Last Rights: The Ethics of Managing the Dead in COVID-19

"My Fathers Funeral" by sridgway is licensed under CC BY 2.0.

Table of Contents

• Abstract

• Introduction

• Background Information: Traditional Funeral Rites of Predominant Religions

  • Abrahamic Religions (USA)

  • Hinduism and Buddhism (India)

• The Effects of COVID-19 on Deathcare

  • Impact of COVID-19 on the USA

  • Impact of COVID-19 on India

• Ethical Considerations 

• Conclusion

Abstract

Humans have had complex traditions for managing the remains of their dead loved ones for millennia. These traditions, religious and non-religious, can offer comfort to the mourning families and help them to begin the process of healing from the trauma of the death of a loved one. The traditions are designed to fulfill the final wishes of the deceased and to provide a time and place for community and healing for those participating in the traditions.

The COVID-19 pandemic has created a public health crisis and has resulted in mass death, with 6.28 million people dying from the illness globally as of May 2022. (World Health Organization, 2022) The number of deaths has overwhelmed funeral industries around the world. This creates a conflict between the need to safely and expeditiously take care of bodies vs fulfilling the final wishes of the person and their families. This paper will examine the ethical tension between fulfilling an individual's final wishes and appropriately responding to the outsized challenges of the COVID-19 public health crisis and the 6.28 million resulting deaths. The specific questions that will be examined are: whether or not is it ethical to prioritize those with religious reasoning behind their burial practices over those who have non-religious reasoning for their burial wishes, and whether the government has the right to restrict religious burials? These questions will be approached through differing philosophies on rights, rights based ethics, utilitarianism and consequentialism. 

Introduction

A mass death incident or mass casualty event is defined as an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time. Often, the images of a natural disaster or terrorist attack come to mind when thinking of mass casualty events but the definition goes beyond an instantaneous event. Pandemics are mass casualty events that occur for an extended period of time, with the number of deceased slowly stretching society’s systems and traditions for deathcare to the breaking point. The COVID-19 pandemic has become a mass casualty event and public health crisis, taking the lives of millions. Other pandemics in the past can serve to teach us about how mass death is handled when aspects of handling it could result in more dying.

"Spanish Influenza 1918" by UNSIC is licensed under CC BY-NC-SA 2.0.

The Spanish Influenza Pandemic of 1918 was the most recent mass casualty pandemic before COVD-19. Influenza spread with the assistance of the mass travel and close quarters of armies during World War I, with estimated infections of 500 million people world-wide. Of these 500 million, it is estimated that 50 million died of the virus, lowering life expectancies and creating overwhelmed deathcare systems across the globe. In the United States, the life expectancy in 1917 before influenza was 54 for women and 48 for men. In just one year, the Influenza pandemic had caused life expectancy to drop to 12 years to 42 for women and 36 for men. (Center for Disease Control, 2018) Philadelphia, Pennsylvania was one of the hardest-hit cities in the world with an estimated 16,000 deaths and half a million cases of influenza. (Shetty, 2018) At that time, the common funeral practice was for the families to manage their dead loved one themselves. The funeral industry and funeral directors experienced a boom during the pandemic due to the incorrect belief that the dead could still transmit influenza. Due to this incorrect belief, families that could afford to do so would send their deceased to be embalmed. The process of embalming must be done by a professional that is usually hired by a funeral home to perform embalmings. The already overwhelmed deathcare industry buckled under the weight of the added time needed to perform an embalming. The funeral homes could only care for a limited number of people.

Those who could not afford or could not secure a funeral director and embalmer would bury their loved one themselves or would leave the body in a pile of coffins awaiting a mass grave burial. Some bodies were stored in the cool cellars of restaurants and breweries to prevent decomposition as they awaited burial. (Mütter Museum of the College of Physicians of Philadelphia, 2019)

Similar responses to mass death as result of illness can be seen in the recent COVID-19 pandemic throughout the world, with the main difference being the governmental involvement in the regulation of funeral rites. During the 1918 Influenza Pandemic, the American government did not restrict funerals for the sake of public safety while in the COVID-19 pandemic, the American government among other governments, regulated individual’s funeral rites during the pandemic. This became a concern as religious funeral practices were unable to be held under the new restrictions. The restrictions highlighted the ever-present tensions between religion and the government regulations. Questions arose surrounding the ethicality of government regulations prioritizing or limiting those with religious burials for the sake of public safety. 

Traditional Funeral Rites of the Predominant Religions of India and the United States of America

In order to fully understand how devastating COVID-19 has been to traditional funeral rites, the “normal” non-mass death funeral practices and traditions must be understood. It should be noted that the funeral rites that will be discussed are the traditional rites and are not necessarily what every individual in that religion does for the funeral of their loved ones.

Abrahamic Religions (USA)

The predominant religions in the United States are Abrahamic Religions with 63% of adults identifying as Christian, 1% as Jewish, 1% as Muslim (The 2020 Census of American Religion) and 29% not affiliated with a religion. (Pew Research Center, 2021) Muslims and Jews have very similar, community oriented burial traditions. In Judaism, community or family members volunteer to wash and clothe the body in a white linen shroud. Someone must be with the body at all times until burial. Performing these rituals is considered one of the greatest mitzvot. In Islam, elder community members familiar with Islamic burial law wash the body and cover it in a white cloth. The body must be accompanied by someone, usually a family member, at all times until burial. Both Jewish and Muslim funerals require an in-ground burial of the body as soon as possible post mortem, usually within 24 hours. These requirements have a spiritual and practical basis as it maintains a sanitary environment for the living relatives as bodies decompose quickly in the hot deserts these religions originated from. Embalming and cremation are forbidden as well as to not deface the body.

Islamic burials do not require a coffin but Muslim citizens of western countries often bury their dead in a plain wooden box. The person is laid to rest in the ground so that their face faces Mecca (Memorial Planning). Jewish burials require the deceased to be dressed in a plain white cloth and buried in a pine box. Funeral goers must all help in the act of burying, shoveling dirt onto the pine box after it is lowered into the ground (Alcalay Klug).

"File:PikiWiki Israel 29371 Religion in Israel.JPG" by אילנה שקולניק Ilana Shkolnik is licensed under CC BY 2.5.

In Christianity, funeral traditions vary by denomination. In the Roman Catholic tradition, A parish priest and other clergy visit the sick person to perform the sacrament of anointing of the sick. If the person is very close to death, the priest may perform a final confession for the dying. When the person passes, they sprinkle the deceased with holy water. The body is then washed and prepared for a wake or viewing of the body is held for family members and friends. This is typically followed by a funeral service and a graveside burial service is performed. Burial is the most common practice but cremation is also permissible. In the Eastern Orthodox tradition, a priest visits the dying person to hear their final confession and give Holy Communion. The body is then washed and clothed for burial, which is traditionally done by the family and friends of the deceased. Afterwards, a wake is held for family and friends followed by a funeral service and graveside burial service. Within Protestantism, the funerals vary by denomination but a common practice is to hold a service, a wake and a graveside service if the body is being buried. The body is washed and dressed in the person’s best clothing. In Western Christian funerals, a funeral director does this. The funeral director may also embalm the body if that was the request of the family. In all major Christian sects, embalming is permitted.

Embalmings are often done when the family is allowing time for relatives who live far away to attend the funeral. The embalmed body can be preserved for weeks in a cold, dry environment. Often, embalmings involve some aspect of beautification such as make up or fillers to preserve the closest facsimile of the person in life in death so those who attend the wake may recognize their loved one. Cremation on the other hand, used to be banned in all sects due to the belief that the body must stay intact in order to be resurrected during the second coming of Jesus. Although recently, cremation has been permitted in Catholicism and Protestantism but it is still not allowed in Eastern Orthodox churches.

Hinduism and Buddhism (India)

The majority of adults in India are Hindu, making up 79.8% of India's population with 14.2% of the population being Muslim. Christians, Sikhs, Buddhists and Jains account for most of the remaining 6% (Pew Research Center, 2021) In the Hindu tradition, the body is washed soon after death and is wrapped in white cloth if the deceased was a man or a widow. If the deceased was a woman whose husband is still living, she is wrapped in a red cloth. The big toes are tied together with a string and a mark called a Tilak is made on the forehead. The deceased is then carried to a cremation site near a river known as Shmashana. There, a cremation ceremony is held after which, the ashes are scattered in the nearest river. The Buddhist tradition is to leave the deceased untouched for an hour to allow the soul to leave the body. The body is then placed in a plain wooden casket in preparation for a service in which the family prays and offers food in the memory of the loved one. Then the body is cremated to follow the tradition of the Buddha’s cremation.

The Effects of COVID-19 on Deathcare

Impact of COVID-19 on the USA

"usa flag" by R.Duran is licensed under CC BY-NC-ND 2.0.

It is estimated that about one million Americans have died of COVID-19 of May 2022. (World Health Organization, 2022) This death toll combined with the transmissibility of the virus resulted in the government creating restrictions on various aspects of daily life, such as mask and vaccine mandates as well as capacity limits. These capacity limits became a challenge for those with more community oriented funeral preparations and traditions. At the beginning of the pandemic, state governments following Center for Disease Control recommendations created capacity limits. In New Jersey, there was an indoor 10 person capacity limit (New Jersey Government, 2022) The capacity limit paired with travel bans made fulfilling the wishes of the deceased and the mourning customs of the living relatives difficult if not impossible. To adapt to these new restrictions and stay safe, the virtual funeral was created. Funerals -- religious or otherwise -- are important to the families of the deceased to facilitate the beginning of the morning process and subsequent psychological healing from the trauma of the loss of a loved one. Being able to physically hold and comfort loved ones creates unity and strength among the mourning that cannot be had in virtual funerals. For those who hold viewings or wakes, it can be comforting to see the loved one for the last time in person but that cannot be held in a virtual setting. In Judaism there is a seven day period of mourning called shiva where friends and community members visit the mourning family and bring food and comfort. This is another mourning custom that could not be upheld under COVID-19. Funerals are also conducted to honor a loved one’s memory, usually in sharing stories and experiences with other grieving funeral goers. This aspect of a funeral was less affected by the virtual format, although the discussion and sharing of a virtual funeral.

New York City (NYC) was among the first to report COVID-19 cases in the USA with the first case in the city being confirmed on February 29, 2020. This area was particularly hard-hit with nearly 67,775 deaths as of early May 2022. When NYC was suffering the most with a seven-day average of 829 deaths in April 2020, funeral homes and morgues were overwhelmed by the bodies of the deceased (The New York Times, 2022) There were also those unclaimed bodies who were either without family or their family could not travel to claim them. Usually, these remains would go to city morgues and would eventually be buried by private funeral homes supported by state funding. But as the system was so overwhelmed, the issue of storing the bodies before burial became a priority. In response the government purchased refrigerated trucks where unclaimed remains of COVID-19 patients were placed for temporary storage. As of May 2021 there were still 750 bodies in storage there as the trucks turned to long term storage for claimed and unclaimed bodies.

A NYC Medical Examiner spokesperson stated on the matter that “Long term storage was created at the height of the pandemic to ensure that families could lay their loved ones to rest as they see fit.” (NBC News, 2021) Some bodies who remained unclaimed were buried in mass graves on Hart Island alongside victims of the HIV/AIDS epidemic. Images of the mass grave burials and the refrigerated trucks were shown without context under sensationalized headlines online and on the news. Many New Yorkers were horrified by the fact that the dead were being treated so impersonally, being loaded in and out of trucks into mass graves. Some thought that as long as the bodies were cared for in one way or another, the bodies were being respected. Others saw the refrigerated trucks and Hart Island as a necessity for the greater good of the public. 

Impact of COVID-19 on India

Image by Shivam Kumar from Pixabay

It is estimated that over half a million Indians have died of COVID-19 as of May 2022, although it has been suspected that the number is much higher than reported due to the number of people dying at home without getting tested for the virus.  (World Health Organization, 2022) The reason why so many die at home is because treatment for COVID-19 became unreasonably expensive due to price gouging and black marketing of medical supplies. At the height of the black market prices, oxygen cylinders in New Delhi changed hands for as much as 70,000 rupees, which is twenty times the usual price and many times the monthly salary of the average Indian. It also became more expensive to perform funeral rites. This practice of price gouging can be seen in the case of Ashok Khondare, whose sister died of COVID-19 in May 2021. The only available hearse driver charged 5,000 rupees-- five times the going rate -- for a four-mile journey to the nearest crematorium. There, he was greeted with long queues of people with their dead loved ones waiting for cremations who had been there for days. He agreed to pay another 7,000 rupees to jump the queue. Already financially set back by the medical treatment of his sister, he was forced to pay exorbitant amounts to respect the last wishes of his sister (Jahav, Sharma, 2021).

Another one of the issues India faced was unauthorized cremations and burials. Those who could not afford to pay the inflated prices to cremate their loved ones still needed to manage their dead and would bury their loved ones on a riverbank or outside of town. On the 10th of May 2021, 71 corpses washed up on the river bank of the Ganges in Bihar's Chausa Village. It was later discovered that these remains were body parts which had found their way into the Ganges after routine cremations on the banks. Incidents like these were not isolated to just Chausa Village. In other riverside villages and cities such as Kanpur, bodies were washing up on the banks of the river. A journalist in Kanpur told the BBC that the corpses were evidence of a "massive discrepancy between the official COVID-19 death figures and the actual numbers on the ground.” He said that officially 196 people had died from the COVID-19 in Kanpur between April 16 and May 5, but the data from seven crematoriums showed nearly 8,000 cremations. “All electric crematoriums were running 24/7 in April,” he said, “Even that was not enough, so the [government] allowed the grounds outside [the crematoriums] to be used for cremations using wood.” (Pandey, 2021) However, the government only accepted bodies for outdoor cremation that were coming from hospitals with COVID-19 being listed as their official cause of death. Many people were dying at home untested and therefore were unable to receive the assistance from the government. If their families could not find wood or a place for them to cremate their loved one, they resorted to burying them along the river. "It is heartbreaking," the journalist said, "All these people were someone's son, daughter, brother, father and mother. They deserved some respect in death. But they have not even become part of the statistics - they died unknown and were buried unknown" (Pandey, 2021).

Another possible contributor to the bodies along the river could be the regional practice of Jal Pravah. It is a tradition of floating the bodies of children, unwed girls, or those who die from infectious diseases or snake bites in the Ganges River. Hindus consider Ganges sacred, they believe that bathing in Ganges will cleanse their sins and use its water for religious rituals. In response to the bodies and the concerns posed by them that were being found in the river, the state government banned "Jal Pravah" and offered funds to poor families unable to afford cremations. (Pandey, 2021)

Those who could afford to pay the exorbitant prices--caused by those taking advantage of those in need paired with the low supply and high demand--are unable to bury their dead as they wish. This creates a greater inequality between the rich and the impoverished financially and creates inequality spiritually. Those who observe religions that require certain funeral rites with spiritual consequences for not obeying the requirement will suffer not only in life but in the after life if they do not pay the required amount to do the rite. 

Ethical Considerations

Now that the situation that families and governments have gone through in the mass death scenario of COVID-19 has been understood, two questions arise: is it ethical to prioritize those with religious reasoning behind their burial practices over those who have non- religious reasoning for their burial wishes, and should the government be able to dictate priority and set restrictions on the religious? To begin the discussion of these questions, different schools of thought on rights and ethical frameworks must be understood and considered.

There are different interpretations of what a right is and how it should function, two being privilege rights and rights as trumps. Those who follow the privilege rights school of thought believe that rights afforded to people and that there are two types of rights, single privilege and a pair of privilege rights. The single privilege-right makes its holder “free to” perform an action while the pair of privilege rights gives its holder liberty to perform the action, but the right-holder has the liberty to decide if they would like to do the action (Wenar, Stanford Encyclopedia of Philosophy) The viewpoint of those who follow the rights as trumps school of thought is that rights permit their holders to act in certain ways, or give reasons to treat their holders in certain ways or permit their holders to act in certain ways, even if some social aim would be served by doing otherwise. They also believe that certain rights can “trump” or overrule other rights. A simple example of this would be if I drive down the road with a green light and there is an ambulance coming, the ambulance’s right of way takes priority over mine and I would let it pass. 

There are various justification of rights but here the focus will be on the deontological justification of rights and the theory of natural rights. Deontologists believe that there is a duty to uphold rights, and they believe we ought not violate rights, even for the sake of maximizing the non-violation of rights overall (as in a “utilitarianism of rights”). Natural rights theorists such as John Locke would agree with the deontological justification for rights, believing that all men have rights to “life, liberty, and estate” as these rights are guaranteed in a pre-political state of nature. These natural rights should not be encroached upon by any authority, especially governments, as it would go against nature and by association, God’s will. 

From Locke's theory of natural rights, the ethical framework of rights-based ethics was constructed. In rights based ethics, natural rights must be upheld no matter the consequence. Locke’s original natural rights were expanded upon to include the right to free will and choice, the right to independent thought and speech, freedom in socialization and relationships and freedom of personal beliefs and values. If personal beliefs and values are rights and are analogous to religious beliefs, are religion and by extension burial practices rights? The United States Constitution was written based on the ideas of Locke and rights based ethics which states that religion is a right and that freedom to practice religion falls under the natural right to liberty. The First Amendment to the constitution states, “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof” Burial traditions and practices are a part of the free exercise of religion therefore, they are a natural right that should not be encroached upon in any sense. Under the framework of rights based ethics, it is unethical for a government to restrict religious burials. 

Defining the right to a religious funeral as a natural right under the right to practice religion, would make the right to religion a pair of privilege rights. The rightholder is permitted to practice their religion and decide when and how they will do it. If viewing the right to a religious funeral vs the right to a non-religious funeral through the lens of rights as trumps, it can be argued that the right to a religious burial would trump the non religious. Both begin with the baseline right to bury your dead but the religious’ addition of the right to practice religion could overpower the right to bury the dead alone. 

If practicing religion as a natural right can trump or “override” other rights, does the right to practice religion trumps the community's and individual’s right to safety? This question calls for the consideration of utilitarianism, and the broader category it falls under, consequentialism. Beginning with the more focused of the two, utilitarianism is a branch of consequentialism claiming that the deed with the greatest good outcome for the greatest number of people is ethical. In order to evaluate an act through the utilitarian lens, we need to identify who the majority is. One could argue that suffering caused by an overwhelmed deathcare system impacts nearly everyone in society and ignoring the religious would only harm the subset of the society that is religious. This interpretation would mean that the good for the greatest number of people would be expediting the burials and ignoring religious requirements. The issue with this train of thought in this scenario is that the majority of people in the USA and India are religious. As there is no real way to determine the majority of people that would be helped, we must broaden our ethical lens to consequentialism.

Image by rdaconnect from Pixabay

Consequentialism compares the consequences of an action and decides the ethicality based on the positive and negative impacts. In this case, there is no true “good” consequence from any decision, so we will be comparing the harms each decision will cause and deciding which is the lesser of the two evils. If we prioritize and let religious funerals do not restrict religious funerals, there is the possibility of spreading COVID-19 and inadvertently killing more people. If we prioritize the safety of the funeral goers and restrict the religious funerals, there will be negative psychological or spiritual consequences. Let us compare the harms shared by both the religious and non-religious families of not having their loved one’s wishes respected with harm done to society by “backing up” the funeral industry in a time of need. Both families will have limited time to prepare, would be unable to say their goodbyes to their loved ones on their terms and within their traditions, and may feel that they and their loved one have been violated since they were unable to fulfill the wishes of the loved one. This impacted the mental health of families of deceased individuals and families’ ability to process the trauma of the death. In some cases during COVID-19, the lack of control and the stress of trying to secure a funeral in accordance with the deceased’s wishes created additional trauma for the family. For religious families, there can be spiritual punishments for not being buried as per the scriptures. Some possible consequences in some religions are; angering deity(ies), damnation, not having an afterlife or having a negative life in reincarnation. This factors into the importance of a religious funeral for religious families. They do not want to “be the cause” of their loved one’s possible spiritual punishment. This consequence may seem less substantial to those who are non-observing but to the religious, this can be one of the most damaging consequences. Spiritual punishments are eternal in most religions with the idea of damnation in Christianity serving as a prime example. Damnation is eternal suffering in hell for sinning or going against the laws of the Bible. To the loved ones, the feeling of guilt that they may have caused the damnation of their loved one through not having a traditional burial would be another trauma to have to reconcile along with the death of their loved one.

Furthermore, consequences of prioritizing the religious over the non-religious also must be examined. Prioritizing the religious over the non-religious due to viewing the religious’ right to bury their dead as a pair of privilege rights that trump the non-religious right to bury the dead could lead the non religious to feel they are being discriminated against. The issue is that if we prioritize the non-religious, then the religious can feel discriminated against. Connecting this issue of religious vs non-religious prioritization to prioritizing safety, the prioritization of safety would have the same outcome (not consequences) of prioritizing the non-religious. The consequences would differ as the justification for prioritizing the non-religious is not based on utilitarianism as the prioritization of safety is and does not have the same support of being a pair of privilege rights. For a government to prioritize the non-religious would seem somewhat unfounded and difficult to justify, leading many to conclude that the reasoning behind it is rooted in prejudice towards the religious, the likely consequence being great social unrest and anger. The justification of safety on the other hand, has the justification of the “good for all people in the long run'' utilitarian backing.

In a scenario where the religious burial rights take precedence, the possible harms done to society are on the environment and mental and physical health of the society. The eventual backlogging of the deathcare system that would result in the time required for a religious funeral would cause bodies piling up. This would create unsanitary conditions and unauthorized burials which would lead to pollution. This issue of an overwhelmed system creating a health risk and pollution could be seen in the previously mentioned unauthorized burials along Ganges River of India. People bathe, drink from and perform rituals in the Ganges every day and the unsanitary conditions of bodies in the river posed a health risk.

Bodies not being managed would damage the psyche of the society of the whole. People would see that others are not cared for in death and question; society does not care for its citizens in death, then does it truly care about them in life? We can see the damage done to the psyche of society in the public’s adverse responses to the NYC refrigerated trucks and Hart Island burials. The unclaimed dead causes the living to feel as though the system does not care for them and results in the people losing hope in the systems. Seeing unclaimed deceased also makes the living feel as though the lives of certain people are less valued than others or that life is devalued in general.

Conclusion

When exploring the ethicality of the difficult scenarios that COVID-19, mass death, and governmental restrictions have placed upon grieving families, this paper finds that the issue boils down to the rights of the individual vs the rights of the community enforced by a utilitarian government. By first understanding that COVD-19 is a mass death crisis and the effects that mass death has had on the deathcare system and traditional funerals, this paper explored the various philosophical and ethical lenses that the issue of rights can be viewed through. This paper has found that the rights of the religious to hold religious funerals should not be impeded on by government regulations, no matter the good will behind said regulations. Viewing religion and the practice thereof as a right, and through rights as trumps, rights and privileges, deontological and rights based viewpoints, this right must be upheld. 

Now that this paper’s viewpoint on religion as a right, a broader question that can be examined is whether only organized religions should be considered rights or if an unorganized religion or personal belief is a right as well. Although the individual has a right to hold a belief, the issue is if one can prevent an individual from acting upon a belief. For example, religious or spiritual justifications for not getting vaccinated. These questions call to judge the justifications of an action and belief and the intentions behind them, bringing virtue ethics into the conversation. The intention behind claiming a belief and acting upon it can either be virtuous or not. The determination of virtuosity or not is what would rule the belief ethical or unethical. If a belief or fringe religion is created and followed with the only intention of forgoing a certain law or requirement, the belief is founded on deception which is not virtuous. If a belief or fringe religion is created to assist its followers spiritually, then it is benevolent and virtuous. In the case of vaccine exemption, this paper’s conclusion could be interpreted in that context to find that vaccine exemption is ethical due to the right of the religious to practice their religion. But, it must be prefaced that the basis of religion for exemption must be founded upon clear and stated rules within the religious scripture or traditions that would prevent vaccination, just as the requirements for burial must be defined. 

Returning to the subject of COVID-19 and pandemics, going forward and preparing for the inevitability of the next pandemic, we need to consider not only the necessary changes in infrastructure but the changes in attitude towards the dead, dying and grieving. Death is a subject that everyone on this planet is destined to become very intimate with. When discussing mass death, we can get caught up in numbers and statistics and lose humanity in death. As death is around us all the time we become jaded and blase about the losses of others. Considerations for the families of the grieving get lost in the overwhelming task that is managing mass death. One could easily dismiss the desire for a religious burial in such a time of crisis as selfish. But I would call for a greater understanding of those who may request or perform a religious burial in such a difficult time for all of us. If a funeral has the power to comfort a family or community in mourning, it cannot be so easily dismissed.

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