How does death reflection promote prosocial behaviors?—a literature review from the perspective of the post-traumatic growth model

Introduction

Death is a subject that evokes fear within us, yet it remains an inescapable reality that all individuals must ultimately confront. Death-related information is commonplace in daily life, like air, permeating every aspect and leaving no possibility of evasion. Each person encounters death either directly or indirectly and is consequently affected. Direct encounters include personal experiences such as surviving a car accident involving fatalities, the loss of an only child, or the bereavement of relatives in an earthquake (1-3). Indirect encounters consist of public health crises such as the coronavirus disease 2019 (COVID-19) pandemic, terrorist attacks like the September 11 attacks, and the cluster suicides of Foxconn workers (4-7). Such pervasive exposure to death-related information arouses our awareness of death unavoidably. Death awareness, which refers to an individual’s recognition of their inevitable mortality, has distinct dual aspects: the negative aspect manifests as death anxiety, while the positive aspect is expressed as death reflection (8,9).

Death anxiety is the intense emotional panic experienced by individuals when they become aware of their inevitable mortality (10). Studies have shown that death anxiety increases the risk of mental health problems such as depressive and obsessive-compulsive disorders (11,12). It also heightens the likelihood of suicidal ideation or self-harm behaviors among the elderly (13). Furthermore, death anxiety might lead individuals to exhibit ageist behaviors towards the elderly (14,15). Significant progress has been made in research on death anxiety (16).

Death anxiety immerses us in fear and leads to numerous negative consequences. Therefore, it is crucial to determine how to find positive insights from death-related information. Cozzolino et al., in their research on post-traumatic growth (PTG) and near-death experiencers (NDErs), proposed the concept of death reflection in 2004, which refers to the process by which individuals intentionally contemplate and process thoughts about death (17,18). This reflection involves deliberately engaging with the concept of mortality, which can lead to personal growth, a deeper understanding of life’s value, and a shift in priorities and perspectives. It contrasts with death anxiety by focusing on finding meaning and insights rather than being overwhelmed by fear. Unlike the psychological stress and self-preservation instincts induced by death anxiety, death reflection empowers individuals to confront the reality of death directly. It guides them toward an internal value orientation, promotes positive personal growth, and encourages the undertaking of more prosocial behaviors (16,19). Prosocial behaviors are actions that have positive effects on others or society (20). When faced with information about death threats, responding with prosocial behaviors can mitigate societal fear, enhance the collective ability to withstand stress, improve interpersonal relationships, and prevent excessive anxiety.

A considerable number of studies have confirmed the positive effect of death reflection on prosocial behaviors (16-18). Existing literature reviews on death reflection have predominantly discussed it in conjunction with death anxiety, primarily through comparative analyses of the differential impacts of these two forms of death awareness on individuals’ psychological states and behavioral outcomes (8,21). Comparative analyses have revealed that death anxiety tends to induce stress responses and emotional tension, whereas death reflection may trigger meaning reconstruction at the individual level, thereby enhancing prosocial behavioral motivations (8). However, the current academic landscape lacks relevant literature reviews specifically focused on death reflection itself, and few studies have explored the underlying psychological mechanisms through which death reflection facilitates prosocial behaviors. Exploring this mechanism will help us understand how to foster individual growth in response to death-related information and encourage engagement in prosocial behaviors. PTG helps explain the increase in prosocial behavior among individuals of all ages in the context of death awareness (22). The PTG model emphasizes the positive impact of challenges to core beliefs (23,24), revealing the changes in the three dimensions of self-perception, interpersonal relationships, and philosophy of life (25-27). Therefore, conducting a narrative review from the PTG model perspective could provide novel insights for developing interventions that reduce the negative effects of death-related experiences and facilitate prosocial behaviors among individuals who have experienced them. We present this article in accordance with the Narrative Review reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-25-8/rc).

Methods

A literature search was performed within online databases such as Web of Science, PubMed and ScienceDirect (see Table 1). The publication dates covered their inception until January 25, 2025. We included English articles concerning “death reflection”, “prosocial behavior”, and “post-traumatic growth”. The research methodology of eligible studies encompassed both quantitative and qualitative studies. In total, 45 articles were finally included for this study.

The impact of death reflection on prosocial behavior

Prosocial behavior, which is a highly regarded value in various cultures, can provide individuals with a sense of self-worth and fulfill their aspirations to find meaning in life (28). Death reflection, a form of death awareness characterized by NDErs, involves three elements: confrontation with specific death, life retrospection, and perspective-taking from others (17,29). Cozzolino et al. (17) operationalized death reflection by having participants read and imagine specific scenarios related to their own death that encompassed these three components and respond to questions. This operationalization has been termed the death reflection task. Death reflection, a specific reminder of death, prompts individuals to acknowledge the finiteness and fragility of life, intensifies their desire to seek meaning and appreciate the existence of others, and enhances their motivation for prosocial behavior (8,30). Studies have indicated that, compared to the control group, individuals undergoing death reflection exhibited a significantly increased willingness to donate to charities and participated more actively in public blood donation activities (31,32). Furthermore, during the COVID-19 period, they also demonstrated a stronger willingness to engage in volunteer activities (19). Death reflection often reduces individuals’ levels of greed and prompts them to demonstrate inherent selflessness (17).

In the workplace, when employees experience death reflection, they develop a strong desire to make self-transcendent contributions or establish connections with others, subsequently exhibiting positive helping behaviors toward colleagues or the organization (18). Death reflection encourages employees to place greater importance on prosocial behaviors, engage in more voluntary activities, and perform organizational citizenship behaviors. Individuals may prioritize jobs with social value, such as mentoring others or participating in community building (33,34). Additionally, studies have demonstrated that individuals undergoing death reflection are more inclined to be driven by long-term interests, consider future generations, and show increased concern for the environment (35).

Although death anxiety sometimes promotes prosocial behavior, it fundamentally involves evasion and denial of death. In contrast, the influence of death reflection on prosocial behavior is more stable. For example, compared to those experiencing death anxiety, individuals undergoing death reflection demonstrate a higher willingness to engage in prosocial behaviors, even when faced with actions that highlight the fragility of life, such as organ donation after death and assisting the disabled (31,36,37). Yuan et al. (16) conducted an in-depth study of the positive influences of death reflection from five aspects: the motivation to help others, the motivation for life, a correct perspective on life, legacy, and connection with others. These aspects vividly illustrate the profound and multifaceted impact of death awareness on prosocial behavior, suggesting that the positive effects of death reflection are both stable and diverse. The reason individuals who have experienced death events tend to help others is that psychological growth has altered their fundamental attitudes and motivations toward life (24,38). Exploring the psychological mechanism through which death reflection affects prosocial behavior is important.

A perspective of the PTG model: influence of death reflection on prosocial behavior

Death reflection from the perspective of the PTG model

PTG is defined as the positive psychological change resulting from the struggle with major life crises (27,39). Tedeschi and Calhoun proposed the PTG model, which has received extensive validation and provides a detailed description of the PTG formation process (24,40-42). According to this model, traumatic events challenge an individual’s core beliefs, and after rumination, the individual undergoes cognitive restructuring, leading to more positive growth.

Traumatic events are those with negative consequences, such as causing individuals to worry about their own or their relatives’ lives and bringing about mental or physical pain (42). The death reflection task, in which participants read a text describing a specific fire situation and imagine themselves in it, simulates trauma (17). Participants are then asked to answer four questions: “Describe your thoughts and emotions while imagining the fire scene”; “If you genuinely experienced this event, how would you handle the final moments?”; “Describe your life prior to this”; “If this occurred to you, what reaction do you suppose your family would have?” (17). Mental factors and the challenge to core beliefs are crucial for individuals to achieve PTG (43). Death reflection, which requires individuals to envision themselves in specific death scenarios, not only challenges their core beliefs but also induces a certain degree of mental shock. The PTG model suggests that self-disclosure and deliberate rumination following a traumatic event help individuals overcome trauma and achieve growth (42,44). The death reflection task, through its four questions, prompts individuals to contemplate their emotions, reflect on their lives, and consider the responses of significant others. This leads to emotional expression and active deliberation on past life experiences and family reactions. It is clear that the death reflection task not only simulates traumatic circumstances but also integrates essential elements such as core belief challenges, deliberate rumination, and self-disclosure. Death reflection aligns closely with the PTG model.

The growth of individuals in three facets under the circumstance of death reflection

Death reflection is a cognitive state in which individuals engage in profound thinking and analysis, offering rational responses (34). By thoroughly reflecting on traumatic events, individuals develop new cognitive schemas and strengthen psychological resilience, thereby achieving PTG (45). The PTG model suggests that individuals predominantly experience growth in three domains: self-perception, interpersonal relationships, and philosophy of life (25). According to previous research findings, the positive effects of death reflection on individuals can be primarily encompassed within these three aspects, ultimately promoting prosocial behavior.

Firstly, death reflection brings about changes in individuals’ self-perception. It enhances the depth of self-perception and emotional understanding (30), promotes identity integration, and improves well-being (16,46). Women undergoing death reflection tend to be more satisfied with their self-image (47). A deep understanding of emotions helps individuals better comprehend others (48). Identity integration is crucial for balancing personal and others’ interests (30). Additionally, individuals with high well-being and greater confidence in their self-image tend to establish connections with others more effectively (49). Secondly, death reflection fosters interpersonal relationships. Individuals undergoing death reflection exhibit a stronger desire to connect with others and show greater gratitude towards the collective (18,50). Studies indicate that death reflection reduces discrimination against COVID-19 patients (51). The aspiration to connect with others and show gratitude encourages prosocial behavior, while discrimination serves as an impediment. Finally, death reflection significantly influences an individual’s philosophy of life. It promotes the pursuit of meaning in life and enhances gratitude. Prosocial behavior is an essential means for individuals to find meaning in life, and gratitude significantly impacts well-being and interpersonal relationships (50,52-55).

Death reflection, functioning as an imagined trauma, promotes individual growth in three aspects, thereby increasing the likelihood of engaging in prosocial behaviors. According to the PTG model, the specific process through which death reflection influences prosocial behavior is as follows (see Figure 1): by imagining specific death scenarios to simulate trauma, a challenge to core beliefs is triggered. Individuals then engage in cognitive restructuring through deliberate rumination and self-disclosure, resulting in positive changes in the dimensions of self-perception, interpersonal relationships, and philosophy of life. Growth in these three aspects enhances the tendency of individuals to engage in prosocial behaviors.

Figure 1 The influence of death reflection on prosocial behaviors from the perspective of the PTG model. PTG, post-traumatic growth.

Limitations and future directions

Limitations

This review integrates the potential mechanisms through which death reflection promotes prosocial behaviors from the perspective of the PTG model, yet several limitations warrant cautious interpretation. First, as a narrative review focused exclusively on English-language studies, the inclusion of a limited number of articles without adherence to systematic review protocols may introduce selection bias. Moreover, the included studies, which are primarily drawn from Western cultural contexts, may overlook culture-specific mechanisms, such as prosocial behaviors in collectivist contexts (56,57). Second, the scarcity of longitudinal studies among the included articles impedes rigorous verification of the long-term sustainability of death reflection’s impact on prosocial behaviors. Furthermore, insufficient attention to moderating variables (e.g., context of death reflection, availability of social support) in the existing literature restricts the design of intervention strategies.

Future directions

Although many scholars have focused on the positive influences of death reflection on individuals, a systematic exploration and practice in this area remain lacking. Significant work is still needed in this field.

Firstly, despite being persistently overlooked, strengthening death education and enhancing the correct understanding of death are crucial for mental health (58,59). In the future, a more insightful approach to death education could be developed by incorporating relevant research on death reflection. For example, individuals could be guided to engage in thoughtful reflection on death and supported in overcoming its adverse implications through measures such as enhanced self-disclosure and interpersonal interaction.

Secondly, the impact of death-related information may vary across different groups. Future research should focus on specific populations, particularly the elderly, who are more prone to death anxiety, which can severely affect their mental health and increase the risk of depression. A good awareness of death is considered key to enhancing well-being for this demographic (16,60,61). Additionally, the effects of death information may differ between direct and indirect experiencers, as well as between natural and accidental death events. Future research could examine these specific influences.

Finally, social media is the predominant medium for disseminating death information. In today’s era of rapid information spread, death-related content can quickly diffuse without proper screening, leading to potential information distortion or dramatization, which may cause psychological responses such as panic and anxiety among audiences (62). This could lead to psychological trauma and post-traumatic stress disorder in individuals, as well as induce undesirable social imitative behaviors, such as the imitation of extreme actions like suicide (63-65). Therefore, it is crucial to address the regulation of death-related information dissemination on social media, drawing on research on death reflection, and to establish effective content review and management mechanisms.

Conclusions

Based on the PTG model, we have meticulously outlined the specific psychological mechanism through which death reflection significantly enhances individuals’ inclination toward prosocial behavior. This finding holds considerable theoretical and practical importance. From a theoretical perspective, this mechanism enriches our understanding of individuals’ psychological responses and behavioral choices when confronted with death-related information, clearly revealing the process by which death reflection promotes prosocial behavior. Practically, it offers several insights. For instance, when faced with the threat of death-related information, individuals can be guided to engage in deliberate rumination and self-disclosure, facilitating positive cognitive restructuring (45,66). Additionally, encouraging people to actively participate in social activities can help them establish connections and build positive interactions with others, thereby promoting more prosocial intentions (67,68).

However, there are also some limitations in this review: the narrative synthesis of English-language studies, which are primarily drawn from Western cultural contexts, may introduce cultural and selection biases. Additionally, the scarcity of longitudinal evidence and insufficient examination of moderators limit causal claims and the design of tailored interventions. These limitations collectively highlight the need for future research employing cross-cultural mixed-methods designs, large-scale longitudinal investigations, and theoretical modeling of moderation mechanisms to enhance both explanatory depth and practical applications of death reflection in fostering prosociality.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-25-8/rc

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-25-8/prf

Funding: This work was supported by National Natural Science Foundation of China (grant number: 71774060), 2015 Irma and Paul Milstein Program for Senior Health Awards from the Milstein Medical Asian American Partnership Foundation, the Young Top Talent Programme in Public Health from Health Commission of Hubei Province (PI: B.L.Z.), and Wuhan Health and Family Planning Commission (grant numbers: WX17Q30; WG16A02; and WG14C24). The funding source listed had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (https://amj.amegroups.com/article/view/10.21037/amj-25-8/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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