dying Process: Patients’ Experiences of Palliative Care. London:
Routledge.
Lunt, B. 1985. ‘Terminal cancer care services: Recent changes in regional inequalities in
Great Britain’, Social Science and Medicine 20(7): 753–9.
Lupton, D. 1997. ‘Consumerism, reflexivity and the medical encounter’, Social Science
and Medicine 45(3): 373–81.
Lysaght, P. 1995. ‘Visible death: Attitudes to the dying in Ireland’, Marvels and Tales
9: 27–60.
Lysaght, P. 1996. The Banshee: The Irish Supernatural Death Messenger. Dublin:
O’Brien Press.
MacConville, U. 2010. A ‘Good Death in Ireland’: Mapping the Edge of Death and

3 Mcconville.indd 54 24/03/2010 17:02:51

 A figurational approach: views of communication, death and dying 55

­Dying. Lampeter: Edwin Mellen Press.

MacCormaic, R., 2006. ‘Death on her hands’, The Irish Times, 11 November.
McNamara, B., C. Waddell and M. Colvin 1994. ‘The institutionalization of the “good
death”’, Social Science and Medicine 39(11): 1501–8.
McQuail, D. 1994. Mass Communications Theory: An Introduction. London: Sage.
May, T. 1993. Social Research: Issues, Methods and Process. Buckingham: Open Uni-
versity Press.
Mennell, S. 1992. Nobert Elias: An Introduction. Oxford: Blackwell Publishers.
Mennell, S. 1996. All Manner of Food: Eating and Taste in England and France from
the Middle Ages to the Present 2nd edn. Champaign, IL: Illini Books Edition.
Novak, D., R. Plumer, R. Smith, H. Ochitill, G. Morrow and J. Bennett 1979. ‘Changes
to physicians’ attitudes toward telling the cancer patient’, Journal of the American
Medical Association 241: 897–900.
O’Brien, T. 1995. ‘Editorial’, Palliative Care Today (Irish Supplement) 1: 1–2.
O’Donoghue, J. 1999. Anam Cara: Spiritual Wisdom from the Celtic World. New York:
Bantam Books.
O’Keefe, S., I. Noone and I. Pillay 2000. ‘Telling the truth about cancer: Views of elderly
patients and their relatives’, Irish Medical Journal 93(4): 27–9.
Oken, D. 1961. ‘What to tell cancer patients: A study of medical attitudes’, Journal of the
American Medical Association 175: 1120–8.
O’Suilleabháin, S. 1967. Irish Wake Amusements. Cork: Mercier Press.
Report of the National Advisory Committee on Palliative Care (RNACPC) 2001. Dublin:
Department of Health and Children.
Seale, C. (1998) Constructing Death: The Sociology of Dying and Bereavement. Cam-
bridge: Cambridge University Press.
Seale, C., J. Addington-Hall and M. McCarthy 1997. ‘Awareness of dying: Prevalence,
causes and consequences’, Social Science and Medicine 45(3): 477–84.
Sheehy, N. 1994. ‘Death ritual as a cultural form’, The Irish Journal of Psychology,
15(2/3): 494–507.
Small, N. 1998. ‘Spirituality and hospice care’, pp. 167–82 in M. Cobb and V. Robshaw
(eds), The Spiritual Challenge of Health Care. Edinburgh: Churchill Livingstone.
Surbone, A. 1992. ‘Truth telling to the patient’, Journal of the American Medical As-
sociation 268: 1661–2.
TNSMRBI 2004. Survey on Attitudes To Death And Dying In Ireland. Dublin: Irish Hos-
pice Foundation.
Walter, T. (1994) The Revival of Death. London: Routledge.
Weisman, A.D. 1974. The Realisation of Death: A Guide for Psychological Autopsy.
New York: Jason Aronson.
WHO 1990. Pain Relief and Palliative Care. Technical Report Series 804. Geneva:
World Health Organisation.
Witoszek, N. and P. Sheeran 1994. The Irish Funerary Tradition. Research Report 4.
Galway: Social Science Research Centre, University College Galway.
Young, M. and L. Cullen 1996. A Good Death: Conversations with East Londoners.
London: Routledge.

3 Mcconville.indd 55 24/03/2010 17:02:51