Ethical Issues of Death and Dying

Although ethics is concerned with the difference between right and wrong, what is right and what is wrong when it comes to issues of death and dying vary widely from culture to culture, religion to religion, and even individual to individual. There are three general sets of ethical issues that need to be faced when considering matters of death and dying: Defining life and the cessation thereof, determining the quality of life that the individual experiences, and deciding how the body should be treated after death. For many people, the parameters of ethical behavior are defined by their religious beliefs. No matter how decisions of death are dying are informed, however, such questions are best faced when the individual is still mentally sound and able to communicate their wishes. This ensures that the wishes of the individual are fulfilled upon death and makes it easier for the family to make decisions and prepare for the loss of their loved one.

Keywords Advance Directive; Culture; Dementia; Do Not Resuscitate Order; Ethics; Euthanasia; Extraordinary Measures; Heroic Measures; Living Will; Medical Device; Palliative Care; Quality of Life; Religion

Ethical Issues of Death & Dying

Overview

The approach of death is a difficult time as people struggle to resolve interpersonal issues before it is too late, put financial affairs in order, and make decisions about medical care. The person who is dying may also be attempting to come to terms with their death, and the loved ones left behind may begin to realize that they are faced with the loss of their dying family member, friend, or partner. In some cases, this realization is met with denial, and the family attempts to do everything in its power to prolong the life of the individual so that they do not have to face the loss. In other cases, either the terminal person or loved one may be overcome by despair, particularly if the patient is facing a lingering, painful death with no hope of relief. In still other cases, the family may be faced with the fact that their loved one is no longer able to communicate either because of dementia, coma, or other incapacitating illness and will have a quality of life that is dismal at best. Despite the fact that neither the dying person nor their loved ones may be emotionally capable of making a rational decision at this time, important decisions still need to be made.

Ethical Considerations

In general, there are three sets of ethical issues regarding death and dying that need to be considered when determining how best to meet one's end with dignity or support someone in doing so: the definition of life, quality of life, and the treatment of the body after death.

Defining "Life"

The first issue to be considered regarding the subject of death is the definition of criteria that constitute life. Before the invention of the mechanical ventilator in the 1950s, death could typically be determined by the cessation of breathing and the beating of the heart (although there were still exceptions to the rule). However, scientific advances enable medical practitioners to prolong the regulation of such bodily functions by artificial means even when there is no hope of a meaningful recovery. So, the question remains: How are we to define death? Some theorists advocate for defining death in terms of the higher brain formulation of death, which is defined as the "irreversible loss of that which is considered to be essentially significant to the nature of man" (Bernat, 2006). This approach rejects the concept that death should be defined as an organism's inability to integrate bodily function. However, some people argue that this definition does not include the concept of an irreversible loss of consciousness and cognition (e.g., as in an irreversible vegetative state). Advocates of the whole brain concept of death maintain that death occurs only after “cessation of all brain clinical functions including those of the cerebral hemispheres, diencephalon, and brain stem” (Bernat, 2006). Although this debate may seem to be the picking of nits, it is an important question because families make their decisions about such issues as extraordinary measures, heroic measures, and life support based on whether or not they think the patient is still alive; sometimes regardless of whether there is any hope of a meaningful recovery.

Quality of Life

The second set of ethical issues regarding death and dying is the quality of life that the individual experiences. The fear of death and the fear of dying are two different things. The first has to do with one's philosophy and theology; the second has to do with pain and suffering. As opposed to the people who believe that life (however it is defined) should be preserved at all costs, other people believe that a terminal diagnosis with a concomitant life of pain and suffering is not life at all and should be voluntarily terminated. In this set of ethical issues lie questions of death with dignity, removal of breathing machines, feeding tubes, and other medical devices that only prolong life but do not cure, assisted suicide, and euthanasia.

Body Treatment After Death

The third set of ethical issues concerns how the body is to be treated after death. Some people believe that a dead body is an empty shell requiring neither reverence nor respect. Others, however, believe that the body—dead or alive—is God's creation and deserves respect even after death. There are, of course, a range of opinions in between. One's stance on this issue can affect whether or not one wants to be buried or cremated, whether an autopsy should be performed, whether or not organs should be donated for transplant, or if the body may be donated to science. Culture, tradition, and religion all play prominently in this debate.

Quality vs. Quantity of Life

Although in some cases there may be technical, medical problems determining whether or not an individual is still alive, for the most part, ethical questions concerning issues of death and dying center on the quality of the individual's life rather than the existence of it. On one end of the spectrum are people who believe that life should be preserved at all costs and that as long as a person can be kept alive (by natural or artificial means), there is still hope. On the other end of the spectrum are those who believe that the quality of life trumps all other considerations and that in terminal situations or those in which there is little hope for meaningful recovery and a reasonable quality of life, the life should be actively ended. In between, of course, is a whole range of other philosophies and beliefs.

A Personal Decision

Given the wide range of permutations on end-of-life issues and strong feelings along the whole continuum of belief, in the end, it can be argued that the ethics of death and dying are best left up to individual choice within the confines of the law. Issues of death and dying are about much more than medical treatment options and legal or medical definitions of death, and they do not affect only the dying person. Such decisions also involve issues of philosophy and theology. They can greatly affect not only the dignity, quality of life, and physical and psychological suffering of the dying person but also the psychological well-being of the living both during the dying process and after it. Therefore, decisions about death and dying are best made before they are needed and when the individual is still mentally sound and able to communicate their wishes. This will help to ensure that the person's wishes are carried out and that the family will not have to make extremely difficult decisions under extremely difficult conditions. In particular, drawing up a medical power of attorney, an advance directive, a do not resuscitate order, or a living will help specify what the person wants and believes to be the right course of action when the time comes.

Applications

Religion & Ethical Views on Death

What makes the field of ethics so interesting is that although ethical questions deal with the process of trying to sort through issues of right and wrong, in many cases, there are no right or wrong answers. For example, opinion is divided in the United States as to whether or not refusing to feed someone who is unable to feed themselves and also unable to communicate their wishes are ethical. However, suicide by fasting to death is not only acceptable but is a highly regarded and even celebrated aspiration within the Indian religion of Jainism. So, what is ethical in one culture may not be in another. There are many considerations in determining what is ethical or unethical in any given situation and given the potential level of physical and psychological suffering in dying and the permanence of death, the stakes are high, and opinions are fiercely held. Religion informs the beliefs about death for many people and may inform the decision-making processes about issues related to death and dying culturally, even for those who, for most of their lives, do not practice a religion. Although the theological principles pertaining to matters of life are death and not necessarily universally held within a given religion, the following discussion illustrates some of the more widely held principles and their theological underpinnings for five of the world's major religions.

Monotheistic Religions

Christianity

The three major monotheistic religions of the world—Christianity, Islam, and Judaism—all have definite theology related to issues of death and dying. Christianity is the largest of these and, in fact, the largest religion in the world (Pew Research Center, 2022). Although Christians may be divided in many ways over issues of theology, they do hold the same core values and beliefs. One of these is that there is an afterlife in which believers will spend eternity with God. Although there may be dissension over smaller matters, in issues of life and death, there tends to be more common ground. Sickness, suffering, and death are viewed by many Christians through their understanding of Christ's suffering and death on the cross and his subsequent resurrection. Christians also believe that God participates in the affairs of humanity, another tenet that informs their views of death and dying. The New Testament teaches that one's body is the temple of God, so most Christians believe that life is sacred, although not necessarily to be preserved at all costs. For example, in questions of withholding or withdrawing treatment, the official position of the Roman Catholic Church is that there is a distinction between ordinary measures (i.e., those medical treatments that are intended to preserve life, such as medicines, treatments, and operations that offer a reasonable hope for preserving life and that can be obtained without excessive expense, pain, or other inconvenience) and extraordinary measures (i.e., medicines, treatments, and operations that do not offer reasonable hope of preserving life and which cannot be obtained without excessive expense, pain, or other inconvenience). There is, of course, no list of procedures that easily fall into one category or another; all such treatment needs to be made with informed consent on an individual basis by the patient or family. For example, a feeding tube or mechanical ventilation at one stage during the course of a disease or illness may provide sufficient time for other measures to take effect and enable the patient to live; given at another time; however, it may only preserve existence with no hope of recovery.

Islam

The second largest (and youngest) major monotheistic religion is Islam. Although Islam has legal rulings or fatawa (sg., fatwa) about life and death issues such as organ donation and euthanasia, there is not widespread agreement about these issues between Muslim jurists from different schools of Islamic law (Sachedina, 2005). In general, however, Islam teaches that death comes to us all and that how we die is important. According to Muslims, God is both the origin and destiny of life, so life is, therefore, sacred. According to the Qur'an, death does not occur except by God's permission. Therefore, in Islam, it is necessary to do everything possible to prevent premature death. The question of preserving life at any cost, however, is the subject of much debate within Islam. Although, on the one hand, there is the obligation to save or even prolong life, on the other hand, there is the argument that one should limit life-sustaining treatment if there is a lack of resources. Further, in Islam, the decision of life-prolonging treatment is not the decision of the individual alone. Islam emphasizes the link between the welfare of the individual and their family and community. Decisions about whether or not an aggressive or invasive treatment can prolong life without causing further harm, therefore, is a matter of concern not only for the individual but for all associated with him/her. Regarding pain, the approach of most Muslims is to act in such a way as to alleviate pain by actively removing its cause. As in Christianity, the human body is seen as a temple of God. Therefore, Islamic law does not recognize a patient's right to die voluntarily (e.g., suicide, assisted suicide, or other types of active human intervention). There are, however, exceptions to this general principle depending on the circumstances: Specifically, the administration of medication to relieve physical and mental suffering in a terminal patient that has the side effect of shortening life or the withdrawal of futile treatment after informed consent (Sachedina, 2005).

Judaism

The smallest, albeit the oldest, of the major monotheistic religions is Judaism. As with Christianity and Islam, the Jewish religion holds that the body belongs to God. This means that human beings have the obligation to seek both preventative and curative medical treatment. However, as also with the other two religions, Judaism recognizes the fact that all human beings are mortal. Similarly, there is not widespread agreement across all Jewish traditions about how this is to be interpreted. In addition, culture (in the form of country, generation, or family) may also affect the interpretation of these matters. Because the individual belongs to God, Judaism does not condone suicide or enlisting aid to end one's life. Judaism has its own criteria for determining death. Traditionally, these have been the cessation of breathing and heartbeat (although sufficient time must be allowed before burial to determine that this is a permanent condition). After developing the Harvard criteria for brain death, Conservative rabbis accepted these criteria as fulfilling the traditional requirements. Criteria for the acceptability of withholding life-sustaining treatment varies, with the strictest interpretation being the prognosis that the patient will die within 72 hours or less and more liberal interpretations allowing for withholding life-sustaining measures if the patient will live up to a year or more. However, most rabbis view artificial nutrition and hydration to be the equivalent of food and liquids required by everyone to live and require them to be used even when other life-sustaining treatments are withdrawn. Regarding heroic measures, most view these as permissible as long as there is some hope of a cure; however, such measures are not required, and the decision is to be made based on the risk/benefit ratio, the patient's best interests, and the patient's desires. Jews are allowed to sign advance directives for health care to specify their wishes in such cases should they not be able to communicate their desires at the time. Pain control, palliative care, and hospice programs in which the goal is to make the patient comfortable but not to cure are all acceptable under Jewish tenets. Further, Jewish tradition considers it an obligation to visit the sick, treat them with respect, and pray for them. Ethical considerations continue even after death. Regarding autopsy and organ donation, the ruling principles are that the dead body should be honored as the property of God and that one has an obligation to save the lives of others. Because of the first principle, autopsies are not routinely performed unless required by civil law, three doctors agree that the cause of death cannot be otherwise ascertained, that the autopsy might help save the lives of others with similar illnesses, or that the results of the autopsy might be of benefit to surviving family members with a hereditary disease. These criteria, however, are debated. Although the donation of cadavers to science or of organs to save others is permitted by most rabbis, there is also disagreement about the circumstances under which these actions are permissible.

Polytheistic Religions

Hinduism

Not every religion is monotheistic, however. In fact, the third largest religion in the world is Hinduism (World Population Review, 2023). Although this religion does not have an institutional framework or demand adherence to particular doctrines, most Hindus do hold certain tenets in common that apply to death and dying. Most Hindus believe that a living being (either human or animal) possesses a soul that moves on from one life to the next. In addition, most Hindus hold that there is a difference between a good death and a bad death. The former occurs in old age either on the banks of the sacred Ganges River or on the ground at home. (For this purpose, many Hindus keep a container of Ganges water to be offered to the dying person and placed on the lips of the corpse.) Hindus prepare all their lives for a good death and enter into it consciously and willingly. A good death requires the correct rituals in order to speed the soul on its way. Bad deaths, on the other hand, are premature, violent, or uncontrolled, happening at the wrong place and time (often signified by vomit, feces, urine, and an unpleasant expression). The worst type of death in Hinduism is suicide which happens for selfish reasons. There is a long tradition of voluntary death in Hinduism, typically where such an action is linked to a specific purpose, such as gaining freedom. However, Hinduism makes a distinction between the willed death of an individual. Suicide for selfish reasons is considered to be morally wrong and cannot be sanctioned with the appropriate rites of death. Some Hindu authorities also argue that humans should not take their own lives because of the karmic effect on the next life. In general, Hinduism stands strongly against involuntary euthanasia primarily because it goes against the principle of autonomy and can be easily abused. However, in all these matters, it is difficult to generalize Hindu attitudes toward death and dying because they are highly correlated with education, class, and tradition.

Buddhism

Another major polytheistic religion (one, in fact, with more adherents than Judaism) is Buddhism. In this religion, the inevitability of death is recognized, and emphasis is placed on the psychological preparation necessary to accept death with calmness and dignity. Buddhists place great value on mindfulness and mental clarity because they believe that it can affect the quality of their rebirth. This fact impacts their philosophy of dying. For example, some Buddhists may forego pain-relieving drugs or sedatives so that their mental facilities can be unimpaired. The Buddhist definition of death involves the loss of three criteria: vitality, heat, and sentiency. Although determining the loss of heat is a rather straightforward matter, determining the loss of the other two criteria is not, particularly given the tradition of yogic trance in which life signs may not be observable. On the other hand, there is no disagreement between Buddhist tradition and modern medicine on the status of patients in a persistent vegetative state: Individuals in this state are clearly alive according to both views. From the Buddhist perspective, irreversible damage to the neocortex is no different than damage to another organ when making ethical decisions regarding treatment. This typically means that unless there are secondary complications, the person should continue to be given nutrition and hydration. Further, Buddhists do not believe in taking a life. Therefore, they do not condone suicide or the incitement of someone to commit suicide. This prohibition also extends to assisted suicide and euthanasia, even though these actions might spare the person unnecessary pain. On the other hand, due to the Buddhist belief in the inevitability of death, Buddhists do not condone attempts to prolong life beyond its natural span through technology but encourage adherents to prepare to accept death calmly when it comes. This, however, does not preclude hospice or other palliative care.

Conclusion

Ethics is a branch of philosophy concerned with the difference between right and wrong. With a few notable exceptions (e.g., murder), what is right and what is wrong when it comes to issues of death and dying vary widely from culture to culture, religion to religion, and even individual to individual. It is exceedingly difficult for a family to make end-of-life decisions when in the throes of losing a loved one. Such decisions are best made earlier when the individual is still mentally sound and able to communicate their wishes. Depending on the belief of the individual or the family, these decisions can be made by the person alone or as a group with the family or others affected. No matter how it is done, however, if the discussion is had and advance directives, do not resuscitate orders, a living will, or other documents are drawn up, it will be easier for the individual to ensure that their wishes are fulfilled when the time comes and for the family to make decisions and prepare for the loss of their loved one.

Terms & Concepts

Advance Directive: A written document in which a person specifies what type of medical care s/he wants to have in case they are not able to communicate their wishes directly (e.g., in case of coma). Advance directives are only enforceable if the person was of sound mind when the directive was signed. Advance directives must be signed and notarized.

Culture: Socially shared way of life which defines meaning and behavior for a human group; includes behavior patterns, arts, beliefs, institutions, and other products of human thought and creation.

Dementia: In the generic sense of the term, dementia is a generalized, pervasive deterioration of a person's cognitive abilities (e.g., memory, language, executive function). The deterioration caused by dementia can be very severe and can significantly impact the ability of the individual to perform on the job, function well within society, or even accomplish daily activities of living. There are many specific types of dementia, including Alzheimer's disease, vascular dementia, Pick's disease, Parkinson's disease, Huntington's disease, and AIDS dementia complex. Brain tumors and other treatable conditions may also cause dementia. Although the onset of dementia may vary, in most cases, it occurs later in life, typically after 65 years of age.

Do Not Resuscitate (DNR) Order: An advance directive that states that a person is not to be resuscitated when their heart or breathing stops (e.g., through cardiopulmonary resuscitation (CPR)). The DNR order goes into effect when the person is unable to communicate their wishes and refuses treatment that would keep them from dying.

Ethics: (a) A branch of philosophy concerned with the difference between right and wrong (i.e., normative ethics) and whether or not such judgments should be considered objective or subjective (i.e., meta-ethics). (b) The principles of morally right conduct held by an individual, group, or profession.

Euthanasia: The act of mercifully and painlessly ending the life of a person or animal either by action (e.g., the administration of a lethal injection) or through the withdrawal of life support or extraordinary measures.

Extraordinary Measures: A medical measure that causes excessive expense, pain, or other inconvenience without a reasonable offer of hope of improvement from the measure. (See also heroic measures.)

Heroic Measures: Medical treatments, procedures, or courses of therapy that are taken as a last resort after all other options have (or would have) failed. Heroic measures often pose a high degree of risk for causing further damage to the patient's health. Cardiopulmonary resuscitation (CPR) is considered a heroic measure. (See also extraordinary measures.)

Living Will: A document in which an individual articulates in writing which medical treatments or interventions they do or do not want in the event of a terminal illness. A living will only go into effect when the person becomes incapacitated and can no longer make their wishes known.

Medical Device: According to the Safe Medical Devices Act, a medical device is an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or similar item or component part or accessory that is intended for use in the diagnosis, cure, treatment, mitigation, or prevention of disease to affect the structure or function of the body, and that does not achieve its primary purposes through chemical action or through metabolism.

Palliative Care: Medical care or treatment that is intended to relieve, reduce, or soothe the severity of the symptoms of a disease or disorder without curing it. The goal of palliative care is to improve the quality of life for individuals with serious or terminal illnesses.

Quality of Life: The sense of well-being that an individual feels regarding their life circumstances and lifestyle; the ability to enjoy one's normal life activities. As opposed to the standard of living, quality of life is both intangible and subjective.

Religion: A personal or institutional system grounded in the belief in and reverence for a supernatural power or powers considered to have created and to govern the universe.

Bibliography

Bernat, J. L. (2006). The whole-brain concept of death remains optimum public policy. Journal of Law, Medicine and Ethics, 34 , 35-43. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=20005292&site=ehost-live

Bodek, H. (2013). Facilitating the Provision of Quality Spiritual Care in Palliative Care. Omega: Journal Of Death & Dying, 67(1/2), 37-41. Retrieved October 28, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=88230747

Dorff, E. N. (2005). End-of-life: Jewish perspectives. Lancet, 366 (9488), 862-865. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=18184553&site=ehost-live

Firth, S. (2005). End-of-life: A Hindu view. Lancet, 366 (9486), 682-686. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=17958400&site=ehost-live

Keown, D. (2005). End-of-life: The Buddhist view. Lancet, 366 (9489), 952-955. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=18170948&site=ehost-live

Key findings from the global religious futures project. (2022, Dec 21). Pew Research Center. Retrieved June 6, 2023, from https://www.pewresearch.org/religion/2022/12/21/key-findings-from-the-global-religious-futures-project

Laidlaw, J. (2005). A life worth leaving: Fasting to death as telos of a Jain religious life. Economy and Society, 34 , 178-199. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=16968058&site=ehost-live

Livne, R. (2014). Economies of dying: The moralization of economic scarcity in U.S. hospice care. American Sociological Review, 79, 888–911. Retrieved December 31, 2014 from EBSCO Online Database Academic Search Complete. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=98673293

Macdonald, G. (2012). The Value of the Person at the End of Life -- Euthanasia: A Threat to the Vulnerable. Australian Family, 33, 39-44. Retrieved October 28, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=79193001

Markwell, H. (2005). End-of-life: A Catholic view. Lancet, 366 (9491), 1132-1135. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=18335494&site=ehost-live

Morhaim, D. K., & Pollack, K. M. (2013). End-of-Life Care Issues: A Personal, Economic, Public Policy, and Public Health Crisis. American Journal Of Public Health, 103, e8-e10. Retrieved October 28, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=89865803

Religion by country 2023. (2023). World Population Review. Retrieved June 6, 2023, from https://worldpopulationreview.com/country-rankings/religion-by-country

Sachedina, A. (2005). End-of-life: The Islamic view. Lancet, 366 (9487), 774-779. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=18033060&site=ehost-live

Voorhees, J. R., Rietjens, J. C., van der Heide, A., & Drickamer, M. A. (2014). Discussing physician-assisted dying: physicians’ experiences in the United States and the Netherlands. Gerontologist, 54, 808–817. Retrieved December 31, 2014 from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=98635560&site=ehost-live&scope=site

Suggested Reading

Amella, E. J., Lawrence, J. F., & Gresle, S. O. (2005). Tube feeding: Prolonging life or death in vulnerable populations? Mortality, 10 , 69-81. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=16573363&site=ehost-live

Brauner, D. J. (2011, December). Later Than Sooner: A Proposal for Ending the Stigma of Premature Do-Not-Resuscitate Orders. Journal of the American Geriatrics Society. pp. 2366–2368. Retrieved October 28, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=69870817

Clark, D., Winslow, M., & Marples, R. (2005). US physicians' attitudes concerning euthanasia and physician-assisted death: A systematic literature review. Mortality, 10 , 43-52. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=16573369&site=ehost-live

Doka, K. (2005). Ethics, end-of-life decisions and grief. Mortality, 10 , 83-90. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=16573368&site=ehost-live

Flemming, R. (2005). Suicide, euthanasia and medicine: Reflections ancient and modern. Economy and Society, 34 , 295-321. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=16968059&site=ehost-live

Huxtable, R. (2014). Splitting the difference? Principled compromise and assisted dying. Bioethics, 28, 472–480. Print.

Jansen, L. A. (2006). Hastening death and the boundaries of the self. Bioethics, 20 , 105-111. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=19826724&site=ehost-live

Jennings, B. (2006). The politics of end-of-life decision-making: Computerised decision-support tools, physicians' jurisdiction and morality. Sociology of Health and Illness, 28 , 350-375. Retrieved July 18, 2008, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=20262883&site=ehost-live

Weidemann, E. (2012). The Ethics of Life and Death: Advance Directives and End-of-Life Decision Making in Persons with Dementia. Journal Of Forensic Psychology Practice, 12, 81-96. Retrieved October 28, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=70332201