Salience is a common word in the psychology literature, like metastasis in oncology. In psychology, salience describes something that is emotionally preeminent or prominent. At a wedding, happiness is the salient emotion. At a murder trial, anger might be salient. At a cancer hospital, the fear and thought of death are salient. Hence, mortality salience.

In the 1980s, three psychologists from Skidmore College in Saratoga Springs, NY, America, developed a theory they called terror management theory (TMT) (Solomon et al. Reference Solomon, Greenberg and Pyszczynski2015). This was based on Ernest Becker’s writings which proposed that the terror of death was always present in our day-to-day functioning, even if unconscious (Becker Reference Becker1973). Becker emphasized that we defend against this terror in many ways. Becker hypothesized that much of our culture – art, religion, sport, and science – plays a role in protecting us against this fear of death. Culture, then, is a response to mortality salience. Becker postulated several cultural mechanisms that defuse the terror of death, including heroism, for example, a sporting hero; belonging to a group such as a religion; a strong curriculum vitae; and the arts, including films, paintings, and music (Wein Reference Wein2018). Mortality salience, of course, is not the exclusive purpose nor function of culture.

Some years after Becker deceased, the psychologists in Saratoga Springs revisited Becker’s hypothesis, developed TMT, and set about to test it. Since then, 100s of studies in different countries and cultures have provided support for the TMT hypothesis.

Here is one of the earliest studies (Rosenblatt et al. Reference Rosenblatt, Greenberg and Solomon1989).

In the introduction to the study, the authors noted that culture created a “conception of reality” which offered protection against the fear of death and meaninglessness. Individuals whose self-esteem is supported by their culture will defend the culture against threat. Military and religious wars might be a response to these threats. Since we are creatures who depend upon cultural symbols to communicate (language, music, and religious icons), any threat to a symbol is a specific threat to life and thus increases mortality salience.

Their study hypothesized that “when people are reminded of their own mortality, they are especially motivated to maintain their cultural-anxiety buffer” (Rosenblatt et al. Reference Rosenblatt, Greenberg and Solomon1989, 682). The “cultural anxiety buffer” is one’s attachment to an item of culture that supports self-esteem and thereby protects (buffers) against the fear of death. For example, if I am highly committed to the Mars Football Club (i.e., dependent upon it to buffer my death anxiety), and someone humiliates my club, then I will defend my “cultural anxiety buffer,” maybe with violence. Should someone praise the Mars Football Club for their gravity-defying marking skills, then I will feel warm and friendly to that person.

The experiment divided 22 municipal court judges into 2 groups. Each judge was given the task of setting bond for alleged prostitution. Immediately before receiving the information about the case, half the judges filled out a questionnaire asking detailed questions about their own death. This was designed to increase mortality salience by subliminally causing the judges to have a heightened awareness of their own death. The results were remarkable. The judges in the control group gave an average bond of $50. The judges who had been reminded of death gave an average of $455.

This result supported their hypothesis as predicted by TMT. People who are reminded about their own mortality will react aggressively against someone who transgresses their cultural value, in this case prostitution. People who do not have a heightened awareness of their mortality will not perceive a threat to their cultural anxiety buffer.

All this got me to thinking about doctors and in particular oncologists.

A patient with incurable cancer may remind the oncologist of a close family member, or indeed him- or herself, and uncover a fear of death. Might an increased threat to ourselves, to our lives, translate into a more aggressive choice of treatment?

A dying patient may not be a cultural threat per se to the oncologist. However, the same researchers showed that self-esteem serves as a symbolic anxiety buffer (Rosenblatt et al. Reference Rosenblatt, Greenberg and Solomon1989). The oncologist’s self-esteem may feel threatened by a failed chemotherapy regime that she/he chose, thus increasing mortality salience. The oncologist might react, unconsciously, by prescribing aggressive antitumor therapy beyond the recommendation of the literature, for the same reason the judges gave a 10-fold higher bond. To pacify the threat of mortality salience.

Of course, there are significant differences between the oncologist and the judge.

There are also significant similarities.