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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.4 São Paulo Aug. 2012
José Siles GonzálezI; Maria del Carmen Solano RuizII
in History and Graduate Nurse. Professor at Escuela Universitaria, Nursing Department,
Universidad de Alicante. Alicante, Spain. firstname.lastname@example.org
IIPh.D. in Anthropology and Graduate Nurse. Full Professor, Escuela Universitaria, Nursing Department, Universidad de Alicante. Alicante, Spain. email@example.com
The objective of this study is to describe the evolution of palliative care in order to reflect on the possibility of its origin in primitive cultures and their relationship with the beginnings of the cult of the dead. It describes the change in the symbolic structures and social interactions involved in palliative care during prehistory: functional unit, functional framework and functional element. The theoretical framework is based on cultural history, the dialectical structural model and symbolic interactionism. Categorization techniques, cultural history and dialectic structuralism analyses were performed. Palliative care existed in primitive societies, mostly associated with the rites of passage with a high symbolic content. The social structures - functional unit, functional framework and functional element - are the pillars that supported palliative care in prehistory societies.
Descriptors: Palliative care; Culture; History of nursing
Difficulties to reach a consensus on the historical origins of palliative care and the need to further elaborate the meaning of caregiving in incurable diseases or end-of-life stages justify this research. First, some reflection is due on the identity of the person who will stand at the center of nurses' attention and a consensus is needed, within the limits of possibility, as to everything that can be interpreted as this palliative care. The meaning of palliative care undoubtedly varies for cultural and historical reasons, but it is also certain that cross-cultural factors exist that have predisposed, also in different times and cultures, to the existence of this type of care, so intrinsically linked with chronicity and with pain and death processes. It is perhaps through the study of magical thinking and rituals, which have served as an instrument to face pain and try and overcome the trance that is hard to assimilate as death, that one can best get to know and understand the origin and evolution of what has been called palliative care over time.
On the other hand, the cultures that have been most reluctant to maintain patients with illnesses of unlimited range, whose sole expected solution is death, have been hardly evolved cultures - except for noteworthy examples - in which the pain associated with the more or less imminent proximity of death ends up representing a taboo. To try and understand why patients who were declared terminally ill were helped to die or abandoned to their luck, like what happened in primitive cultures and in some tribes nowadays, in which not only the ill are abandoned, but aged people, when they reach the age tradition has determined, have to start a ritual trip without return, the lack of medicines to relieve the pain that had weakened the ill, the uncontrolled and lasting pain that could solely end with a fast and as painless as possible death.
The researchers departed from the aim of analyzing and describing the evolution of palliative care in primitive cultures, from the perspective of cultural history and the dialectical structural model(1), in view of the incidence of ways of life and everything they entail in daily life and in structural social and mentality transformations. Therefore, the following specific objectives are due:
To identify both the social structures implied in palliative care, including beliefs, values and the meanings this concept had in primitive cultures.
To analyze the dialectical interpretation of the causes and remedies of illnesses that demand palliative care in primitive cultures: rational or natural interpretation (daily life) and supernatural interpretation (animism/religion).
STATE OF THE ART
About the history of palliative care, contributions have been consulted that originate in the culture of death; that is, in the different forms man adopts in society when confronted with the irruption of an incurable disease and the feeling that death is close. This is undoubtedly a universal theme that has aroused highly transcending and complex questions(2), given the biological, cultural, religious, esthetic and ethic code the nature of this class of care entails. From the perspective of medical anthropology, studies have been developed in indigenous societies in which the tribe continues as a basic functional unit or social cell of survival and socialization, contributing to knowledge on palliative care in primitive cultures(3). When studying the history of palliative care, a fundamental question arises: Is palliative care a part of ritual processes? That is more than probably the case, mainly when considering the work of anthropologists who demonstrate that processes as transcendental as death have always been linked with rituals(4-5). Other authors, from different perspective, reinforce the idea of considering primitive people in the palliative care team as a ritual component that is part of the cultural and social system(6). On the other hand, even today, there is a strong cross-culturalism that permits appreciating the equivalent of care before the final phase of illnesses, like in Africa(7) or Europe (8), for example, identifying a persistent ritual structure with distinguished formal aspects. A research that studied indigenous folk and popular healing systems identifies the characteristics of palliative care systems developed in the context of primitive cultures: folk and popular(9). Paleopathology, in turn, has provided knowledge on illnesses and healing techniques in bone remnants(10-11). From a nursing perspective, the historiography of palliative care started to develop in very recent times, as a consequence of the integration among these studies in the academic nursing curriculum. Studies in the 1960's(12) and by other Anglo-Saxon authors have made room for the development of historiography on palliative care in other countries like Spain, where historical-cultural research on the theme has been accomplished(13-14).
To follow the footprints of palliative care through history, and due to its multifactorial case load, the most adequate is to assume the theoretical and methodological foci characteristic of nursing's cultural history(15). What sustains this is, on the one hand, the contributions of structuralism(16) and, on the other, the anthropological functional focus, supporting a global perspective through anthropological and social functionalism(17-19). Also, to value the symbolic nature of palliative care, contributions of theoretical principles have been used, applying the concept of Health Care Systems (HCS) and its organization in three categories: folk, popular and professional(20). To value the ritual and transitional nature of palliative care, the concepts of rite and transition have been adopted(21). The principles of cultural history consider both the structures and symbolic nature of the social actions they enhance. If culture is interpreted as: The set of behaviors, knowledge, values, beliefs and feelings implied in the process of attending to a human group's needs(22), the model and methods of cultural history are very suitable. Consequently, palliative care will be analyzed from the perspective of supernatural or animist interpretation on the one hand, and from the rational, empirical or daily-life perspective on the other; in both cases considering the functioning of social structures and the symbolic meaning of social and health actions linked with palliative care. Among the structures that permit studying palliative care in different historical ages, those structures can be highlighted which, like the tribe or family, permit observing their evolution, responding to permanent or continuing uses and traditional customs as well as changed beliefs(15).
Functional unit: the institution or structure that grant coherence and a symbolic load to care and socializes human group members, providing them with knowledge, attitudes and beliefs and distributing the work needed to satisfy needs in general and care needs in particular: religion, family, solidarity. The functional framework is the place where palliative care is developed: camp, temple, hospital and home.
Functional element is any social actor in charge of directing and/or applying palliative care: wizard, witch, priest, woman, health professional, volunteer.
Qualitative meta-analysis, a term developed in the mid-1970's that refers to the process of systematically combining the results of different related studies to reach a synthesis in the form of a conclusion(23), has been accomplished through sources that produced pertinent data for the study. To locate these sources, keywords were used in English and Spanish in different databases (pre-historical care; palliative care in pre-history; paleopathology and care; terminal illnesses in pre-history; history of palliative care): CINAHL, ENFISPO, BIREME, MEDLINE, CUIDEN, LILACS, SCIELO; ISBN and CUIDATGE. Given, its specificity, the time interval for this search was quite large (1970-2010). The study selection criteria kept to the following characteristics: studies on paleopathology whose theme addresses incurable diseases in pre-history and their care; studies about rituals in the transition between life and death, related to care and to the origins of the cult for the death in the Mesolithic period; health care systems of indigenous people and their classifications regarding the proximity of death; and, more specifically, research about the cultural and structural history of palliative care.
Etymology of palliative care
The term care (from Latin cogitare) implies: thinking, reflecting about a concern with a past, present or future problem (which is why it should not be interpreted as something that does not go beyond more punctual action). From the semantic viewpoint (concerning its potential meaning), the care concept constitutes a sufficiently broad category to cover more specific categories in the scientific and professional ordering process of nursing. Departing from this generic nature of the most emblematic and core term in the nursing discipline, it is pertinent to adopt non-limiting definitions that do not undermine the concept's central dimension. Consequently, an open and flexible definition is provided, interpreting health care as:
The product of reflection on the ideas, feelings, facts and circumstances (theoretical, practical and situational reflection), related to the optimizing process of health needs that guarantees integrity and harmony among any and all phases of human life(20).
In a way, palliative care and death tend to be associated mainly in cases of patients' extreme suffering, who experience unbearable pain and, at the same time, despair, granting them the certainty of being closer or further from a death without any quality of life. That is why palliative care and euthanasia, whose etymological meaning (good death, deriving from Greek eu: good; and Thanatos: death), has varied in history. The term palliative, in turn, deriving from the Latin verb palliare, is a concept that generically indicates the action of covering up and dissimulating. The substantive pallium means cape, cloak or wide clothing used to cover the body, face, identity or something concrete that, at a given time, is necessary or convenient and goes by unnoticed. In the care context, palliative action can be interpreted as a form of therapeutic action that serves to mitigate the problems a disease causes, but without the aim to solve or cure it. One might say that the sphere of influence of palliative action is in those situations that are compromised in chronic-pain-death processes and in the mechanisms adopted to mislead the pain or confront it, undermining its strength, although without the hope of seeing the liberating light of cure at the end of the long tunnel; all of this responds to a plural typology, but with essential common traits that permit including them in such a broad and flexible concept as the so-called palliative care, whose meaning is loaded with cultural, religious, social, scientific and technological connotations.
Primitive cultures and palliative care.
During the Paleolithic Period, the longest period in the history of mankind (its pre-history, covering more than 600,000 years), during which scientific, social and cultural advances happen at the slowest pace, nomad lifestyle continued, which obliged tribes to move periodically, always in an incessant search for natural resources to see to their most basic needs: a physiologically acceptable climate, hunting, fishing, forest fruit and water. Nomadism represented a lifestyle that hardly favored the development of something as little useful from the perspective of primitive people's mentality as palliative care. It is more than probable that primitive men did not even gain awareness of the need for palliative care, given the short life expectancy and, plunged as they were in daily survival, the chronicity concept, which demands the ability to plan and control time through calendar use, would go by unnoticed for some lives that extremely agitated by the urge of immediacy and imminent needs. In this context, in view of situations as compromising for the maintenance of tribal group dynamics as births with anomalies or illnesses that went beyond mild problems or small arrow or ax wounds that they were killed or abandoned(24). The palliative concept needs to be reinterpreted in the context of primitive cultures, given that even acute infectious-contagious illnesses or gangrenous wounds could also cause death, with shorter or longer agony that fundamentally required palliative care. In the context of primitive cultures, palliative care has to be considered as an activity that goes beyond the strict limits of incurable chronic processes. Remnants have been found that confirm curative or ritual trepanning, the existence of tumors, malformations that made it difficult or impossible to survive without help(25). It was in the framework of the Mesolithic cultures that the care started to develop that is closer or equivalent to what is considered palliative today. The form of thinking that helped them to explain natural phenomena in general and facts directly related to the processes of life-health-death in particular was called animism, which consisted in the attribution of a soul or spirit to all things, whether animate or inanimate: trees, stones, stars, animals and water. In 1873, one author(26) coined this term in the publication Primitive cultures to designate man's first intent to explain and order everything that happened around him and to himself. In this complex process, pain and particularly death constitute an unfathomable mystery that is hard to interpret and assimilate, but is something man faces one way or the other: some keep the pain in check and provoke the death of the dying; others persistently extend life through the care and technology within their reach. Historically, primitive peoples represent the childhood of humanity. To understand the immature situation of primitive societies, the historical development concept needs to be considered as a construction and progress reflex of human awareness, of man's knowledge about himself, including chronic and/or terminal illnesses (which undoubtedly are the hardest to assimilate). Therefore, primitive man does not control nature and is incapable of calculating the vegetable cycles and develop agriculture to his benefit. In these conditions, difficulties to control times on all fronts are understood: the duration of delivery, the periods of a certain type of illnesses, the passage from one phase to the other of human growth. In short, palliative care planning, which due to its nature demands a sequential-ritual order of the process, probably did not take form until the final phases of the Paleolithic period (higher or recent Paleolithic age 50,000-10,000 before Christ), coinciding with early cults for the dead and the birth of funeral rites. Also, the observation of certain animal conducts influenced the start of rites like that of the voyage without return of the elder, which was still practiced until recent times in cultures like the Japanese and some indigenous North American tribes. Another practice that makes men related to animals derives from the abandonment of children born with malformations (a falsely hidden form of infanticide). The abandonment and/or finalization of severely wounded or ill people supposed another practice that was not uniform, but frequent in the hard context of the nomad way of life.
Palliative care from the animist or supernatural perspective:
The functional unit or basic structure of coexistence and socialization of tribal life from the supernatural perspective is animism, given that this interpretation system of phenomena contributes to order the daily life of the members of society(22). Through its socializing potential, animism regulates the Health Care System (HCS) and grants meaning to the behaviors produced in response to health problems through values, beliefs and standards that constitute the folk health care system, in which the causes of diseases and their treatments are interpreted as arising from the supernatural world(27). In short, the animist system provides each person with a role and, consequently, socially supports cooperation in the benefitting human group, so as to reach the tribe's objectives: survival and satisfaction of needs, as the two sides of the same coin. The main manifestation of terminal illnesses originated in pain, and possibly in some functional impairment. The cause tended to be a malign spirit nested in the zone where the pain appeared and pain was mitigated through the accomplishment of different ritual techniques to make the spirit abandon the body. When the cult of the dead appears in the Medium Paleolithic, in many cases, palliative care is integrated in transition rites and, still during the lifetime, rites of transition to the other world are put in practice which, guided by the wizard, prepare the dying for the trip, according to each tribe's animist beliefs(21). The symmetric nature of these rituals can be proven when evaluating how care is extended to the person after death and follows the preparation of the trip through care for the dead body, grave goods and burials. In this sense, the care we could somehow consider equivalent to palliative care would figure between the sphere of the folk care system (supernatural interpretation) and the sphere corresponding to the popular care system (empirical or daily-life interpretation).
Functional element: The wizard or shaman and the witch were the social actors (functional elements) occupied with care. Rites represent the antecedent for current health care procedures, given that they consisted in ways to structure some ceremonial acts the wizard (functional element or key social actor involved in palliative care) performed, who was promoted as the interpreter of the phenomena related to illness and its manifestations, applying the disordered rule of the main animists. Together with the witch, the wizard constitutes the start of a new art that is closely linked with disease treatment: magic. Magic basically represented the art of manipulating the hidden forces of nature. One author affirms that, in some primitive communities, the head was venerated as an incarnation of divinity but, when he reached old age, they used to ritually kill him before the effects of senility could manifest themselves. Over time, this would make room for awareness of parenthood and the prohibition to "kill one's father" as a consequence of totemism(28). The same author cites the examples of the elderly on the Fiji islands, who voluntarily kill themselves without awaiting their destiny of decrepitude. Euthanasia or "good death" is as old as humanity, although the goal may essentially have been the same: to end with pain. The means that exist today permit significant distinctions among the motivations that drive euthanasia in the Western cultures of the early 21st century. In line with the thoughts of different anthropologists, the proper fact of maintaining and caring for the terminally ill constitutes a trait of stability in the human group and its cultural civilization level(29-30). The wizard or shaman is then the figure in charge of directing all rites involved in interpreting the causes of illnesses and their treatments. Primitive man did not distinguish between dream and reality, so that contact with the dead, revealed through dreams, represents the most remote antecedent of the intent to communicate with the supernatural, with everything that goes beyond death. As exponents of the intelligence of the tribe, the wizards will be in charge of interpreting dreams as a mechanism to diagnose the causes of illnesses and prescribe their treatments. Dreams are promoted to be authentic mechanisms to interpret the most mysterious and unknown phenomena and are used as a fundamental tool to respond to the most basic questions through creativity, myth, metaphor and rites, but also to the most transcendental questions affecting primitive society: "Any society, as a set of significant interactions among human beings, tries to respond to fundamental questions. It is only when these questions are solved that we can understand the passage from disorder - chaos - to order - the cosmos. But the answers to basic questions are not found in the material or rational, but in the imaginary, the symbol, rite and myth"(2). "Savage" thinking contains the structures in which rites and myths are developed and allocate to different social actors (wizard or shaman, witch) in the tribe a certain and highly hierarchized role in care(31-32). Through dreams, contact continues with those who have surpassed the threshold of life, the dead, and this contact will be projected in a new need that reveals the evolution of the human being: the cult of the dead and the consecration of processes preceding death through the staging of funeral rites.
The functional framework: The place where rites were staged was near the central campfire, given that fire was considered something sacred and transcendental for the survival of the tribe. The wizard, helped by female caregivers, directed the rites around the fire, dressed up in skins, horns and a whole range of paraphernalia to invoke the spirits of nature. The characteristics of health care in primitive people are noticeable in different types of rites: treatment, survival, conservation and healing. Also, the rites made room for punctual techniques like massage, trepanning, purging and emetics. Palliative care is part of those actions to maintain the conservation of the ill's life, but without too many pain relief resources, representing an uncommon practice until the most recent or higher Paleolithic due to the rough living conditions.
Palliative care from the perspective of daily life.
Functional unit: The tribe constitutes the basic social structure of contact and socialization in daily life (functional unit). The tribe, through its socializing potential, regulates the Health Care System (HCS), developing a social and symbolic construction process that produces the meanings, values and standards that direct a certain type of social behavior towards disease and death(27). Through this primitive social structure and its socializing potential, through standards, beliefs and values, the human group's daily life gets organized, with men hunting and women collecting fruits and plants and maintaining the camp, in which maintaining the fire and the major part of basic care for tribe members play a central role. That is, a sexual division of work is already produced in this pre-historical phase, a gender division of functions that will entail very significant consequences for health care in general and for palliative care in particular, as one can already talk about a popular tribal system that regulates the basic care woman is responsible for; also, in these cultures, a folk health care system exists that centers on the supernatural interpretations of diseases and which wizards or shamans are in charge of(20).
Functional element: Women socialize as functional elements through a cultural projection process of their biological characteristics. As a consequence of their long trajectory in delivery care, perinatal care, breastfeeding and child raising, women take up the role of caregivers in the tribe. They will mainly take charge of survival care in the different chains that constitute human beings' system of needs: fertility-pregnancy, delivery-perinatal care, breastfeeding-child raising, fire-feeding, clothing-heat-body temperature, sleep-rest and which constitute the empirical heritage of the popular or pre-domestic health care system. Since prehistoric times, women are responsible for seeing to the ill, wounded and elderly in the tribe until their last sigh. Therefore, they will explore the knowledge they gained themselves and from her predecessors in the collecting of plants, as they will be capable of preparing potions, based on the medicinal properties of a wide range of herbs and plants.
Functional framework: The camp represents the place where health care will be developed (functional framework). In prehistory, some of the keys are formed that will persist for millennia, turning into a constant when treating the ill in view of pain and death. Women will continuously see to palliative care, while the other characters involved in the world of health and illness will only punctually deal with this type of ill people. Paleoanthropologists have found signs of practices like the voyage of no return of the elderly, who went away from the camp when the time had come when they no longer felt useful to the community or sensed their death. Children born with malformations that implied important problems for survival were also abandoned and cast out of the camp and, despite evidence of cases going against this infanticide, this was common practice under such circumstances.
While some authors(17-18) describe the functioning of the social and cultural structures involved in health care in a synchronous way, pay little attention to their historical evolution; others center on the historical study of beliefs, traditions, myths and the incidence of magic and religion in primitive as well as in ancient cultures(30-31). The authors did not intend to describe the way the ill without solution are taken care of as a result of a religious, magical, ritual practice; but to offer a dynamic panorama through which the relation is analyzed in which palliative care, as a practice in its structural framework, at the mercy of the magical foundations and normative beliefs deriving from animism, goes through a transformation process into rites that are integrated/mixed up/merged with those practices. Consequently, health care is integrated in ritual processes that are part of cultural and social systems in which beliefs influence conducts(6). It is in palliative care, because of its proximity with death as a great mystery of human beings, that this fusion between care practice and rites makes more sense, as that is when one starts to gain awareness of death and the cult for the dead starts. When considering the dying as someone who will start a trip towards another level. The postmortem care that occurs as from the Medium Paleolithic and mainly in the Mesolithic, represent an extension of the preparation for the beyond the dying receive according to different beliefs, in prehistory as well as in antiquity: prayers, communion and extreme unction. In primitive cultures, the social actors were the wizards who interpreted the standards of the ruling animist system from the supernatural perspective, the folk system; and women who looked after palliative care, orally transmitted for generations from grandmothers to mothers and granddaughters, the popular or domestic system; finally, in primitive as well as in antique cultures, different systems somewhat live together: the folk and popular systems in primitive cultures, given that, in many cases, women's empirical care was absorbed by the wizards(20). This study comes with the limitations inherent in meta-analysis, to the extent that, despite critical efforts, meta-synthesis and the study selection criteria, it derives from different types of studies with different results.
Based on the different contributions from several disciplines: paleopathology, structural or functional anthropology, cultural history of care, a consistent synthesis can be woven that answers the questions raised and permits reaching the goals set: Palliative care, in its ethical, conceptual and technological equivalence of each age, already existed in primitive societies. The prehistoric social structures that looked after palliative care delivery went through a transformation that originates in the Neolithic period and is linked with the change from nomad to sedentary life, the birth of cities, family, home, temples, polytheist religions and science: the functional unit, the functional framework and the functional element; they derived from man's permanent need to interpret diseases, pain and death natural and supernaturally. In this sense, both technology and sciences (rational remedies) and animism and religion (beliefs) have been very important in the interpretation and organization of palliative care. Consequently, the rites surrounding death constitute a significant part of palliative care history, which has mainly been studied by anthropologists, given its cultural nature.
Palliative care develops, taking the forms of transition rites when, in the Medium Paleolithic, man becomes aware of the meaning of death and starts the cult of the dead and beliefs in the beyond.
The social context and modus vivendi determined the way palliative care was organized through a double transition: from tribe to family and from nomad to sedentary life. Concerning palliative care, both the folk (interpretation of supernatural causes and treatments) and popular care systems (natural interpretation and empirical remedies) developed in primitive cultures and continue in ancient civilizations. Nevertheless, the birth of the professional cure and care system only appears in the Neolithic period, in the framework of the ancient world.
It can be affirmed that the social, commercial, economic and technological development of societies has been somewhat related with the palliative care impulse.
Palliative care is a fundamental part of the historical evolution of human beings and the world, and its historical knowledge contributes to a further understanding of the phenomenon in current society.
Cultural history and the dialectical structural model are adequate to study the global reality of palliative care in pre-history and ancient cultures, because it seeks both the meaning of palliative care conducts and the underlying characteristics of their motivation.
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