Imaginaries of Dying: The Visual Rhetoric of Stock Images Tagged with "Palliative Care"

Article OMEGA—Journal of Death and Dying 2025, Vol. 92(1) 395–411 © The Author(s) 2023 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/00302228231184296 journals.sagepub.com/home/ome Imaginaries of Dying: The Visual Rhetoric of Stock Images Tagged with “Palliative Care” Gaudenz Urs Metzger 1 and Tina Braun 2 Abstract In digital culture and its global economy, images circulate transnationally and shape cultural ideas about social and existential issues. While there is growing interest in death online, few studies have investigated the role of visual material in different forms of communication in this field. In this article, we examine the depiction of dying and death in stock photographs tagged with “palliative care”drawing on an image corpus of 618 photographs. Stock photographs are images produced for commercial purposes that are stored in databases by agencies on the Internet. To analyze how these representations depict fictional palliative care settings, we used visual grounded theory. The findings show that typical caregivers are portrayed as emphatic individuals, while patients appear as composed human beings facing death without fear. We argue that the images represent aspects of the modern hospice philosophy and the cultural narrative of healthy aging. 1 Department Design Trends & Identity, Zurich University of the Arts, Zurich, Switzerland 2 Institute of Design Research IDR, University of the Arts Bern, Bern, Switzerland Corresponding Authors: Gaudenz Urs Metzger, Department Design Trends & Identity, Zurich University of the Arts, Pfingstweidstrasse 96, Zurich 8005, Switzerland. Email: [email protected] Tina Braun, Institute of Design Research IDR, University of the Arts Bern, Fellerstrasse 11, Bern 3012, Switzerland. Email: [email protected] Correction (June, 2023): The funding statement is revised with the open access funding information. Keywords stock photography, palliative care, hospice philosophy, dying and death, visual rhetoric Introduction Since the 1990s, individual and collective negotiations of illness, dying, and death have become increasingly visible in the public sphere through various media and in both verbal and visual communication. Thomas Macho and Kristin Marek (2007) have pointed to the “new visibility of death”and shown how media and the arts counteract the modern sequestration of death and make this (taboo) topic the subject of lively societal debate. Other authors have emphasized that digitalization is changing the way Western societies deal with existential givens, such as illness, loss and death (Andersson, 2019;Arnold et al., 2018;Caduff, 2022;Lagerkvist & Andersson, 2017; Walter et al., 2012;Walter, 2020). In recent years, the Internet and social media have become important components of a new culture of death in which images as vehicles of meaning, emotions, values, and knowledge are becoming increasingly important alongside verbal communication. Up to now, however, death studies have paid little attention to the “pictorial turn”(Mitchell, 1992,1994), which affects both the practices of mourners and dying people (Gibbs et al., 2015;Metzger, 2023a) as well as communications produced by health care providers. Today, hospitals and outpatient services advertise their palliative treatments and therapies through different online and offline media channels using a variety of visual materials. In this paper, we aim to contribute to this emerging field of study by analyzing commercial stock images tagged with “palliative care”found in the online catalogues of four large image agencies. These images, which circulate globally on the Internet, have not been explored to date and are utilized, for example, on websites to advertise hospice and palliative care. In this article, we will demonstrate that the examined stock photographs articulate values and norms of a humane, patient-centered end-of-life care that addresses the physical, emotional, spiritual, and social needs of patients according to the ideals of the modern hospice movement (Clark, 1998,2018;Graven & Timm, 2021;Hart et al., 1998;Metzger, 2023c;Randall & Downie, 2006). Cicely Saunders—the founding figure of this movement—herself used the medium of photography to document positive emotional states among dying patients and to promote her concept of terminal care and its associated ideals, practices, and values (Saunders, 1965,1972). Criticizing the “medicalization” 1 of death, Saunders offered a new care paradigm of how “this event might be viewed, managed and celebrated within a new psychological landscape”(Nash, 2013, p. 129). As we will show, the analyzed images can be located within this Western tradition of dealing with dying and death and its particular kinds of discourses, such as, for example, that of spirituality (Walter, 1994,2002). They portray a vision of a “good death”in which death appears as a gentle farewell and the possibility of religious transcendence, while individual nuances and experiences of dying are blanked out, especially those that are negative, such as grief or despair. This can be problematic as it 396 OMEGA—Journal of Death and Dying 92(1) might create false expectations among patients and relatives about the last phase of life. Furthermore, we argue that these images do not represent dying, but the desire for healthy aging. Our analysis is based on a large corpus of commercial stock photographs tagged with the keywords “palliative care”that can be found in the online catalogs of the agencies Gettyimages,shutterstock,iStock, and Adobe Stock. Editorial stock images, that are used, for example, in newspapers to document events related to dying and death, were not included in the corpus. Our focus is on photographic representations that depict fictional palliative care settings, as we will further elucidate in the methods section. We regard these photographs as digital artifacts that offer a vehicle for understanding the social world. According to Manfred Lueger and Ulrike Froschauer (2008), artifacts include all objects that are anchored in the material world and “have been created, handled, modified, or transformed by human intervention”(p. 11, author’s translation). Digital photographs, as two-dimensional artifacts, are excellent tools for gaining insights into a society’s cultural beliefs about dying and death. As photographs and other forms of pictorial representation do not merely depict objects but exemplify perspectives that have been formed culturally (Wiesing, 2007), they mirror the ideas, values, and narratives of both individuals and groups. In today’s digital culture, where photographs are constantly being taken, shared and stored on the Internet, large amounts of data have become accessible to researchers, opening up new sources for understanding practices related to dying and death. In this article, we take this opportunity to examine how palliative care and its ideas and values are represented in commercial stock images. Stock Photography: History and Production Stock photos are images that are produced and stored by agencies in databases for future commercial use; they are classified according to classical topics such as “nature,” “leisure,”or “sports,”as well as current topics such as “portraits of diversity”or “stand up for pride.”Photo agencies have been in existence since the beginning of the 20 th century (Blaschke, 2016). In recent decades, however, digitization has brought about a significant change in the market. A myriad of images can now be found and purchased easily in catalogs that are accessible via the Internet. Bill Gates and Mark Getty played a fundamental role in this development by investing in the digitalization of archives. Gates founded the Corbis agency in 1989, while Getty founded Getty Images in 1995. Corbis owns the valuable Bettmann Archive (among others), which is a unique historical collection of approximately 11 million images. From the moment they were founded, both Corbis and Getty Images have bought up numerous archives and agencies and have been producing digital copies of historical photographs. Gates and Getty became the leaders on the global image market. Their declared goal was to produce images strictly in line with demand and to sell these images worldwide (Ullrich, 2008). In addition to these two large-scale providers, so-called “microstock Metzger and Braun 397 sites”are also increasingly popular on the Internet today. These sites are primarily supplied by amateurs and are notable for their relatively low price levels. Overall, digitization profoundly changed the conditions for the production of photographs and the possibilities for their reproduction, as well as their different modes of reception and archiving practices. The technical reproducibility of artwork and images was made possible in the early 19th century by the invention of the photographic process that had a decisive impact on the perceptual reorganization of modern culture (Benjamin, 1935/1969). From the 1980s onward, digital methods expanded these possibilities and allowed individuals to reproduce photographs with a few clicks of a mouse and to store them in electronic archives. Today, photographs can be mixed with text, graphics, audio, film, etc., and have metadata inscribed directly into them. The semiotics of photography in the digital age resembles that of other forms of visual representation (Lunenfeld, 2000;Mitchell, 1994), yet the traditional function of the photo archive has remained the same: it transforms what is specific and idiosyncratic about a picture into something typical and emblematic (Sekula, 1986). Unlike in the past though, where the task of producing such catalog data used to be assigned to professionals, today it can be undertaken by amateurs and even by intelligent machines working with pattern-recognizing algorithms. In this way, images circulating on the Internet, such as stock photographs, are made accessible and retrievable, but even more importantly, the metadata inscription culturally codes phenomena such as palliative care and defines what is a typical instantiation of it. Borrowing a concept from the French Philosopher Jacques Rancière, we argue that stock photos as hybrid text-image-assemblages establish a “distribution of the sensible” that influences what is visible and invisible as well as sayable and unsayable in a society about a topic, such as dying and death. According to Rancière (2004), the “distribution of the sensible”are systems that steer our perception and disclose “the existence of something in common”(p. 13), while at the same time excluding alternative views and perspectives. 2 The stock photos examined in this article, as we will see, are designed based on common Western assumptions of a “good death”. They reduce the sensitive topic to a handful of motives and thus influence how it is imagined. A crucial factor in this narrowing down of motives, to which we will now turn, can be seen in the economy of production of this specific image type. The way in which commercial stock photos are produced provides an important key to understanding their function and aesthetics. In contrast to editorial images that document the details of a situation or event, commercial stock photos are intended to be as non-specific as possible. This relates to the economic premise of their reusability, as Wolfgang Ullrich has noted: Apart from their open context, it is important that a stock photo should show nothing that can be dated precisely or might have only a short half-life. Seasonal fashion accessories or distinctive hairstyles are therefore not desirable; ideally, nor should the design of a cell phone be precisely recognizable. (Ullrich, 2008,p. 53, author’s translation) 398 OMEGA—Journal of Death and Dying 92(1) In addition, according to Ullrich, stock photos should not violate any taboos of the cultures that are their largest markets (USA, Europe, East Asia, etc.), such as nudity or certain political gestures or topics. Stylistic elements such as blurring or a narrow perspective are often utilized to realize the economic premise of reusability. As a result, stock images often appear generic and lack idiosyncrasies. What might be an aesthetic shortcoming on the one hand is in fact an economic advantage on the other. The images that are especially marketable across the world are those that express as few cultural idiosyncrasies as possible. For this reason, Ullrich calls stock images “pictures to forget”that allow for little or no personal references: Since they [stock images, author’s note] lack any anecdotal impact, and since even the models in them are selected so that their faces look as average as possible and possess few distinctive characteristics, it is hardly possible for the viewer to associate stock photos with their own experiences and thereby to remember them: these images do not allow one to feel any personal relationship towards them. (Ullrich, 2008,p. 57, author’s translation) This market orientation prevents visual idiosyncrasies and makes commercial stock images particularly well suited for purposes of idealization and for expressing stereotypes. These images have to appear relatively realistic in order to achieve their communicative goal, but ultimately they do not attempt to fulfil documentary photography’s promise of authenticity (see e.g., Barthes, 1981;Talbot, 1844–1846/2011; Walton, 1984). Paul Frosh has argued that commercial stock images primarily operate in the register of the symbolic and the rhetorical: […] stock images are not usually governed by a rigorous realism and empiricist code that presume and emphasize their “truth value”, their fidelity to the depicted reality […]. In other words, the modus operandi of stock images is overtly symbolic rather than documentary: their master discourse is rhetoric, not science. (Frosh, 2003, p. 99) Embedding stock images in communication contexts can intensify their symbolic meaning and their rhetorical function, with the latter being intended to influence the viewer’s attitudes and convictions in a manner that is both immediate and affective (Sachs-Hombach & Masuch, 2007). Such contexts, for example, could include the website of a hospital that is advertising its palliative care services. The images be aimed at convincing potential patients and their relatives that one can die there in good hands and that dying people are not “banished behind the scenes”(Elias, 1982/2001, p. 11), as was often the case in modernity’s death-defying culture. Although the modern hospice philosophy reacted against modernity’s sequestration of death (Thoresen, 2003) and tried to tackle its problems, this fear still seems present in people’s minds. A recent study by the Berlin Institute and the K¨ orber Foundation found that one core unease of the respondents was that nursing staff have too little time, and that one ultimately dies alone (Carrasco Heiermann et al., 2020). As we will show, it is precisely such fundamental fears that stock images endeavor to address and ameliorate. Metzger and Braun 399 Image Corpus and Analysis Method Our analysis is based on an image corpus of 618 stock photos. In order to obtain a comprehensive overview of the stock images available, we searched through four principal stock agencies, namely Gettyimages,shutterstock,iStock and Adobe Stock, using the keywords “palliative care”. Similar search terms such as “end-of-life care,” “end of life,”and “dying”were excluded so that we were able to focus as closely as possible on the visual representation of palliative care. When collecting the material, our focus was on commercial stock images that stage palliative care situations or settings, although the boundaries between staged photography and documentary photography are not clear-cut. 3 As mentioned above, we did not include editorial images of deathbed settings, nor illustrations or pictograms in our collection of materials. Our research interest was in how photography is employed as a means to create fictional palliative care realities that convey cultural ideas and norms. In principle, we tried to achieve a degree of completeness and representativeness by searching through four main stock agencies, although we did not include mircrostock sites. Visual Grounded Theory Our analysis of the visual material was undertaken in line with the methodological principles of visual grounded theory (Grittmann, 2018). Elke Grittmann (2018) highlights that grounded theory—developed by Glaser and Strauss (1967)—offers distinct principles and procedures for the collection and interpretation of different types of data that enable researchers to better understand complex phenomena. The open-coding method can be used to examine social worlds and the fabric of practices, narratives, values, artifacts, media etc., that constitute them. According to Grittmann, 2018,(pp.195–197) the aim of visual grounded theory is to reconstruct recurring image motifs that are similar to each another, and that provide information about cultural constructions, for example gender, identity or religious ideas. Such image motifs can be discovered utilizing the coding technique of grounded theory, which consists of the constant comparison and grouping of data. The ultimate goal of developing these types is to uncover connections between the sociocultural context and the representation of the phenomenon—that is, to find the cultural patterns and narratives out of which it originated. In an initial step, we sifted through the images and organized them into different groups by looking for thematic similarities among them. In line with grounded theory (Corbin & Strauss, 2008) we began our analysis with open coding that identified actors, interactions, and phenomena in the stock images. To do this, we printed the photographs as thumbnails and laid them out on tables (Figure 1). In the iterative research process, we combined the tasks of selection, analysis, and interpretation; we subsequently employed axial and selective coding to group images with similar themes and finally to arrive at concepts and categories. This enabled us to identify typical representations of palliative care in commercial stock images that we have labeled as follows: (1) presence; (2) composure; (3) empathy; (4) transcendence. However, these 400 OMEGA—Journal of Death and Dying 92(1) categories also overlap and their boundaries are not always clear-cut. In the following, we present these four representations of palliative care using exemplary image tableaus and image descriptions that illuminate the rhetorical and stylistic devices utilized in these photographs. These stylistic devices include, for example, color moods, perspective, cropping and sharpness/blurring. Imaginaries of Dying Presence The subject that is by far the most common in our image collection is “holding hands.” These photographs have been tightly cropped, with the focus on interlocked hands and fingers; occasionally, part of an arm is also visible. The patients are recognizable by details such as cannulas and plasters on their arm, while the nursing staff are characterized by items such as their clothing (surgical gowns) and medical instruments (stethoscopes). Often, the shallow depth of field means that these details are only hinted at, and are reduced to a minimum in accordance with the above-mentioned economy of production. No faces are shown. The context of “illness/dying”is communicated visually through bed sheets and blankets and by the parts of bed frames, arm grips, or wheelchairs that are only just visible. Some photographs also allow us to draw conclusions about the type of people on site—such as when someone is sitting on a chair next to a patient and holding their hand. These images depict the motif of holding Figure 1. Laying out and arranging the photographs. Metzger and Braun 401 hands in a very similar way, and they all suggest that we do not die alone and that someone is there for us in what is perhaps the most difficult moment of our life. This desire is given rhetorical support by the tight cropping of the image detail, directing the viewer’s gaze to tightly entwined fingers symbolizing human attachment, warmth, and the presence of a fellow human being at the end of life. Another rhetorical device found in these photographs is the use of fabrics. The hands are depicted as resting on soft materials such as terry toweling and bed coverings, emphasizing feelings of comfort and being cared for. This interplay between perspective, materiality, and the motif of holding hands accentuates close, physical bonds in order to construct an imagination that provides a human face to the end of life and even to death itself. We have assigned this image type the category “presence”(Figure 2). Composure The second theme we identified is “composure.”Numerous photographs depict portraits of contented, relaxed, smiling patients who are being cared for lovingly by relatives or nursing staff. The actions depicted here include, for example, a nurse bringing a patient a cup of tea, or placing a woolen blanket around them. During these activities, the nurses and the patients exchange friendly glances; the eyes of the latter seem to express gratitude. All those depicted have bright smiles on their faces. Topics such as grief, fear, or despair—which are all part of the dying process—are omitted here. These images express our desire for humane care when dying and a painless, contented farewell to life. This idea is reinforced by the use of light as a stylistic feature. Warm hues—such as a Figure 2. Presence. 402 OMEGA—Journal of Death and Dying 92(1) background sunset—emphasize the intended visual impact that aims to convince the viewer of the loving, caring atmosphere to be found in a palliative care setting. In addition, these staged scenes are brightly lit, which serves to mitigate any sense of fear that the topics of dying and death might convey, given that they often have negative social connotations. By contrast, dark and cold moods invoked by blue tones—which are often utilized in depictions of surgical and medical practices—are absent from these images. Furthermore, as in the photographs discussed above, the message intended by the image is underscored by the textiles depicted. The patients are enveloped in bright white blankets and are wearing dignified shirts, T-shirts or blouses. The context of medical care is largely obscured from view. The care scenes are often staged in settings close to nature, such as a garden or an immaculate home. This prevents the viewer from being reminded that death might be associated with machines or the cool rationality of modern medicine. The images instead suggest that dying is a peaceful, painless process in an aesthetic environment—one in which we can face death with composure (Figure 3). Empathy The third category, which we call “empathy,”concerns the construction of typical nursing staff in palliative care by means of recurring image motifs portraying interactions, actions and gestures. The focus of these photographs is entirely on the patients as individuals. They are being cared for by predominantly young, slim, good-looking women. By contrast, the patients depicted are elderly, predominantly white people. 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Knappe (Ed.), Bildrhetorik (pp. 37–48). Verlag Valentin K¨ orner. Author Biographies Gaudenz Urs Metzger is an interdisciplinary researcher in the fields of anthropology of religion, death studies and visual medical humanities. He was a lecturer in photography at the F+F School of Art and Design in Zurich, a fellow at the Centre for Death and Life Studies at Durham University, and a research associate in the SNFS project “Settings of Dying –an interdisciplinarity perspective 2020-23”. Tina Braun studied “Visual Communication and Iconic Research”at the Bern University of the Arts and at the University of Art and Design in Basel. She worked for several years as a designer for design agencies in Berlin, Copenhagen and Zurich, and founded her own design studio in 2016. Since 2020, she has been a member of the SINTA doctoral programme at the University of Bern and a collaborator in the SNFS project “Settings of Dying –an interdisciplinary perspective 2020-2023”. Her research focuses on the topic of communication design in the field of palliative care. Metzger and Braun 411