The will to live: gender differences among elderly persons
Introduction
The desire to continue one's existence is a natural instinct of all living creatures. Among humans, the will to live, which includes a motivational component, is the psychological expression of this instinct. Thus, a person who says that he/she has a strong will to live expresses, on the cognitive level, the desire and commitment to life, which also exist on the physical and emotional levels. The will to live is one of the most important existential issues that has concerned all religions and many of the great philosophers. It has also been addressed in fiction and poetry, mainly in terms of traumatic events that weaken or strengthen it, and how it affects survival. Behavioral scientists, however, have not given this concept much attention, even though it may be an important indicator of well-being and a predictor of survival among elderly persons. Some of the basic questions regarding this concept include: Do people differ in their will to live ? Is the will to live constant or does it change with age? What are the factors that affect it? The purpose of this study is to investigate the will to live by assessing relationships between this concept and the wish to prolong life in different hypothetical illness conditions, and by determining the physical, psychological, and social correlates of the will to live among men and women.
All cultures deal with the meaning of life and death, but people of different cultures and religions may hold different perceptions and beliefs about these natural physico-biological phenomena and behave accordingly. In the past few years, the Western world has witnessed the power of beliefs about life and death when members of certain cults committed mass suicides.
In the context of current dilemmas faced by post-industrial societies regarding medical treatment at the end of life, the question that arises is: To what extent are the will to live and wishes to prolong life in a terminal illness condition related? Assuming that the basic drive to continue living holds even when physical conditions worsen dramatically, and considering the high value of life in Western societies, it is hypothesized that they will be related.
Throughout the history of the Western world, changes in philosophical and religious thought have brought about significant changes in perceptions about life and its finality (Choron, 1963). As regard to fear of death, Homans (1965) suggested that all Western religions cause death anxiety among their believers, but also supply mechanisms to reduce that anxiety. In support of this thesis, findings of two Israeli studies that used different measures of fear of death indicate that religious Jews fear death more than the non-religious (Florian, Kravetz & Frankel, 1984; Carmel & Mutran, 1997b). This was explained by the nature of the Jewish religion, which focuses more on life than on afterlife (Ponn, 1998; Carmel & Mutran, 1997b). According to the Jewish religion, life is of infinite value and everything must be done to preserve it regardless of its quality (Rosner, 1971). Based on the above, the will to live is hypothesized to be related to the degree of religiosity of those who belong to the same religion, as well as to their fear of death and dying.
There are indications in the literature that the will to live is significantly affected by psycho-social factors. Durkheim (1966) showed the harmful effects of low social integration on suicide rates in different societies. The relationship between social support and mortality has also been demonstrated in epidemiological studies (Berkgman & Syme, 1979). Frankl (1972) has suggested that the meaningfulness of life affects survival in difficult life conditions, such as in the Nazi concentration camps. These works lead to the hypothesis that the will to live is related to indicators of psycho-social well-being such as self-esteem, satisfactions with life, and social support. In our times, in secular societies with their underlying utilitarian principles, quality of life, or perceived well-being, in physical terms as well as on the social and psychological levels, is also intuitively related to the will to live. A significant decrease in a person's quality of life, or perceived well-being, with no hope for improvement, is, therefore, the main reason for the current tendency of limiting medical treatment at the end of life in Western countries. Based on these, it was hypothesized that the will to live will be related not only to beliefs regarding life and death, but also to one's psychological, social and physical well-being. Significant differences would, therefore, be expected in the will to live of groups of people who differ in their perceived well-being.
Gender differences in well-being have been frequently reported by social scientists and social epidemiologists. Many of them have long argued that although women live longer than men, they are disadvantaged on most indicators of well-being (Miles, 1991; Arber & Ginn, 1995). As regard to health, women experience physical morbidity and functional disability more than men, even when conditions associated with reproductive functions are excluded (Blaxter, 1987; ]Marcus & Seeman (1985), Verbrugge (1989)). Women also subjectively evaluate their health as worse than men, although women's illnesses are more often nonfatal, while men suffer more from fatal diseases (Marcus & Seeman, 1981; ]Nathanson (1986), Verbrugge (1989)). Gender differences are also reported as regard to health and illness behavior. In comparison to men, women use health services more often, consume more prescription and over the counter drugs (Nathanson, 1975; ]Marcus & Seeman (1985), ]Nathanson (1986); Nicholl, Beeby & Williams, 1989; Cleary, Mechanic & Greenley, 1982), and invest more than men in health-protective behavior (Hibbard, 1983–4; Carmel, Shani & Rosenberg, 1994). Women are also disadvantaged in other areas of life. They are more likely to be employed in low status jobs, have lower incomes (Karasek, Gardell & Lindell, 1987; Jacobs & Steinberg, 1990), and more responsibilities at home than men. All these expose them to more stressors, resulting in more anxiety and depression (Kessler & McLeod, 1984; Gove, 1984; Kessler, Price & Wortman, 1985; Rosenfield, 1989; Verbrugge, 1989; Carmel, Anson, Bonneh & Maoz, 1991; Lennon, 1995; Mirowsky, 1996; Kark, Carmel, Sinnreich, Goldberger & Friedlander, 1996).
A comparative analysis of the present data has also shown that although the women respondents are similar to men in age, number of chronic diseases, and recently experienced life events, which are relatively objective evaluations of physical condition, and stressors, they score lower than men on the more subjective evaluations of health and on indicators of psycho-social well-being (Carmel & Bernstein, submitted). Considering these findings, it is hypothesized that elderly women will have a weaker will to live than men. This and the first hypothesis, suggesting that the will to live is related to people's wish to prolong life in difficult health conditions, have some empirical support in findings from different societies, which have shown that women are more likely than men to express preferences for withholding the use of life support treatment in severe health conditions (Gunasekera, Tiller, Clements & Bhattacharaya, 1986; Frankl, Oye & Bellamy, 1989; Mills, Harris, Norburn, Patrick & Danis, 1993; Griffith, Wilson, Emmett, Ramsbottom-Lucier & Rich, 1995). It should be noted, however, that some findings regarding gender differences would lead to an opposite hypothesis. For example, in most studies regarding religiosity, women were found to be more religious than men (DeVaus & McAllister, 1987; Miller & Hoffmann, 1995), and also to fear death either more than men or similarly to men (Pollak, 1979-1980).
In summary, the purpose of the present study was to promote the understanding of the will to live conceptually, and its potential as a global and parsimonious tool for evaluating elderly persons’ well-being by testing the following hypotheses in a sample of elderly persons:
Section snippets
The sample
The study was conducted on a random sample of Israeli Jews aged 70 and older, drawn from the records of the Israeli Institute of National Insurance (NI), which include all Israelis who receive a monthly payment from the Institute. All Israeli elderly citizens (women age 60 and over and men age 65 and over) are eligible for this payment except for a very small and insignificant number of elderly who receive payments from other countries.
Data collection proceeded in the following steps: First, a
Results
A comparison between men and women on socio-demographic characteristics showed significant differences between the two groups on three items: Women perceived their economic status more negatively than men (3.63 vs. 3.40, p<0.01), they were less likely to live with a partner (55% vs. 84%, p<0.01), and to be of Western origin (86% vs. 78%, p<0.01). No significant gender differences were found on level of education (3.22, SD=1.52 vs. 3.29, SD=1.55) or age (77.54, SD=5.59 for men, and 77.61,
Discussion
The purpose of the study was to investigate the concept of the will to live, and its relationship to the wish to prolong life in different health conditions and to determine the physical, psychological and social correlates of the will to live among men and women, who according to the literature and this study differ in their well-being.
As hypothesized, the findings indicate that elderly Israeli women have a weaker will to live than men. Compared to men they also consistently score lower on the
Acknowledgements
This study was supported by a grant from the U.S.-ISRAEL Binational Science Foundation (BSF-No. 92-00114). The author gratefully acknowledges this support.
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