Book Reviews 573

The book concludes with a set of recommendations for are willing to embark on an open and frank discussion about making choices but within a particular set of conditions choices in health care. whereby “choices are made using a community-oriented Decisions about choices or rationing a&t us all. This approach in which individual rights are limited and the book is a must for anyone who wishes to enhance their un- professional autonomy of health professionals is curbed in derstanding of the difficult issues relating to choice and how the interests of equity and solidarity in health care”. one country in particular has sought to channel the debate.

As the debate about choices or rationing in health care grows apace this book is timely, topical and thought- Nufield Institute for Health TOM RATEWELL provoking. It offers no panacea and although it does present Services Studies a policy agenda for the Dutch health care system, much of Ufliversity of Leeds what the book contains is pertinent to most (if not all) health 71-75 Clarendon Road care systems. The Dutch may not have it right but at least they Lee& LS2 9PL

Facing Death: Images, Iwights, and Interventions, by interpretations to ponder, and contrasts or similarities to SANDRA L. BERTMAN. Hemisphere, New York, 1991. consider.

One may divide the field of death and dying into two approaches: a quantitative approach which emphasizes survey research methods, theory construction, and ‘number crunching’ as contrasted with a qualitative approach which stresses case studies, value clarification, and subjective meaning. This work clearly falls within the second approach with an explicitly stated purpose of providing ‘an edu- cational process for using visual and literary images of illness and death to elicit personal feelings and reactions to dying and grief.’ The book is geared to provide ‘frontline staff (those who deal directly and closely with those facing their own or other’s death) with materials that evoke responses pertinent to their concerns. These responses can then be shared and compared with the responses of others.

The main criticisms of the images is the lack of color and size. The published art work, of course, can be found in other places, but the contributions of the participants lose much in this format. Reproductions in color and larger size, however, would have made this book prohibitively expensive. Many of the images are extremely moving and commanding.

Chapter three, entitled ‘Responses to the Images’ reports on data collected from five different categories of partici- pants to whom the double-slide presentation was made. Many of the participants completed a small selection of questions from Shneidman’s ‘You and Death’ question- naire, and many made very absorbing responses to the author’s request to comment about a ‘most memorable image’ in the presentations.

Bertman basically reports on her own work with what she calls ‘double-slide’ presentations wherein a series of two slides of contrasting but thematically similar materials are presented to an audience. The audience is then asked to comment on the presentations immediately after the presen- tation and sometimes in writing, but always in the company of experienced facilitators like Dr Bertman. To me, the final chapter provided the most dramatic examples why Bertman used double-slides rather than single slides.

The book has four chapters, the first one of which is a brief explanatory introduction which sets the tone for the following chapters.

The first group of participants encompassed junior and senior high school students aged 13-1. They were ‘alerted ahead of time of the nature and power of the material, of the voluntary aspects of their participation, and of the availability of resources-including (the group’s leader+ for private consultation.’ Including younger people, I think is a positive contribution of Dr Bertman and she reports that young people have indeed thought about death and dying and many have generated informed opinions.

Chapter 2 presents the artistic ‘raw material’: the paint- ings, drawings, poetry, prose, etchings, watercolors, sculp- tures, letters, photographs and even cartoons, organized into a variety of themes. The themes include:

1. The Art of Dying: The Chosen Death, 2. Death and Afterlife, Views of Mortality and

Immortality, 3. Aloneness, 4. Loss of Control, Unmentionable Feelings, Grief, 5. Tolerance for Ambivalence, 6. The Moment of Death, 7. The Birds of Sorrow.

Theme 6, The Moment of Death, for example, begins with an oil painting by Charles Emile Callandre de Champ- martin entitled, ‘After Death, Study of A Severed Head.’ This image is later compared to a picture of the head of ‘Gramp’ right after his death, ‘Gramp’, photographs (1976) Mark Jury and Dan Jury. Other illustrations include Edward Munch’s ‘Death in the Sickroom’ (1895) Benny Andrews’ ‘Mourners’ (1977) and Edward Munch’s ‘Death Agony’ (1896). Interspersed between these images are quotations and excerpts from The Death of Ivan Ilyich by Tolstoy, Notes of a Survivor by Robert Anderson, What rhe Cystoscope Said by Anatole Broyard, and Last Letter to the Pebble People by Virginia H. Hine. A running commentary informs the reader of things to observe,

The second group of participants, consisting of graduate students, were asked to create a picture or image related to their concerns about or attitudes toward death and also to explain their creations. One particularly thoughtful creation portrays a drawing of a woman’s grandmother in a hospital bed a month before her death. In her commentary the granddaughter described how her grandmother was quite ready to die; she refused to eat, wear glasses and hearing aid. But when visited by her granddaughter she became quite animated and held her granddaughter’s hand with an in- credible grip. The granddaughter concluded that although she could understand her grandmother’s symbolic ‘giving up’ she was afraid of dying-‘gripping my hand to hold on the same way I would hold onto someone if I were going to die.’ Later the same participant reveals her work with the aged and her own dislike of bathing and cleaning up after them because she figures they are embarrassed by their lack of autonomy.

Seventeen other portrayals by the participants are compared with or contrasted to images from the slide presentation in quite interesting ways.

The third group of participants, members of a first- year medical student class, were solicited for images and explanations regarding their upcoming experiences with dissecting human bodies. Responses reveal concerns about where the cadavers came from, what kind of lives they had led, guilt and other feelings about dissection. Thirty student images are presented and discussed. The short twelve-page section which discusses the medical students’ responses to the most memorable image assignment demonstrates the great variety of interpretations possible to the slide

574 Book Reviews

presentation. The importance of affording the student an Why are the scrolls on the floor? How does this work change opportunity to express concerns in a relaxed nonjudgmental your view of caring for or interacting with seriously ill atmosphere is stressed by the author. persons?

The fourth group of participants were graduate nurses 21-58 years old and more experienced. The author con- cludes that many had already experienced death in their personal lives but had not been able to ‘process’ their experiences; the slide presentation offered a way to heal some of the suppressed pain.

In addition to asking questions about images, Bertman suggests other ways of involving students. Suggestions include changing the captions of images, complete partial images or make changes to images.

The last group of participants were hospice volunteers and many were quoted with regard to the effects the slide presentations had on them.

The numbers given with regard to frequency of responses by various groups and sub-groups do not always make sense but can be ignored without detracting from what is essen- tially case study material.

The most powerful and effective explanation for the use of a double-slide presentation (as opposed to a single-slide presentation) is presented by juxtaposing Munch’s ‘Death Agony’ with other images. These included ‘Physician Watching Over a Sick Child’ by Sir Luke Fildes, ‘The Wait’ by Benny Andres and ‘Jacob Blessing Sons of Joseph’ by Rembrandt.

The last chapter, ‘Broadening the Perspective,’ contains some of Berman’s philosophical and professional beliefs as well as an extremely useful guide on how to use the arts to complement teaching and counseling on death and dying.

The chapter also has suggestions for not only other topics such as aging and deformities, but also other forms of artistic expression including films and videotapes. The chapter concludes with about four pages of the most succinct and poignant guidelines for dealing with normal grief I have seen in a long time.

With reference to the first image of the book, ‘The Death of Socrates’ by David, a rather comprehensive and enlight- ening series of general and specific questions are presented (I counted at least 65 questions). Examples include the following: Who are the figures going up the stairs? Why does the central t&me have a head that seems older than his body? Is the artist making a social or political statement? What story is the painter trying to tell? Why is the student touching Socrates knee? What are you (as an observer) experiencing? (e.g. boredom, anger, amusement, sadness)?

In sum, Bertman provides the reader with a remarkable collection of images about death and dying as well as an exceptional methodology for using these artistic images to expose and review inner responses-be they ‘emotional’ or ‘intellectual.’

California Stare University, Fullerton Fullerton, CA 92634 U.S.A.

TONY BELL