Keywords

Introduction

Death and bereavement represent life’s most dreadful and inescapable realities through which social, cultural, spiritual, religious, and even political ideology manifests itself. The outlook on life and death can be especially mystifying in collective Middle Eastern societies where the private intricacies of family life are closely safeguarded, but life and death matters are dramatically and publicly shared by extended family and the wider community. Middle Eastern families are fundamentally bound by history, unwavering cultural traditions, and deeply internalized religious practices. These are highly demonstrative cultures that are fearless in celebrating life or mourning loss, which may seem overly melodramatic to Westerners. This chapter focuses on death and bereavement from the individual, familial, and societal perspective of the Jewish majority in Israel, as well as the Arab minority comprised of Christians and Muslims who reside in Israel. Religious and cultural practices are tightly interwoven, and depending on the circumstances of the loss are often infused with political overtones reflective of historical trauma.

Precipitating Historical and Political Factors

A brief introduction to regional geography, history, and politics of Israel is vital to sensibly appreciate the cultural conceptualization of death and bereavement. Israel is small Middle Eastern country situated along the Mediterranean Sea and bordering the Arab countries of Egypt, Jordan, Lebanon, Syria, as well as the Gaza and West Bank regions. The entire area totals 20,770 km2 and is often described as being “slightly larger than New Jersey” (Central Intelligence Agency, n.d.). Referred to as the “Holy Land” due to its significance to Christianity and Judaism, and with close ties to Islam, endless bloodshed, wars, and occupations have plagued this land in the name of God and religion. An Arab majority and Jewish minority coexisted in the region for hundreds of years and well before the establishment of the state of Israel in 1948. The Jewish quest for a homeland was supported through the British Balfour Declaration in 1917 and in 1918 following World War I when Britain took over Palestine as a mandate. World War II and the Nazi persecution and murder of six million Jews during the Holocaust illuminated the need for a Jewish home and hastened the British division of Palestine into separate Jewish and Arab states in 1948. While celebrated by Jews, surrounding Arab countries perceived the division as favoring the Jews and declared war on the newly established country, resulting in defeat and additional loss of Arab territory. A large percentage of Palestinians either fled or were forced to flee their homes to neighboring Arab countries where they assumed refugee status. Meanwhile, the new Jewish state declared victory and the Jewish minority replaced Arabs as the majority. The Palestinians who remained in Israel are now referred to as “Israeli Arabs,” identify themselves as such, and maintain a fragile relationship with the Jewish population due to the imposition of oppressive Jewish policy and practices. The Arabs who remained in the Palestinian regions of Gaza and West Bank refer to themselves as Palestinians, and due to Israeli security concerns have been subjected to military rule and restriction, occupation, as well as social and economic constraints that have greatly undermined their wellbeing and national autonomy. Additionally they continue to struggle against Israeli takeovers of their land to support the expansion of Jewish settlements. The outcome is Palestinian fury leading to acts of martyrdom or terror as viewed by the Israeli side, acts that have perpetuated national and racial insecurity among Jews and tremendous oppression and human suffering in the Palestinian region.

This brief history describes the origin of the Israeli-Palestinians conflict, where similar arguments are asserted and destructive means are employed to legitimize them by each side. The outcome is seemingly perpetual generation and reenactment of collective trauma endured by each side, where loss of lives is viewed as collateral damage and grief is something that Jews and Arabs accept as part of their fragile fate and existence. While most Western nations feel the compulsion to take sides, the reality is that trauma takes a heavy toll on every segment of the population regardless of age, religion, or ethnicity, as the need to preserve one’s people is supreme. Attic (2000) reports that grief is experienced on multiple levels that include individual, familial, community and collective. Such response is typical following terroristic attacks or other traumatic events in Israel or West Bank, where people are forced to cope with personal and community destruction. Reliance on protective factors such as family, religion, and culture is central to the bereaved and those who witness the loss. Strength-based interventions and programs are used to support families and to promote their continuing adjustment.

Country Demographics and Profile

According to the Israeli Central Bureau of Statistics (CBI), the 2013 population count is approximately 8.018 million, of which 75.3 % or 6.042 million are Jewish, 20.7 % or 1.658 million are Arabs, and 4.0 % or 318,000 represent other groups, such as non-Arab Christians and unclassified groups. The CBI (2013) broke down the Arab population in 2012 as being majority Muslims at 1.371 million, followed by 157.1 thousand Christians (this includes Christians who reside in Israel but are non-Arab), and 130.5 thousand Druze. As with other Middle Eastern societies, Israel maintains a collectivist orientation where family and community play a central role across the lifespan of individuals and families, and religion provides a framework to guide life’s most important milestones from birth through death. The collectivist outlook influences individuals throughout the lifespan and through end-of-life decisions. Glick (1997) describes these as “communitarian” values that are ingrained in the collective consciousness and temper personal interests with collective values. Whereas Western experiences with loss and bereavement are likely to be somewhat private, they are more prolonged and public in the Middle East and involve immediate and extended family, friends, and the community. “Successful” bereavement entails accepting the inevitability of death and loss, restructuring life to preserve the memory and bond with those mourned, and making sense not only of the loss but the need to continue life’s journey despite the loss. These are informal and formal social processes that are recognized by the community, supported through religious and cultural frameworks, and legitimized through laws and established social and political programs.

Cultural Perspectives on Death and Bereavement

Israel provides its citizens with generous social welfare programs, advanced medical technology and universal healthcare, and a network of services to support citizens across the lifespan. While the patient’s right to know their diagnosis and prognosis is recognized by healthcare professionals who are required by law to disclose it, some families may resist and limit that information out of respect, to protect the sick or dying. Jewish bioethics challenge informed consent and truth telling to patients and assert that such decisions be guided by Halacha (Jewish religious laws), which “determines the value system and God that is in possession of one’s body” (Hirschprung, 2012, p. 420). However, as Hirschprung notes, in reality Halacha does not support informed consent as patients are apprised of their condition when viable treatment options that could possibly reverse the condition are available, but forces risky treatment that they may refuse if it could save their life. Moreover, shielding seriously sick patients from bad news such as the death of a relative or their own poor prognosis is justified as a protective measure to prevent them from losing hope. While this practice finds its basis in the Jewish Talmud (text of rabbinic Judaism), it is commonly accepted, even in non-Jewish Middle Eastern societies.

Research has also demonstrated that end-of-life decisions and care are greatly impacted by other factors such as immediate and extended family, and the role of women and community. In one study, physicians were found to be more likely to withhold rather than withdraw treatment if they were Jewish, Greek Orthodox, or Muslim as opposed to those who were Catholic, Protestant, or had no religious affiliation (Sprung et al., 2007). Sprung et al. (2007) noted Israel’s rare use and unclear status on advanced directives, as well as a lack of written or unwritten policies or practices regarding euthanasia. Blank (2011) further confirms that active euthanasia is highly unlikely in Israel due to cultural and religious beliefs. While these seem to present more obstacles to a patient’s right to self-determination, Israel’s policies and services underscore its commitment to serving the wellbeing of individuals through an extensive network of services aimed at upholding strong religious, cultural, filial, and community supports for individuals facing death and for their families.

Common themes exist among Jews and Arabs that relate to religion, the role of extended family and community, and a prolonged mourning process. Burial is done within 24 h or as soon as possible, and begins a weeklong mourning process where family and friends gather to support the bereaved family, and where grief is expressed through clothing and minimal self-care. These concepts are shared by Lobra, Youngblut, and Brooten (2006), taking note of Judaism’s belief in the soul’s immediate return to heaven upon death, the wearing of dark ribbon or torn clothing to express grief, the weeklong “sitting Shiva,” the presence of family and guests to support family, minimal self-care, covering of mirrors, and daily reading of Kaddish (meaning holy) prayer. Lobra et al. (2006) also outline Islam’s view of earthly life as preparation for eternal life and the soul’s immediate exposure to God upon death. Dying patients are situated to face Mecca, the room is scented, and Quran recitations are shared with the dying. The following section will contextualize loss and bereavement within each of Israel’s ethnic groups, and the implications for individuals, families, and society.

The Jewish Experience with Loss and Bereavement

Bachner, O’Rourke, and Carmel (2011) found that fear of death, communication about death with terminally ill relatives, and psychological distress were significantly lower among secular Jews compared to religiously observant Jews. The authors explain that Jewish beliefs in life after death and the judgment upon one’s entire life contributes to caregivers’ fear of death and psychological distress, and limits the communication of religious caregivers with their loved ones. Judaism supports the idea of tikkun or healing through human intervention and the provision of care to prevent suffering, restore health, and save lives (Shalev, 2010). While valued, the authority and expertise of doctors does not supersede the patient’s right to informed consent and autonomous decision-making. This right was protected through the parliamentary passage of Basic Law: Human Dignity and Liberty in 1992. Reaffirmed through an Israeli Supreme Court decision in 2004, this law protected the patient’s right to medical information, a right (?) reinforced further through the passage of the Dying Patient Law in 2005, which regulates end-of-life decisions, while limiting the scope of patient rights and decision-making (Shalev, 2010). Cohen-Almagor (2011) highlights the 2005 law’s primary functions, which apply to competent patients who are dying and have expressed treatment preferences or the need to end or prolong their life: the law specifies that a patient’s medical condition, wishes, and the degree of suffering are to be accounted for in making end-of-life decisions; and outlines the care and decision-making process for minors and those considered incompetent to make their own decisions (Cohen-Almagor, 2011).

Shalev (2010) asserts that the passage of the Dying Patient Law of 2005 demonstrates the influence of Orthodox conservatives and the ongoing tension between Orthodox religious beliefs that stress the sanctity of life and duty to preserve it, and the ongoing discourse with secular humanism that stresses democratic ideals to safeguard autonomous decision-making and patient rights. The Dying Patient Law gives precedence to life preservation over right to refuse care; extends medical treatment despite prognostics and justifications to discontinue it; prohibits physicians from any practice that hastens death despite patient requests; provides palliative care despite risk to the life; and respects advanced directives only within limits and with restriction (Shalev, 2010). Jewish religious law prohibits active euthanasia or removal of treatment;, however, withholding treatment is acceptable as it is viewed as an act of omission and non-interference with natural processes that are best left in the hands of God (Ravitsky, 2005). Attempts are made to balance the emphasis on individual liberty related to end-of-life decisions with collective values and Jewish religious laws. For example, as Ravitsky notes, a patient’s exercise of autonomy and request for removal from ventilations poses a challenge to religious laws or communitarian values regarding hastening death, and so this challenge was resolved through the use of timers that can expire on ventilators, thus allowing patients to not “renew” treatment rather than “discontinue or withdraw,” therefore “converting commissions into omissions” (Ravitsky, 2005, p. 417). A patient is permitted to issue a Do Not Resuscitate (DNR) order as long as it does not hurry death. Thus the application of palliative care in Israel is mindful of Jewish religious law while focused on fulfilling the expectations of the World Health Organization (WHO) to ensure quality of life for terminally ill patients and families by addressing physical, psychological, and social needs while minimizing suffering (2002).

Whereas most Jews are secular, Orthodox Jews otherwise known as Haredim (Orthodox, non-Zionists) promote conservative and fundamentalist beliefs that have greatly influenced public policy. The Orthodox rabbinate is the provider of all religious services relating to marriage, divorce, or death in Israel for all Jews alike, a source of controversy for secular or non-observant Jews. Despite the emergence of groups such as Tzohar and ITIM to challenge their presence and to provide services to secular and non-observant Jews, the Israeli rabbinate remains the recognized government religious authority, and understanding the role and services related to death and burial is important for our discussion (Ferziger, 2008). Therefore, the following discussion about the Haredi community is highly relevant to contextualizing the Jewish experience with loss and bereavement.

The Haredi community adheres to strict interpretation of Jewish religion and segregates itself from Israeli society (Stadler, 2006). They reside in separate homogenous neighborhoods, attend special schools, and maintain a different lifestyle. Whereas military service is compulsory for all Jews, Haredi men abstain from military service and participation in the labor force, and instead dedicate their lives to the study of Talmud. Women attend separate educational systems and work to financially support their large families and their spouse’s dedication to religious studies. Haredi families tend to live in poverty or maintain a modest lifestyle that is often supplemented by governmental assistance (Stadler, 2006). The Ministry of Religion in Israel oversees burial services; however, with few exceptions, the Haredi burial society known as the hevra kaddisha, meaning sacred society, is responsible for all funeral and burial arrangements for Jewish citizens. Jewish traditions require burial as soon as possible because human remains are considered impure and may contaminate the purity of people and things that come in contact with the body. Jewish communities have entities dedicated to caring for the dead, removing them from the home, purifying and covering the body, and managing all informal and formal funeral details (Stadler, 2006). Zaka is a Haredi group that specifically responds to terror related deaths, recovers body parts and organs, and ensures proper care for the victims’ remains in accordance with Jewish law and religious practice. This has been described as a way for Haredi society to contribute to Israeli society and redeem its parasitic image to secular Jews (Stadler, Ben Ari, & Mesterman, 2005).

When exploring issues of loss and bereavement from a cultural perspective, the impact of history, collective trauma, and religious ideology must be examined. Lebel (2011) offers research studies that describe Israel as “militaristic society” where life seems to revolve around experiences of national loss and trauma, and sensitivity to loss is heightened. He asserts that parents of fallen soldiers are afforded special treatment and status that allows them to shape public opinion and military decision. This in turn influences military decisions to use combat strategies that minimize loss of life, and results in compromising national security and the wellbeing of civilians (Lebel, 2011). Malkinson and Bar-Tur (1999) reaffirm the emergence of a “bereavement culture,” where military death is regarded as sacrifice and heroism of national significance. Bereavement is persistent for parents who lose children in military service and the attachment continues across the lifespan and ends only with their death. When death the result of acts of war, terrorism, or traumatic events such as the Holocaust, the heroes or victims are honored during holidays such as Memorial Day and by national monuments (Possick et al., 2007). Possick et al. discuss how Jewish society utilizes Hantzacha, meaning the “perpetuation or immortalization” of lost loved ones to “re-membering” the dead into the life of survivors, and reconstructing their existence to promote a lasting bond (2007, p. 111). Through Hantzacha, survivors honor the dead for their sacrifice to their country or for their victimization, and allow their memory to influence and guide the living.

Hantzacha can be a private commemoration to achieve “emotional catharsis” by and for family members by memorializing the dead through tangible items such as pictures and albums, and/or via a less tangible approach whereby the family carries on the legacy of the dead member through their own existence and the way they live life. It can also involve a public commemoration that attempts to make meaning of martyrdom or victimization of loved ones through publishing personalized memory books or monuments; or by presenting memorial lectures or marathons (Possick et al., 2007). Such processes allow the meaning of the relationship with the dead to continue despite the loss.

The Arab-Israeli Experience with Loss and Grief

Arabs total 20.6 % of Israel’s population and are classified as 16.9 % Muslim, 2 % Christian, and 1.7 % Druze (CIA, 2013). Whereas differing religious beliefs dictate the practices of each group, common themes exist. The view of God as having the ultimate authority and power for matters relating to life and death, and respect for His will dominates the various Arab cultures and their outlook. God is referred to as Allah in Arabic, and his wisdom is integrated into daily interactions, as well as proverbs and metaphors that are organically embedded in the way people communicate and interact. Belief in the Maktub or written depicts the fatalistic stance on life assumed by most Arabs and describes their view of life as predetermined by God. Inshalla, meaning and referring to God’s will or God willing is a typical response used in response to requests or invitations. A simple wish for someone’s recovery from illness will most likely invoke a response of Inshalla. Thus, it is God’s will that dictates responses to health, life, and death. As noted in Barakat (1980), this is contrary to Western cultures where personal control over one’s life is perceived as vital for health and positive adjustment. The following narrative describes how each Arab population segment experiences episodes of loss and bereavement.

Smith and Haddad (2002) note Islam’s view of death as God’s will, and grief as a consequence that those bereaved are expected to accept as their loved ones are destined for Jannah (heaven), especially if they led a moral life filled with good deeds, or if they died in childhood and before the age of responsibility. Illness and death are viewed as tests by God, and life’s challenges as a way for Muslims to demonstrate their reliance on God (Hamdan, 2007). The deceased’s body is not embalmed but washed or purified by close family and wrapped in white seamless sheets for burial. It can then be placed at a mosque or another place of prayer where family and friends gather. The entire community is invited to attend the funeral, which usually occurs within 24 h (Philips, 2005). Attendees must purify themselves by washing of hands, feet and face, and engage in prayer and readings from Quran (Islam’s holy book) led by the Imam (religious leader). Men and women are usually separated during this process, and women generally don’t attend burials at the cemetery. The body is buried without a coffin and faces Mecca. Typical words of consolation used are based on Quran and translate as, “To Allah we belong and to Him is our return” (Ali, 1989). It is typical for the public grieving process to last 3 days, during which extended family, friends, and the community are expected to provide support to bereaved families through their presence, bringing of food, and prayer.

Arab families are expected to care for loved ones from birth into death, and personal issues are generally addressed within the family system. Therefore, institutionalization is perceived as a last resort and is sought only in cases of severe illness and disability where family resources are scarce or it is deemed in the person’s best interest. While potentially burdensome, dependence on natural and informal support systems within the family and community to attend to the physical, social, and emotional needs is viewed as a moral obligation. Therefore preference is for the ailing or dying to be cared for at home with subsidized institutional services to be provided through end of life. Aziza, Ron, Shona, and Gemini (2010) studied death anxiety among Arab Muslims and found that death anxiety was higher for residents of nursing home facilities than for elders in the community who enjoyed a higher degree of social support from family. Anxiety was also higher for women and those lacking education, with overlap between the two in this study; anxiety was found to be unrelated to religion (Aziza et al., 2010).

The Druze are a minority Arabic-speaking community that descended from Islam in the eleventh century (Dwairy, 2006), and integrates beliefs from Judaism, Christianity, and Islam, as well as Gnosticism, Neoplatonism, Pythagoreanism, and other philosophies. The Druze religion is secretive and closed to outsiders; however, adherents pledge allegiance through military service to any country of residence. The Druze community maintains a strong belief in the afterlife, which promotes better adjustment and recovery from the death of loved ones (Benore & Park, 2004). Belief in the immediate rebirth of the soul into another Druze body or into a realm close to God tends to discourage or inhibit expressions of grief [or its process?] (Bennet, 2006). Death is viewed as a “temporary state” with gender and religion being maintained through reincarnation, and thus burial and mourning rituals are minimal (Dwairy, 2006, p. 30). Belief in reincarnation seems to ease the grief, and the knowledge that the soul of a deceased family member lives on in a newly born child seems to make the pain associated with the loss more tolerable (Littlewood, 2001). Dwairy notes situations where bereaved parents were able to identify young children who have recollections of past lives that match the story of their deceased family member, and the attendant positive or therapeutic impact on the grieving process (2006). Research by Somer, Klein-Sela, and Or-Chen (2011) compared the impact of reincarnation and fatalistic beliefs on the parental bereavement of fallen Jewish and Druze Israeli soldiers and found that Druze maintained a stronger view of reincarnation and fate than their Jewish counterparts and had a better adjustment to family tragedy. Moreover, a minority of Druze parents expressed difficulty accepting their loss versus a majority of Jewish parents, which also translated to a reduced sense of helplessness, guilt, and anger among the former.

According to Faraj-Falah (2009), bereavement issues for Druze widows are exacerbated by their status within the traditional community. Druze women are educated in separate schools, and they are generally not allowed to drive, and if they do, men are not permitted to ride in the same car. While Druze women may inherit property, the absence of explicit provisions in a will results in any inheritance going to their sons. Young widows with children may be forced to marry their brother-in-law, and those without children are frequently forced to return to their family with no rights of inheritance; either way their fate is often decided by the family (Faraj-Falah, 2009).

Arab Christians face double marginalization in Israeli society where they are oppressed by the Jewish population for being Arabs and ostracized by Muslims for their Christian beliefs (Ventura, 2012). The reality is that Arab Christians combine old Middle Eastern traditions with Western approaches. They share the fatalistic outlook on life and strong reliance on their faith for cultural and political identification, and view matters of life and death as resting in God’s hands. Prayer, belief in miracles, fasting, and alms giving are used to appeal to God’s mercy for ailing, dying, or dead relatives. Death may be viewed as merciful for those who have suffered through terminal illness or the consequences of old age, but cruel when the deceased is young or leaves behind a young family. The deceased is dressed by family members, placed in a coffin, and buried within 24 h. The body is placed either at home or in a prayer hall where family, friends, and community members pay their respects, all dressed in black or dark colors. It is rare for women to accompany men to the burial; however, they visit the grave site the following morning where they light candles and recite prayers. The family wears black, wears no or minimal cosmetics, and avails itself of those who wish to pay respect for a full week of mourning. This mourning period may conclude a few days earlier, on the fourth or fifth day, at which time a prayer service is conducted on behalf of the deceased. For the duration of public mourning, relatives provide meal service for all attendees and are expected to offer prayer and whatever support is needed. Mass service dedicated to the deceased marks the fortieth day, six month, and one year anniversaries. While traditional practices are slowly changing regarding the mourning process, it is traditional for the immediate family to dress in black or dark colors for a designated period of time depending on gender of the mourner, the age of the deceased, and the relationship. Widows and mothers of deceased children may wear black for a number of years, and dark colors thereafter. Family members refrain from participating in public ceremonies, commemorate the deceased through prayer services, display pictures of the deceased throughout the home, and visit the grave site where they light candles or leave flowers.

Terrorism Related Bereavement

Deaths resulting from acts of terror provoke the strongest of emotions and often compel people to take sides. Suicidal acts leave behind families and communities that not only suffer from the loss of that life, but also oftentimes pay a staggering price for the act. Suicide bombings carried out by Palestinians may be followed by Israeli retaliation where entire neighborhoods are demolished, hundreds of families displaced, and whose casualties often involve innocent children and other civilians. Abbott (2009) investigated the effects of politically driven violence on seven Israeli Jewish families who lost five children and two adults and nine Palestinian Arab Muslim families who lost seven children and two adults between the year of 2000 and 2005. While this phenomenological study used a small sample size, the outcome is of value as it provides a general representation of how Israeli Jewish families and Palestinian families in the Occupied Territories of Gaza and West Bank areas cope in the aftermath of violence. The outcome revealed ramifications on individual family members, marriage, parenting, and community. Intense grief and prolonged distress was reported on both sides, even years later. Both viewed the loss as endless, the pain as constant, a “hole that cannot be closed” and an “open wound.” Israelis viewed the loss as a “senseless act of terror,” while Palestinians viewed martyrdom as a mean to an end (Abbott, 2009, p. 121). Both sides reported strain on the marital relationships, increased tolerance in parenting and closeness with their remaining children, behavioral and emotional difficulties for surviving siblings, and a wide range of community supports. Both sides reported partial withdrawal from community activities and communal celebrations such as weddings and birthdays for several months or years, and Israeli parents reported restrictions placed on their children’s activities in public places. Abbott (2009) found that coping strategies utilized by each side included memorialization of the dead through display of photos of the deceased at home, erecting of monuments at the site, public honoring of the deceased, and memorial services. For some, replacement of the deceased child with a new one and participation in support groups or with families who experienced loss and grief were used to promote healing. Whereas Jewish families participating in the study were secular, Muslim families tended to rely on their faith and viewed martyrdom as God’s will and as paving their way to paradise.

National Response to Loss and Bereavement

As noted earlier, Halacha guides religious and non-religious life as well as healthcare policy and practice regarding life and death matters in Israel. Medical personnel are expected to provide services to preserve and prolong life, except for hopelessly ill patients. The Israeli Dying Patient Law of 2005 is based on Halacha principles and provides tools for making advance medical directives, views palliative care as a universal right of every citizen, ensures the selection of a person who makes healthcare decisions with family input, guides medical decisions and actions, appoints a senior physician to ensure accurate documentation and communication, and empowers local and national ethics committees to resolve disputes and avoid legal actions (Sprung, 2012, http://www.chabad.org).

Israel provides an extensive network of medical and social services to support the life of every citizen regardless of age, ethnicity, religion, and background. These services are initiated through physician or family referrals and activate a range of interventions aimed at allowing terminally ill patients to die with dignity and the least amount of suffering. According to the Israeli Association for Palliative Care (IAPC), eleven organizations provide palliative care for adults, which include twenty-seven services for home hospices, four inpatient hospice units, and two hospital-based units. Six of these services provide pediatric palliative care as well. Community health centers are available to provide home health service and for pain management, and cancer clinics provide psychosocial support. Patients diagnosed with cancer are provided free medication and those diagnosed with other illness qualify for prescriptions at a reduced rate (http://www.palliative.org.il).

A unique program found in Israel is Ambulance for Wishes, which was created through Magen David Adom (Israeli ambulance service for emergencies) to grant wishes to terminally ill patients who are confined to their beds but wish to visit one last time their favorite beaches, religious sites, nature reserves or other places. The ambulance is furnished with refrigeration, medicine, advanced medical technology, and a rooftop camera to allow patients to track the route of the ambulance through a plasma television. This service is organized in collaboration with physicians and is provided free of charge to all patients (Gal, 2009).

A paper published by the IAPC reveals some of the ethical challenges encountered by physicians and helping professionals who work with end-of-life patients in Israel. First on the list is the disclosure of prognosis to patients as the law requires in the midst of family pleas to withhold information for fear that their loved one will lose hope or commit suicide. The dilemma of when to continue, withhold, or discontinue treatment is another challenge, especially when patients and their families are not fully educated about their options, especially appropriate factors in the consideration of withholding or discontinuing treatments intended to save or extend life. The third challenge relates to the cultural tendency of wanting to shield children from the painful reality of death by not allowing them to see their dying relatives, thus complicating closure and separation issues. The remaining challenges include fear of opioids for sedation and pain relief, provision of care for patients who lack family support, and provision of palliative care for patients who simply want to die, or who request assistance in ending their life (IAPC, http://www.palliative.org.il/articles/israel_country_report.pdf).

Case Scenario and Strengths-Based Culturally Sensitive Interventions

We begin this section by sharing a case scenario that demonstrates the experience of Edna and her family with end-of-life issues. At the age of 75, Edna came to her medical appointment accompanied by husband and son. Devastated by the physician’s news of her cancer diagnosis and dim prognosis, a decision was made by the family to utilize all necessary means to treat the disease. This required daily rounds of chemotherapy, radiation, and medicine. The family decided to move Edna and her husband into her son’s house where they can be cared for attentively, taken for daily rounds of treatment, and be surrounded by grandchildren and family. Edna and her husband were clearly depressed about the impending loss, although no one spoke of it directly. Within a few months, Edna’s poor prognosis became apparent as all treatments concluded with failure. She was moved back into her home, where palliative care was introduced and a team of professionals was attentive to her every need. Home health nurses oversaw her medical needs, while social workers addressed her psychosocial wellbeing and that of her family. A government-paid caretaker attended to household chores, despite the family’s constant presence and company. Edna and her family were strong believers and kept candles lit along with ongoing prayers and pleas for healing. Edna passed away and hundreds of family, friends, and community members attended her funeral. It has been 2 years since her death and her husband still shows symptoms of depression and loneliness. He visits her grave most mornings and keeps a candle lit in front of her picture. More recently, he joined a club for elderly men and attends for a couple of hours every day after visiting her grave. Family members care for his home and physical needs; however, the adjustment continues.

While unlikely to seek formal therapeutic services, Israel provides Edna’s spouse with plenty of opportunities to promote continued community engagement and support. Culturally appropriate interventions are crucial in supporting grievers within Israel’s various population segments. Israeli Jews, Muslims, Christians, and Druze share common themes that serve as protective factors that foster resilience. These include the guiding and regulating role of religion when it comes to matters of life and death; the role of faith and prayer in conceptualizing the loss and coping with grief; the centrality of the family unit in making healthcare decision and caring for the dying; and engagement by and with the wider community. Jewish and Arab cultures are collective in nature and clinicians are advised to contextualize problem identification and diagnosis within that framework, and to utilize interventions that engage and reinforce natural support systems.

Culturally sensitive interventions need to account for issues of historical trauma, ongoing political discourse, and the perspectives that patients have related to their sociopolitical reality. When death is sudden, or is hastened by violent acts, the bereaved may experience a range of mental health issues such as complicated grief or prolonged grief disorder (PGD), major depression, post-traumatic stress disorders (PTSD), and anxiety disorders. Kristensen, Weisaeth, and Heir (2012) stress the need for mental health clinicians to understand the nature of loss and the increased threat for mental health disorders among bereaved. Possick et al. (2007) encourage community workers and mental health professionals to view the Hantzacha (commemoration) in therapeutic terms to assist survivors to cope with their loss, especially when death results from untimely violent terrorist attacks. This would require using traditional cultural rituals and practices already employed by the bereaved.

When addressing issues of grief with bereaved Arabs, recognizing the perspective of collective over individual, the important role of family and kinship, and strong engagement with wider community is crucial. Help-seeking behaviors may be inhibited by cultural expectations for families to take care of their own, to save face in the community, and to rely on religious and natural support systems for assistance. Building a supportive and trusting relationship with those seeking help becomes the vehicle for helping them. Seeking healthcare services seems natural, however the preference is for people to be cared for and to die at home with the provision of supplemental informal and formal care. Al-Kenai and Graham (2000) view the Arab integration of individual and group and the acceptance of sociocultural norms and values as psychologically beneficial due to the sense of security, belonging and identity they provide. They recommend incorporating support systems in providing mental health services. Family is viewed as “sacred,” a “continual source of support” and its participation in times of crisis is expected (Al-Kenai & Graham, 2000, p. 14). While privacy with respect to outsiders is guarded by Arabs, it is nonexistent within the family where healthcare decisions are made. Al-Kenai and Graham (2000) advise practitioners to be aware that what may appear to be an “Arab family’s over-involvement, overprotection, blatant codependency, or enmeshment” is culturally appropriate whereas the absence of these may indicate neglect and abandonment (p. 14). Thus for Arabs, issues involving illness, impending loss, death, and bereavement are culturally bound family matters.

Prayer is a coping mechanism used by Muslims to seek comfort and to show acceptance of God’s will. Since Islamic beliefs play a central role in a Muslim’s life, Hamdan recommends incorporating such beliefs and applications into the helping process as a way to regain spiritual strength to cope with illness or other situations (2007, p. 95). Awed (1999) confirmed that 90 % of Muslims used prayer, 95 % used confessions for wrong deeds, and 61 % read Quran regularly. Helping professionals are advised to employ culturally sensitive strategies in addressing loss and grief related issues with Muslim families. This would include supporting coping strategies and systems such as prayer, extended family, and community traditions. Baggerly and Abugideiri (2010) highlighted the importance for grief counselors to appreciate Islamic beliefs and traditions related to loss, grief, burial, and healing, as well as to use interventions that stress collaboration, outreach, and advocacy.

While seemingly worlds apart, Jews and Arabs in Israel are more alike than different. They share a history filled with historical displacement and trauma, maintain strong value systems that are rooted in religious ideology, recognize the pivotal roles of family and community, and hold a unique set of cultural and spiritual rituals to cope with loss.