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Human values, rights, ethics, legal issues, and dignity in death during COVID-19: mental health perspectives

Guru S Gowda, Barikar C Malathesh, Bhavika Vajawat, Vinay Basavaraju, Channaveerachari Naveen Kumar, Suresh Bada Math

National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, India

Abstract

The funeral rites of the deceased are a part of our culture since time immemorial, and it varies across the globe. Following the coronavirus disease 2019 (COVID-19) pandemic, the World Health Organisation and other statutory bodies have released guidelines for conducting the funeral of the COVID-19-related deaths to prevent the spread of the COVID-19 infection. Even with the above guidelines in place and religious preferences of the funeral process being adequately addressed, there are few unfortunate incidences of obstruction to the funeral of COVID-19 infected dead body. This article highlights the mental health perspectives, legal issues, rights, human values, and dignity in COVID-19-related deaths.

Keywords: SARS-CoV-2, patient rights, funeral rite, bereavement, attitude to death

Correspondence: Dr. Guru S Gowda, Assistant Professor, Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Hosur Road, Bengaluru - 29, India. drgsgowda@gmail.com

Received: 23 March 2021

Revised: 27 May 2021

Accepted: 3 June 2021

Epub: 10 June 2021

INTRODUCTION

The coronavirus disease 2019 (COVID-19) has been declared a “pandemic” in March 2020, affecting almost every country in the world. Many countries are now facing the second wave of COVID-19, which has taken a somewhat different trajectory depending on the country’s public health measures. As of 14 April, 2021, more than 137 millions have been infected with COVID-19 and 2.96 million have died worldwide. The estimated case fatality rate is around 2.87% worldwide and 1.53% in India.[1] Irrespective of nature and cause of death, every family has a right to conduct the funeral of the dead body, upholding religious customs, and respecting the dead body. The practice of performing funeral rites is as old as the history of mankind. The funeral rites are highly structured and vary among different religions and customs. These variations can be seen in how they pray, do a ceremonial cleaning of the dead body, put on new clothes, read from religious scripts, sprinkle holy water, directly touch, kiss, or hug the dead body. Burial is highly favoured over cremation in Christian religions in India, although this practice varies significantly around the world. In the Hindu and Sikh faiths, ceremonial washing of the dead body and open-air cremation is practised, while in Islam, burial is practised, and cremation is discouraged. Depending on local traditions, Buddhists may practice cremation, water burial, or inhumation.[2] In many places, the deceased will get buried/cremated in their desired final resting place. In many religions, the mourning ritual continues for three days to one month after the death of a person. In this period, friends and relatives visit the deceased and emotionally comfort the family. These are all based on religious preferences concerning the last rites, followed for many years.

FUNERAL GUIDELINES FOR COVID-19 DEATHS

Epidemic diseases like COVID-19, Ebola, and Nipah are highly contagious and associated with a high transmission rate. So, the state had to make policies to prevent the spread of the virus and at the same time had to ensure that religious preferences concerning last rites are respected. However, a number of unfortunate incidents occurred around the world, such as the Chinese government cremating a COVID-19 infected dead body in a hurry without informing the deceased’s family or keeping religious views into consideration. Sri Lanka ordered mandatory cremation of COVID-19 infected dead bodies and had banned burial completely, without considering religious preferences. These have occurred before the funeral guidelines framed by the World Health Organization (WHO).[3]  In contrast to the above, countries like Australia, Brazil, France, India, Israel, the United Kingdom, and the United States of America (USA) allowed the burial of COVID-19 infected dead bodies, which is in line with the WHO guidelines.[4,5] Table 1 shows the WHO interim guidance on safety management of a dead body with a history of COVID-19 infection. Most guidelines advise the following: a) COVID-19 infected dead body can be either cremated or buried, and b) the standard precautions are taken at all times by the healthcare personnel and the family members while handling the COVID-19 infected dead body. Under standard precaution, healthcare personnel and family members are advised to use masks and gloves, and practice hand hygiene during cremation. Also, personal protective equipment (PPE) is a must for healthcare professionals while transferring the COVID-19 infected dead body from the isolation wards. Any ritual that involves direct touching, kissing, or hugging the body is advised against, though the dead body can be touched with gloves on. Viewing the face, doing religious rituals such as reading from religious scripts, sprinkling holy water is allowed if standard precautions can be ensured. These guidelines have restricted the number of persons who can attend the funeral process. In many places across India, multiple unfortunate incidences have occurred. The public has obstructed the burial or cremation of the COVID-19 infected dead body, even though the government recommended guidelines for the burial/cremation of the COVID-19 infected dead body were in place.[5-9] These incidents have raised serious concerns among healthcare workers and public authorities. These may be due to misconceptions among the general public about the spread of the novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) from the burial/cremation site to their locality.[10] In the USA, in cases where families could not afford the funeral of the COVID-19 infected deadbody, the authority has facilitated a mass burial.[11]

INTERFACE OF COVID-19 RELATED DEATH AND MENTAL HEALTH ISSUES AMONG THE FAMILIES/RELATIVES

COVID-19 is a medical disaster, which comes with significant psychological impact for the families affected by this.[12] It starts right from the point the infected person is sent for quarantine/isolation centres. Families may develop feelings of guilt that they are not with their loved ones during their battle against the COVID-19 infection. This feeling worsens when the individual succumbs to COVID-19. The mental agony further increases due to restrictions imposed on funeral processes like not allowing for religious preferences and restricting the number of people.[13] In a few places, the dead could not be buried/cremated in their desired final resting place due to severe restrictions on the transport facility. The survivors have also missed providing social and emotional support due to restrictions on the number of people who can attend the funeral process, which has further complicated the concerns.

Funeral practices vary across the globe. It allows the expression of culturally approved loss-related emotions and comes to terms with the reality of loss. Group mourning processes are culturally determined mechanisms of alleviating anxiety and are considered as “cultural defences”.[14] Funeral and mourning also allow the survivors to accept reality and form a new relationship with the deceased. When the funeral and morning processes are interrupted or restricted, the healing process gets disrupted. The families of the deceased may develop worry and ruminations about the unfortunate events that occurred around the funeral of their loved ones. Families might also develop feelings of guilt and self-blame for not being able to give a dignified farewell to the deceased. In the case of violent disturbances to the funeral process like obstruction by the public, individuals may develop posttraumatic stress disorder, with intrusive thoughts and images of the disturbed funeral process.[15]

There is a need to be cognizant of the psychological issues and emerging mental health problems during this critical period. These mental health problems can range from pathological grief to posttraumatic stress disorder.[16] Identification of issues that are interfering with the normal grieving process and addressing them is of paramount importance. The psychological help can initially focus on letting the family ventilate their emotions, validate and normalise their emotions, which are essential parts of any grief counselling session. Specific enquiries about the performance of last rites and the guilt of not supporting the COVID-19 victim (when he was alive) would be prudent. The professionals can facilitate the process of accepting the loss and new life without the deceased. These can be done through various methods like motivational interviewing, interpersonal therapy, and cognitive behavioural therapy.[17] Public health authorities and mental health professionals’ availability and proactively providing psychological assistance to family members of COVID-19 victims would be a much-required step.[18]

STRATEGIES TO COPE WITH COVID-19 DEATHS IN INDIA DURING PANDEMIC

New or alternative acceptable ways are needed to provide support and comfort to family members, friends, and relatives during a pandemic. These rituals support survivors in overcoming a critical point in their grief, reducing the likelihood of experiencing complicated grief.[19] In India’s sociocultural, religious, traditional norms, and standard COVID-19 precaution, the following strategies can be adapted. This include the following: a) trying to follow a possible ritual to relieve their pain, such as lighting a lamp in front of a deceased person’s photo and praying a song; b) watching and living through a shared video of rituals performed by the deceased; c) accepting that the deceased person was ill and/or aged, the hope of a quick death also relieved the agony, as death was seen as the natural course of events; and d) through social media platforms, providing assistance and support to others helps to mobilise internal resources to cope with the loss of deceased.[20]

HUMAN VALUES, RIGHTS, ETHICAL AND LEGAL ISSUES IMPLICATIONS OF DEATH DUE TO COVID-19

The funeral rites are believed to be as old as the history of mankind. It varies among different religions and customs. In few religions, it is intended that, it is to help the soul of the dead person to reincarnate.[21] The funeral rites are associated with many socio-cultural, ethnic values, and emotions, so the dead body cannot be treated just like any other non-living object. As per many international conventions, dignity and respect of the dead body cannot be violated even in wars, leave aside non-war situations. The process of disposal of the dead body is to be done in a dignified manner, including unclaimed deadbody irrespective of how the victim died.[22-24]

In India, if anybody obstructing the funeral of the deceased or for causing an indignity to any dead human body or causing disturbance to persons assembled for the performance of funeral ceremonies considered as offence under the Indian Penal Code (IPC) 297 and prescribes a  maximum punishment of one year or fine or both.[25] Following multiple instances of obstruction to the funeral of COVID-19 dead body in various places of India, a suo moto public interest litigation was taken up by the Honourable Madras High Court and interpreted article 21 of the constitution in a broader sense, broadening its scope to include ‘right to have a dignified burial’.[26]

The above unfortunate obstruction to funeral might have occurred because of a lack of understanding and misconceptions about the spread of COVID-19. The general public needs to be educated about COVID-19, especially about the cremation or burial procedure of COVID-19 victims. These issues of handling a dead body during the aftermath of a disaster have been explained in the National Disaster Management Authority Act, Government of India. It helps the healthcare volunteers and public authorities to deal with the situation effectively and efficiently.[27]

Furthermore, the COVID-19 global crisis has raised several ethical considerations. Patients’ families are often restricted access to hospitals and unable to see their dying relatives due to isolation measures in many countries. If one member contracts COVID-19 infection, several members of the family living in the same household get exposed. This might prevent their participation in the funeral rites if there is a death in the family as they are themselves in either quarantine or isolation. Additionally, also to preventing infection and ensuring the safety of the general public who attend the rituals. However, it raises the important ethical question of community safety vs. cultural and religious rights of deceased family.[28]

CONCLUSION

Funeral rites during COVID-19 pandemic have important socio-cultural, psychological, legal, and ethical implications. With the emergence of the COVID-19 pandemic, many guidelines for performing funeral rites are inherently attempting to protect a number of religious and cultural practices while also ensuring the safety and prevention of the infection spread. So, adherence to these guidelines is imperative as they strike to balance the safety, prevention, and cultural practices. Obstruction of funeral rites and cultural practice could have far-reaching psychological and legal unforeseen consequences.

FUTURE DIRECTION

In the current COVID-19 pandemic, many unpredictable situations arise due to the social distancing norms, difficulties in travel, and others. This has resulted in families becoming incapable of completing the religious preferences concerning last rites. This may have major mental health implications for relatives and family members. These can be alternatively addressed by live streaming of video or video recording of the ceremonies for relatives who are unable to participate in the funeral process. This strategy could have translational implications for individuals who are unable to participate in the funeral process of their loved ones, even in non-pandemic situations. Healthcare professionals must take adequate steps to screen and treat the survivors who have lost their loved ones to the COVID-19 infection. The demand for such consultations is likely to increase shortly, for which one may have to gear up their services and be sensitive to these issues. Telemedicine services would be essential to reach out to individuals living in remote areas. It is essential to create awareness about these issues and prevent unwarranted obstruction to the funeral process. Research in the future could be directed to assessing the long-term mental health consequences of the survivors whose loved ones have succumbed to COVID-19.

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Gowda GS, Malathesh BC, Vajawat B, Basavaraju V, Kumar CN, Math SB. Human values, rights, ethics, legal issues, and dignity in death during COVID-19: mental health perspectives. Open J Psychiatry Allied Sci. 2021 Jun 10. Epub ahead of print.

Source of support: Nil. Declaration of interest: None.