Dying with Meaning: Social Identity and Cultural Scripts for a Good Death in Spain

doi:10.4236/aasoci.2013.32016

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Advances in Applied Sociology

2013. Vol.3, No.2, 124-130

Published Online June 2013 in SciRes (http://www.scirp.org/journal/aasoci) http://dx.doi.org/10.4236/aasoci.2013.32016

124

Dying with Meaning: Social Identity and Cultural Scripts for a

Good Death in Spain

Fernando Aguiar, José A. Cerrillo, Rafael Serrano-del-Rosal

Institute for Advanced Social Studies (IESA-CSIC), Cordoba, Spain

Email: faguiar@iesa.csic.es

Received February 8th, 2013; revised Mar ch 12th, 2013; accepted March 20th, 2013

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the

original work is properly cited.

In this article we examine, through six focus groups, the various arguments put forth by social actors to

defend or reject the right to choose how to die, including palliative sedation, euthanasia and even assisted

suicide. This qualitative technique allows us to establish the relative weight of traditional, modern and

neo-modern models of coping with death in the discourses of the Spanish subjects sampled within the

study, how these models are reflected in specific cultural scripts and to what extent these scripts for a

good death are the product of a reflexive project of identity.

Keywords: Assisted Suicide; Cultural Scripts; Euthanasia; Reflexive Identity; Spain

Introduction

Spain is one of the countries of the European Union (EU)

that has experienced the greatest and most rapid social, political

and economic changes in the last three decades (Pérez-Yruela

& Serrano-del-Rosal, 1998; Harrison & Corkill, 2004). The

country ceased to be a dictatorship in 1975 to become a de-

mocracy whose model of transition has been emulated by other

countries. Spain underwent a transformation from a rural coun-

try with 23.4 percent of its active population engaging in agri-

culture (Spanish National Statistics Institute, 1975) to become,

in less than three decades, a post-industrial society with just 4.5

percent of its workforce in the farming sector (Spanish Ministry

of Environment and Rural and Marine Affairs, 2011). It is,

therefore, a society, such as those of its neighboring countries,

characterized by high levels of technology and consumption.

These changes, among other effects, have led to a mortality

reduction in Spain, as it is shown both by the infant mortality

rate, that lowered from 18.89 per thousand in 1975 to 3.2 per

thousand in 1990, and the life expectancy, that increased from

77.08 years of life to 81.58. Moreover, 17.07 per cent of the

population today is over 65 years of age compared to 10.45 in

1975.

Not surprisingly, such far-reaching changes have affected the

way in which the Spanish conceive of themselves. Spanish

society now sees itself as a more egalitarian and more modern

society than thirty years ago (Royo & Manuel, 2003). An im-

portant indicator of these changes is undoubtedly the way the

Spanish conceives of death today in general, and palliative

sedation, euthanasia and assisted suicide in particular. In light

of the profound social changes occurring in the last two decades,

a new culture of the good death has emerged in Spain which is

similar to that of other countries of the EU. In these countries a

good death means, on average, being free from avoidable dis-

tress and suffering, on the one hand, and choosing as far as

possible how to die in a way consistent with clinical, cultural,

and ethical standards, on the other (IOM, 1997; DeSpelder &

Strickland, 2005). As we shall see, however, this does not mean

that this conception is uniform across the Spanish population or

does not coexist with other more traditional conceptions typical

of the previous decades. In that regard, Spain is not different

from its neighboring countries or any other post-industrial na-

tion either (Cohen, Marcoux, Bilsen, Deboosere, Van der Val, &

Deliens, 2006a; Cohen et al., 2006b).

Indeed, new experiences related to death that are characteris-

tic of a medicalized, post-industrial society (oblivion of death,

dyin g in hospitals) , and more pr ogressive legislation in relation

to these issues have changed the image of Spain as a Catholic

country unable to accept individual rights associated with death

(Simón-Lorda, 2008). The social debate arising from dramatic

cases such as the quadriplegic Ramón Sampedro who received

illegal assistance to commit suicide (Guerra, 1999) or that of

Inmaculada Echevarría, who after an arduous legal battle

against public health authorities was disconnected from the

artificial respirator that kept her alive (Simón-Lorda & Bar-

rio-Cantalejo, 2008), have no doubt contributed to these

changes.

A study conducted by the Center for Sociological Research

(CIS; Spanish acronym) as early as 1992 revealed that 78 per-

cent of Spanish citizens was in favor of palliative sedation and

66 percent agreed that laws should allow doctors to end the life

of a terminally ill patient who so requests it (CIS, 1992). These

figures, which remained stable throughout the nineties, have

experienced a notable increase in the last decade. While 62

percent of respondents supported “physicians providing the

[terminally ill] a product to end their life without pain” in 1995

(CIS, 1995), this percentage rose to 70 percent in the next dec-

ade (CIS, 2008, 2009). Unlike other European countries, Spain

—alongside Belgium, Sweden and Italy—has experienced a

remarkable increase in the acceptance of euthanasia (Cohen et

al., 2006b: p. 666; Council of Europe, 2004) not only among

F. AGUIAR ET AL.

the population as a whole, as we have seen, but also among

health professionals (CIS, 2002).

The survey data clearly point to the emergence of a new cul-

ture of the good death in which palliative sedation, euthanasia,

and even assisted suicide are not only put to debate, but widely

supported by the population. Yet what are the central elements

of this new culture? Is this changing perception of death and

dying in Spain related to the development of a modern, reflex-

ive notion of identity (Giddens, 1991; Mellor & Shilling, 1993;

Stets & Burke, 2003)? Do elements of a pre-modern identity

survive in Spanish culture, which is presumably influenced

strongly by the Catholic religion? Do the perceptions of the

Spanish people about the end of life fit in the models of coping

with death (traditional, modern and neo-modern) proposed by

Walter (1994: pp. 47-65)? Are these models reflected in specific

cultural scripts, that is, socially determined representations of

death that can guide individual decisions (Seale, 1998)?

The perceptions and attitudes towards the notion of death are

complex and therefore not readily available through survey data

alone (Cohen et al., 2006a: p. 753). As Stanley and Wise (2011)

have pointed out, each social configuration tries to “domesti-

cate” death in its own way. Survey data indicate a clear change

in Spain, but do not tell us enough about the inner nature of this

change, that is, how it is perceived by the actors themselves. In

this paper we aim to shed some light on the perception of death

and the good death debate in Spanish society. Specifically, the

objectives of this article are to:

1) Explore and sort out the discourses circulating in Spanish

society concerning good death in general and palliative sedation

and euthanasia in particular to establish the relationship be-

tween these discourses and traditional, modern and neo-modern

models of death and dying (Walter, 1994).

2) Examine in depth the justifications and arguments that

arise from such discourses by means of different cultural scripts

that defend or reject the right to choose how to die, including

palliative sedation and euthanasia, and the notion of dignity and

autonomy in the process of dying.

Methods

In line with the proposed research objectives and the advan-

tages of qualitative methodology to address them, we chose the

focus group technique. This technique is most suitable for re-

constructing social discourses, understood as broad, shared

representations which, in relation to our topic, are reflected in

diverse narratives (scripts) grounded on cultural models about

death and dying process on the one hand, and in expressions of

identity (reflexive or not) of the participants on the other. Hence

the focus groups are more appropriate than interviews to recon-

struct cultural scripts (Martín Criado, 1997).

Specifically, we took into account the place of residence (ru-

ral or urban), age, educational level and gender to design our

sample. Previous quantitative studies have shown that these

variables bear statistically significant relationships with the

defense or rejection of the right to die (Sesma, Ranchal, &

Serrano-del-Rosal, 2009; Cohen et al., 2006a, 2006b). Although

we did not select religion and moral attitudes as variables, they

appear in the discourses as explanatory narrative elements.

Regarding gender, most of the groups were mixed, with half of

the participants of each gender, with the exception of group 1

(composed of advanced age, urban resident males only) and

group 2 ( of advanced age, low schooling rural resident women),

since we found it interesting to explore their specific percep-

tions.

Bearing in mind the above, we formed six focus groups as

described in the Table 1.

Eight participants were convened for each group, with only

three absences, one in group 4 and two in group 6. However,

these absences did not weaken the meetings, since the debates

in both groups did not differ in their richness and duration from

those registered in the other groups. The participants were re-

cruited with the help of a company specialized on qualitative

field work services, and each one received fifty Euros for their

efforts. The discussion groups were held from 17 November to

3 December 2009:

The groups were led by a moderator (one of the researchers),

who ensured that the discussion progressed in as orderly a

manner as possible, asked the participants questions from time

to time, brought up previously debated issues to be discussed in

greater depth, and raised some issues in the final leg of the

discussions that had either not been dealt with or on which

agreement or disagreement had not been reached. Thus, unlike

other studies (Underwood, Mair, Bartlett, Partridge, Lucke, &

Hall, 2009), no data were obtained by means of in-depth or

semi-structured interviews. To obtain cultural scripts for a good

death it is important that the process be conducted by the par-

ticipants themselves without the moderator guiding the out-

come. To do so, we decided to convene the groups to discuss a

direct and general question that encouraged the participants to

discuss the main objective of the study but did not anticipate

subsequent responses: “What does a good death mean to you?”

The discussions were transcribed verbatim and the transcripts

analyzed with the aid of Atlas.ti version 5.2 software to relate

what was said literally (textual analysis) and the process

through which it was said (contextual analysis, in this case the

group dynamics) to the structural dimensions of reference (dis-

course analysis) (Ruiz, 2009). The original recordings as well

as the literal transcription are available (in Spanish) to re-

searchers upon request. Data were gathered and presented here

with permission of the persons that took part in the focus

groups, following the Code of Good Scientific Practices of the

Spanish Council for Scientific Research (CSIC, Spanish acro-

nym).

Results

In the following, we present a selection of the discourses

Table 1.

Focus groups.

GroupGenderAge Educational level Habitat

Approx.

duration

11 Men60 - 7 5Intermediate (secondary

education or similar) Urban

(Granada) 96 min.

22 Women50 - 60Low (no education or

primary schooling Rural

(Cazorla) 94 min.

33 Mixed36 - 50High (university

education) Urban

(Seville) 97 mi n.

44 Mixed36 - 50Low (no education or

primary s chooling) Rural

(Adamuz) 106 min.

55 Mixed22 - 3 5Intermediate Urban

(Malaga) 116 min.

66 Mixed18 - 25Low (no education or

primary s chooling) Rural

(El Rocío)97 min.

F. AGUIAR ET AL.

which are grouped into two main sections: in section A we pre-

sent the discourses against a good death understood as the right

to choose how to die; in section B the discourses in favor of

that right (including euthanasia) are showed. Section A is not

divided into subsections, because the discourse is homogene-

ously against the right to decide how to die. However, we em-

phasize some key terms upon which the discourse focuses (de-

shumanization, my life is not my own, where there is live there

is hope, the denial of death). The discourses in favor are not

homogeneous and we divide them into three subsections de-

pending on the nature of the argument: the emotional discourse,

the negative freedom discourse and the autonomy and positive

rights discourse. For each discourse we indicate the group from

which it proceeded and if the person being quoted is a man (M)

or a woman (W).

The Discourse against the Right to Choose How to

Die

DehumAnization

The most outstanding feature of the opposing discourse is its

emphasis on the dehumanization of today’s world and nostalgia

for the past. The present is viewed as a progressive degradation

of an idealized past, which is considered a model of a good

society, or at least one that is better than today’s. According to

this discourse, society in the past was better because it attached

greater importance to concern and respect for others. In relation

to death, this means that common values regarding the obliga-

tion to care for (“deal with”) the sick and dying prevailed:

M: Today, the thing is that we have become, truthfully …

less responsible ... for centuries and centuries there have always

been sick people, right? And because before …, in the old days,

people put up with the sick ..., that is, people with few means

dealt with the situation, and today, now that we can do it ... we

can do it because we are more prepared, we live better. Why do

we think ... that we have to get them out of the way or take

them to a facility [Group 1]?

In the discourse opposing the right to decide how to die,

death has turned into just another way of doing business. This is

manifested in the clear opposition to legalizing the right to

choose because it is thought that the ultimate objective of any

process that speeds up death such as euthanasia or assisted sui-

cide is not to relieve the suffering of the dying, but due to some

kind of economic interest that either benefits the family (in-

heritances), funeral homes (revenue from burials) or the state

(savings on health expenditure):

M: What [euthanasia] can’t be is a trick to deceive others. I

mean, a guy has a lot of money and is alone ... so, the family,

when he gets sick and has been in the hospital for two months ...

requests euthanasia [Group 1].

M: It is a failure of society, right? They don’t know how to

give the person [the sick or dying person] a quality of life that

provides even the slightest ray of hope [Group 3].

My Life Is Not My Own

Most of the participants who supported the opposing dis-

course had little power over their life circumstances. These

were elderly people living in rural settings with a low educa-

tional level who alternated between precarious jobs with long

periods of unemployment, earned low wages and pensions, and

lived on a day to day basis. They lived far from the centers of

power and decision making, which are completely alien to them.

They did not fully understand the world they lived in; either

because it is very different from the world they grew up in or

because they lacked the education or information to understand

it, or both. These are people whose reality is unstable and pre-

carious and cannot anticipate their future. The precondition of

an action oriented towards the future is to have minimal control

over present circumstances, or at least believe that that is so

(Bourdieu, 2002; Sennett, 1998).

W: But they don’t let you live they way you want to either.

You live within your means, right? Or as best as you can. At

least I ... I try to live within my means, I don’t live the way I

want, or how I would like to live. Or how they let me live, or ...

Exactly. No ... I would like to live ... to die within my means.

No ... I’m not going to ask for a death ... You know? (Pause) I ...

I would try to do that. For me it would be like that. I don’t

know. I don’t know. You don’t live the way you want, [you live]

the way you can. [...]. I would try to die within my means ...

like I live.

W: Dying, you’re going to die when the time comes. Really.

And then …

[Interrupting.] W: That’s right, if it comes … the moment …

unexpectedly, then it’s time.

M: Well ... That’s right. The time comes and that’s it, right

[Group 6]?

Where There Is Life There Is Hope

According to the discourse of opposition and rejection, when

the person has a chance of surviving, however small that

chance may be, life must be pre served at all costs, regardless of

the will of the person involved, be yourself or someone else:

M: Because when the re is a ray …, a ray of …, of light, you

have to grab onto it. That much we agree on [Group 1].

These narratives reveal religious faith in a miraculous recov-

ery. In the discourse against the individual right to decide, the

positions are Christian. Such positions are an outright denial of

the sovereignty of the individual over their own lives because

only God has the power to give or take life.

M: I am of the opinion that God has given us life and God

has to take it away. For me, life ... death must be a death with

great respect and dignity. A human being can’t take a life away

[Group 1].

The Denial of Death

Almost all the groups attempted to avoid the discussion at all

costs. To do so, the participants would at times mention the

unsuitable nature of the topic being discussed: death is not an

appealing subject because it is unpleasant, ugly, sad, distressful,

and is therefore best not to talk about it. On other occasions, the

participants stated that death is a strictly private affair and must

be dealt with as such. When one is not involved, it is best to just

show respect and keep quiet about it, but never express atti-

tudes to death in public:

W: It isn’t a pleasant topic.

W: It’s a sad topic.

W: […] Yeah, I think a lot…but don’t talk about it.

W: Talk, people talk little about these things.

W: No, no about that I don’t usually … not with my closest

family or …

W: Since it’s something that’s sure to happen, we don’t need

to discuss it much.

W: Right, and in a meeting like today, even less [Group 2].

126

F. AGUIAR ET AL.

Discourses in Favor of the Right to Choose How to

Die

In line with the results of surveys, pro-right to die discourses

were more frequent than anti-right to die discourses among the

participants of the focus groups. Nevertheless, as already men-

tioned, a wide range of views and concerns arise from these

discourses that provide the opportunity to gain insight into what

drives 70% of Spanish citizens who, in 2008, stated that they

were in favor of euthanasia (CIS, 2008). As we shall see, the

reasons for defending such a right differ enormously.

Emotional Discourse

We call an emotional discourse one which supports the right

to euthanasia based more on the suffering of the dying than on

the individual’s autonomy to decide for him or herself. It is a

discourse grounded in a subjective and emotional conception of

morality (Bauman, 2000; Bauman, 1989) that is defined as an

innate impulse in human beings which arises from proximity to

others and that moves us to be concerned about them and to

take responsibility for their welfare and happiness. Morality

understood in this way belongs to the realm of emotion

(Bauman, 2000).

W: My father died of lung cancer ... and I asked him to be

sedated, I asked him to be sedated, to have a dignified death

and to sedate him because I didn’t want to see him suffer. He

was sedated and died very peacefully [Group 2].

The emotional discourse is more intense among individuals

with an intermediate and mid-to-low education, who are mature

adults or nearing old age and live in the rural setting. This pro-

file is very similar to those who sustain the discourse of rejec-

tion and opposition. Although both discourses share in common

the fact that they are based more on emotionality than rational-

ity, the anti-right to choose how to die discourse is conditioned

by negative emotions such as fear and insecurity, while the

emotional discourse reflects positive emotions such as compas-

sion and love:

M: I was taking care of my father, and already in the last

months I entered the room and asked ... I looked up and asked

the Lord to remember him. I tell to you with my heart in my

hand. And I think I loved my father as a son can love his father.

Do you understand what I mean? And I asked it to God, day

after day, and he doesn’t answer. Why? What was he doing

lying there? I spoke and spoke to him, he couldn’t answer me

and I burst into tears ... What was that man doing there, God of

my soul? And I said, my God, what can I do [Group 1]?

W: Because I remember when my grandfather was ill ... I

would say ... please, let him die... the thing is that you have a

hard time seeing him like that [Group 5].

Discourse Based on Negative Freedom

Contrary to the previous discourse, in this one the partici-

pants state that every person has the right to decide about their

life and their death, and that others should respect their decision.

It is therefore a discourse in which freedom is understood as

negative freedom, that is, as the absence of restrictions as to the

action itself, with the exception of actions that may interfere

with the freedom of others (Berlin, Hardy, & Harris, 2002).

M: Of course, that ... if you live the way you want, without

bothering anyone, then no one should bother you when you are

going to die [Group 1].

W: I agree ... everyone should do what they want [Group 3].

W: I think they should let people who can’t ... move or any-

thing, and if they want to die let them do it. Because they can’t

live like that [Group 6].

This is the discourse of self-ownership (Brenkert, 1998)

which holds that we are the owners of our bodies and therefore

of our lives. In today’s society, however, the rights related to

death and dying (particularly euthanasia and assisted suicide)

are an unmet social demand.

W: Let everyone decide about their body. Whatever they

want. Whatever they wish. Whatever … they think is best

[Group 3].

W: Who should decide for me if I’m living? Why don’t they

listen to me if it’s about me [Group 4]?

The notion of self-ownership enters into conflict with estab-

lished religious ideas, especially those of the Catholic Church,

which not only negates the notion that one is master of oneself,

but is also opposed to discussing euthanasia or assisted suicide.

M: Yeah, I mean, that’s the way it should be. Sure. A Catho-

lic who follows that ..., that religion, well ... he can do whatever

he wants, but ... religion shouldn’t intervene to tell the rest of us

what the morally right thing to do is.

W: No, religion. The thing is that religion in this country, it’s

that it is ... restrictive and to me that doesn’t seem right, be-

cause I ... I agree that everyone can be Catholic and I think

that’s fine, but ... everyone should be able to do what they want

to do and that’s all there i s to it.

W: The Catholics want to be respected about everything but

they don’t respect others or how others think. They don’t re-

spect us. Come on, I’m Catholic ... I’m [Catholic] too, but they

don’t respect those things [Group 3].

Citizens’ Discourse: Autonomy and Positive Rights

Finally, this discourse is very similar to the former one, al-

though it has nuances of some importance that set it apart. The

discourse of citizens encompasses all the tenets of the discourse

that advocates negative freedom, but takes it further to its ulti-

mate consequences, proposing what we could call with caution

a “social project”. In the citizens’ discourse, freedom of choice

is more than a right, it is a way of life, or at least a way of life

that is characteristic of contemporary societies; something

which truly shapes citizenship:

W: In this life we must continually choose one path or an-

other, one path or another, one path or another, you have to

know that.

W: We have to continually decide and that [how to die] is

one of the decisions we must make ... It’s hard, horrible, but we

have to do it [Group 3].

W: The thing is that euthanasia ... You decide for yourself: “I

don’t want medication, I don’t want surgery”. Nature takes its

victim ... and someone has to help [Group 3].

The citizens’ discourse shares the basic tenet of freedom of

choice and the need to eliminate obstacles to permitting citizens

to decide, but it elevates the discourse to the level of public

concern in an almost civilizing way: in the life that we live, we

have to choose our path. In this sense, choosing is not only a

right but a duty.

In the discourse that emphasizes negative freedom, individu-

als often speak from the viewpoint of the singular “I”, or at the

very most from an impersonal perspective when the argument

moves from the expressive to the denotative (“death is not to be

spoken about”, “if legislation needs to be made, let it be made”).

Citizens’ discourse is also expressed in these terms, but at times,

F. AGUIAR ET AL.

as in the above example s, the “I” gives way to “we”: “We have

to continually decide and that is one of the decisions we must

make”; a “we” that clearly refers to all citizens; to society as a

whole. For this reason we say that the citizens’ discourse ex-

presses a social and not just an individual project; the notion of

a good society, a common good and, therefore, a good death as

a common good.

M: I know a lady who was diagnosed with cancer ... that is, a

brain tumor and she decided not to have surgery and not to

take ... medication or chemo, no radio, no nothing and she died

when she had to die, period [...]. That’s euthanasia that she

practiced on herself [Group 3].

It should come as no surprise that this discourse chiefly

arises among those who have most control or believe that they

have control over their lives. For this reason, it is found almost

exclusively among the young or middle-aged; those who are

building or are in the process of building their life project. It is

a discourse that is more frequent among urban dwellers—not to

mention city dwellers—than those living in villages, where

pressure by the community is stronger and individual initiatives

fall under greater pressure (Sennett, 2008). Moreover, cities

provide better and broader opportunities where life is perceived

as an open menu with multiple options. In particular, the citi-

zens’ discourse is more common among individuals with a high

educational level and, more rarely, high income. This is so not

only because such an elaborate discourse requires good linguis-

tic proficiency, but because understanding the complex world in

which we live and die (to adapt and even take advantage of it)

requires having a significant amount of knowledge and infor-

mation. Not surprisingly, people who adhere to the citizens’

discourse are those who hold more stable and better paying jobs

and report more satisfaction.

Discussion

Depending on their age, beliefs, educational level, perception

of themselves as people who make crucial and independent

decisions concerning their lives or not, and place of residence,

the participants in the focus groups expressed a variety of posi-

tions regarding their notion of a good death and the individual

rights that ensure such a death. At the very beginning we found

the logical idealization of what one would hope death to be—

painless, surrounded by loved ones at home and at a late age

after having lived a full life—which coincides with the findings

of other studies both in Spain (Marí-Klose & de Miguel, 2000)

and elsewhere (Long, 2004: p. 925; Lee, Jo, Chee, & Lee,

2008). However, once the participants realized that this ideal

cannot be chosen at will, two different accounts emerged: one

which was more homogeneous and opposed to the view that a

good death involves an individual’s right to decide about his or

her own death (and body); and a more heterogeneous one that

supported free, individual choice for various reasons.

These discourses could be organized by means of cultural

models of dying according to age, social class, education, and

the habitat of individuals that took part in the focus groups

(gender, however, did not make any difference in our groups at

all). As it is well-known, these cultural models on death in

post-industrial societies can be divided into three ideal types:

traditional, modern and neo-modern (Walter, 1994: pp. 47-48).

Traditional model develop in community-based social contexts,

and continue to survive in developed societies where death has

a large social presence (death is not hidden) and in which relig-

ion is the central authority. In the modern model, however,

death is medicalized, kept at a distance, hidden away from eve-

ryday life. Here medicine is the authority and death is consid-

ered a private matter which must not be talked about. Finally,

the neo-modern model is a “revival” of death, which is consid-

ered another channel by which to develop oneself—a reflexive

self (Giddens, 1991)—and control one’s own death: the when,

how and where one wants to die. In this case, death is no longer

a purely private affair, but becomes a public issue that must be

discussed and in which the self has full authority.

These models, which are “ideal types”, may be reflected or

embodied differently in cultural scripts that determine the dis-

courses about death depending on the cultural traditions of each

country. Indeed, one of the central features in post-industrial

societies is the existence of multiple cultural scripts (Seale,

1998; Long, 2004). Thus, in Britain and other English-speaking

countries Seale (1998) found four cultural scripts: modern

medicine, revivalism, anti-revivalism and the religious script.

The traditional elements of Walter’s ideal type are related to

anti-revivalist and religious scripts that oppose the notion of a

self that takes charge of one’s own death, either because they

prefer “a closed awareness” of dying (anti-revivalism) or be-

cause they believe that the decision to die is in the hands of

God (religious scripts). In British culture, these scripts are relics

of the past and associated with low-income individuals with

little education. As Seale notes, religious and anti-revivalist

scripts are related to “those who are not well-schooled in the

kind of reflexivity self-aware projects of identity that Giddens

describes” (quoted by Long, 2004: p. 916).

The scripts that appeal to modern medicine are in conso-

nance with the modern ideal type, in which the project of per-

sonal identity, although reflexive, does not consider decisions

about death as an option for personal development and are

therefore left up to physicians (i.e. medical technology). In

contrast, revivalist scripts are a reflection of the neo-modern

ideal type in which the patients’ reflexive self “colonizes”

medicine, transforming it into patient-centered medical care and

making the process of dying—the how, when and where—an

inalienable right (Seale, 1998: p. 94).

Although the traditional, neo-modern and modern ideal types

are present in post-industrial countries, they are reflected in

each country differently through the four scripts proposed by

Seale (Seale, 2000). For example, two countries as different as

Japan and the USA, but which share common elements, also

reveal traditional scripts determined by religion, albeit they are

expressed differently due to the specific religious traditions of

each. In Japan, the religious and anti-revivalist scripts are not a

relic of the past: the Japanese combine a religious sense of life

after death (Shinto, Buddhist or Confucian) in a vague way

with cultural elements of a society in which science plays a

very important role (Long, 2004: p. 917). In the USA, however,

this synthesis between religious and modern views is not as

clear. While the revivalists claim the right to decide how, when

and where they want to die, people with strong Christian, Mus-

lim or Jewish beliefs fully reject the notion that human beings

should determine issues related to life and death: “They found

unacceptable to stop aggressive treatment, since death is some-

thing only God decides” (Long, 2004: p. 921).

In the case of our study the discourses on death can also be

identified as traditional, modern and neo-modern models. The

perception of death and its relationship or not to a reflexive

identity has its own characteristics in the individuals sampled

128

F. AGUIAR ET AL.

within the study. In general, however, their discourse is closer

to the discourses found in anglophone countries than to those

present in a country as developed and yet as religious as Japan.

The influence of religion has dropped sharply in Spain since it

again became a democratic country four decades ago (CIS,

2008, 2009; Brañas, García-Muñoz, & Neuman, 2011). Quanti-

tavie studies have shown that in Spain the traditional beliefs on

death are no longer predominant, although it is widely present

and remains the most homogeneous in our groups. Traditional

model is reflected in a script that is clearly more religious than

anti-revivalist. Indeed, we have not found an anti-revivalist

discourse that is not also religious. The traditional ideal type of

Walter, which is present in our groups in its purest form, is

manifested in the religious traditions of the country; traditions

which provide subjects with the intellectual tools they need to

oppose the right to choose how to die. The notion that one’s life

belongs to God and that people’s bodies are not their own, the

absence of a reflexive project of identity, the conviction that

while there is life there is hope, the rejection of the patient’s

autonomy to decide when, how and where to die are all charac-

teristic of a religious script, which in our study is not a relic of

the past even if it is a minority view. However, it is a fairly

sizeable minority that has been estimated at about 25 percent of

the population in quantitative studies (CIS, 2008); a much

smaller percentage than those who declare themselves to be

Catholic. As we have seen in the discourses, this indicates that

many of the individuals sampled who declare themselves to be

Catholics are, at the same time, revivalists.

Indeed, the majority of discourses support the right to choose

how to die, but they are also more heterogeneous than those

based on the traditional model. We have found a clear transi-

tional revivalist script: those who support the right to decide the

way to die either by euthanasia or assisted suicide out of com-

passion. From the standpoint of their social composition, these

individuals are very similar to those who defend traditional

positions in that they have low incomes and educational levels,

live in rural environments, their identity is not reflexive and

they do not conceive of the decision to die as part of their per-

sonal process of development. However, when faced with a

long and painful illness, they support euthanasia out of com-

passion for the patient and their families when the patient has

lost consciousness. They do not appeal to rights or freedoms,

but to the emotional aspects of the end of life. Given their lack

of education and conceptual references to justify their position

such as freedom, rights, or autonomy, these people often resort

to films (especially The Sea Inside by Alejandro Amenábar),

examples appearing in the media or their immediate environ-

ment to strengthen their position. As in the case of religious

scripts, in this transitional script from the traditional to the

modern we also encounter individuals who are not well-

schooled in reflexivity self-aware projects, but who take part in

a modern conception of death through the emotions that arise

from a near death process rather than a rational and reflexive

justification.

The other discourses support the right to die fit well into the

modern and neo-modern ideal types. In both cases we find a

similar social profile, but with differences with regard to educa-

tional level. These are people who live in an urban environment,

and are usually young or, at best, mature adults (there are few

elderly people) and who advocate a conception of the body

based on self-ownership and, therefore, the sovereignty of the

patient, thus suggesting that they have a clearly reflexive pro-

ject of identity, that is, they are citizens who are aware of their

rights. However, those we include in the modern model have a

lower educational level than that of the neo-moderns—in the

first group we find discourses by those who have a secondary

education, while those in the second group have a univer-

sity-level education. This is clearly reflected in both their pro-

jects of identity and the scripts that guide their discourses. As

we have seen, the modern ideal type is manifested in discourses

in which negative freedom forms the core of their argument.

These are disc ourses guide d by a revivalist script, but in which

there is no opposition to the medicalization of patients if the

patient agrees to delegate authority to doctors. Although the

identity is reflexive, it is only partial as it does not dwell much

on aspects related to personal development that involve deci-

sions about death. Rather, it is a discourse that revolves around

the notion of “live and let live”, including the end of life in this

freedom.

The neo-modern model is also embodied in a revivalist script,

but with interesting nuances that differentiate it from the above

model. This discourse does not revolve around the notion of

negative freedom, but is instead rather a question of building a

self who has a constant need to decide and choose; a multiple

and diverse self. These subjects have—or believe they have—

full control over a life that is purely choice and in which one

day they must face the ultimate choice of how and when to die;

a decision that must be taken autonomously. It is not only a

question of live and let live, but of defending a positive free-

dom to do with one’s life what one wishes (even it means tak-

ing one’s own life) for we are own masters. The private and the

public merge in these cases (Walter, 1994: p. 48) and the self

becomes a “we” that is not the “we” of traditional communities,

but of citizens’ rights.

Conclusion

Most European Union countries support the notion of a good

death as being free from avoidable distress and suffering and

having the right to choose how to die, especially with regard to

palliative sedation and euthanasia. As some quantitative studies

have shown (CIS, 2008; Cohen et al., 2006a, 2006b) Spain is

no exception. Although a large majority of Spaniards continue

to define themselves as Catholics, religion is no longer the chief

determinant for defending the notion of a good death that re-

spects the right to choose how to die (CIS, 2009). In spite of the

similarities, however, there are many differences across Euro-

pean countries given that “each country will have its own de-

bate, influenced by its cultural backgrounds” (Cohen et al.,

2006a: p. 754). For this reason, more country-specific, qualita-

tive research is needed. This has been the objective of this arti-

cle as there is ample evidence from Spanish and European sur-

veys that the Spanish support respecting the right to choose

one’s own death, but there are few qualitative studies on the

subject.

The qualitative study presented here reveals that the social

changes occurring in Spain in recent decades are reflected in

the discourses of the individuals within our study. The tradi-

tional, modern and neo-modern ideal types are presented in the

discourses, but reflected in sometimes confusing cultural scripts.

Firstly, it is clear that the traditional ideal type, which is em-

bodied in a religious script, is by no means a relic of the past.

But it is also true that on occasion this script clearly reveals

elements of the modern medicine script. On the other hand,

F. AGUIAR ET AL.

130

there is no anti-revivalist script, suggesting that the scripts that

emerge from the discourses are clearly polarized into religious

and revivalist scripts. The anti-revivalist and modern medicine

scripts that Seale finds in Britain are divided the individual

sampled within the study into religious and revivalist scripts. In

turn, the revivalist script reveals a confusing mix of justifica-

tions depending on the sociodemographic characteristics of the

individuals who participated in the focus groups (particularly

age, habitat and educational level seem to explain these differ-

ences to a larger degree). This polarization can be explained by

the rapid social changes that Spain has witnessed in just a few

years; changes that have also affected the notion of death, but

which have left little time for their discussion and assimilation.

For this reason, we have also found in this study that a clear,

reflexive project of identity which considers the right to die as

part of one’s personal development occurs only among more

highly educated individuals (university graduates). On the other

hand, it should be noted that in regard to identity, the gender

variable has had no influence on the discourses of the various

focus groups.

We are aware of the limitations of the present study due to

both its exploratory character and to the fact there are not many

qualitative data on good death in Spain that permit us to con-

trast our own findings. Further qualitative research would be

needed then to explore these findings as qualitative studies on

social identity and cultural scripts for a good death in Spain

having not reached theoretical saturation. In this respect, it

would be especially important to look further into the question

of gender and a good death, because the present study does not

allow us to firmly claim that there are no real gender differ-

ences regarding good death conceptions in Spain. That will be

one of our main research targets in the future.

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