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Introduction

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Welcome to this free course, An introduction to death, dying and grief. It is comprised of five sections that will take about 7 hours to complete in total. In Section 1, you will be introduced to different ways in which death is understood, by looking at language around death and how language conveys how people make sense of death. In Section 2, you will examine the meaning of a ‘good death’ and how this principally applies in the West. In Section 3, you will learn about assisted dying and will consider the different sides of the assisted dying debate. In Section 4, you will briefly be introduced to ethics and ethical dilemmas in practice. In the final section, you will explore grief and the expression of grief in private and in public.

This OpenLearn course is an adapted extract from the Open University course K220 Death, dying and bereavement.

Please note that this course includes video about people talking personally about their experiences in relation to death and dying.

If you have been affected by the issues in these videos, you can call Macmillan Cancer Support free of charge on 0808 808 00 00. You can also call Samaritans free from any phone on 116 123 (it will not appear on your phone bill), email jo@samaritans.org, or visit www.samaritans.org to find details of your nearest branch. The Motor Neurone Disease Association also provides support to people affected by motor neurone disease in England, Wales and NI - 03457 626262 or visit The Motor Neurone Disease Association

Learning outcomes

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

After studying this course you should be able to:

understand that individuals and societies make sense of death in different ways
understand that there is diversity in our beliefs about death and dying
understand some key ethical dilemmas in dying and assisted dying decisions
understand some of the diverse expressions of grief.

1 Understanding death

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Death is a central aspect of the human condition. At some point in time, human beings developed an awareness that life was finite, and from that moment on, people have tried to ‘make sense’ of death. Yet the way in which death is understood and represented, and the extent to which it is a taboo topic (which refers to how comfortable people feel talking about it), varies hugely depending on place, historical period and culture.

This has led to questions like:

Why do we die?
What happens after we die?
How can we prolong life?
How can we experience a ‘good’ death?

Over the course of human history, people including philosophers, theologians and artists have attempted to address these questions. More recently, scientists and medics have had a significant impact upon how people (particularly in the West) understand death, dying and grief. Our understandings of death have also been influenced by the work of social scientists and ‘thanatologists’ (people who specialise in the academic study of death and dying).

However, what is so fascinating about this topic – once you start to dig a little deeper – is that there continues to be so much variation in how death is understood by different people and different cultures.

Figure 1 The Tana Torajen community believes that relationships with the deceased continue after their biological death.

Long description

1.1 Talking about death

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

The meanings people ascribe to death (i.e. what is important to people, or what matters to them) are not static. They change over time, within and between cultures. In the west, death is sometimes considered a taboo topic and we use careful or sensitive language when talking about death. In Activity 1, you will explore different perspectives on talking about death.

Figure 2 How we are introduced to the topic of death as children or young people can shape our attitudes later in life.

Long description

Activity 1 Talking about death

Allow approximately 1 hour.

Part A

Think about the terms to describe death that you have used or heard. What do you think might be the purpose of these terms, and do you consider them to be helpful?

When have you heard these terms used, or when might you use them? Enter the terms against the following categories in the table below (there is no right or wrong answer here). Two examples have been added to the first box, to help get you started.

Table 1 Talking about death in different contexts

Context	Language or words used to talk about death
Talking to family/friends about the death of a loved one	Table 1 Talking about death in different contexts 1‘Passed away’ ‘died peacefully’
Expressions in popular culture (TV, film, music, books)	Table 1 Talking about death in different contexts 2
Language used in funeral services	Table 1 Talking about death in different contexts 3
Talking about death with colleagues	Table 1 Talking about death in different contexts 4
Talking about someone you don't know personally (for example, a famous person)	Table 1 Talking about death in different contexts 5
Talking to someone who is ill, or vulnerable	Table 1 Talking about death in different contexts 6

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Discussion

You may have noticed that the language you use or hear in association with death and dying varies depending on the context. Perhaps there are some terms that you would use with colleagues but not with vulnerable people. Perhaps you adjust the language you use depending on the belief system of the person who you are talking with; maybe your own belief system means that the terms you use are consistent. You may have found yourself using humour to talk about death as a coping mechanism, or have been aware of others doing this. Many people adapt the way they talk about death depending on the context they find themselves in.

An Open University academic wrote: ‘After my mum died, I struggled for a long time to find the words to talk about what had happened. I fluctuated between expressions such as ‘she passed away’ and ‘I lost my mum’ (to which a close friend replied, jokingly – ‘how careless of you!’), until eventually I found the confidence to say that ‘she died’ (which somehow felt more final to me). But when talking to others about the death of their loved ones, people often feel the need to ‘say the right thing’. This can be very hard to do, and may explain why many bereaved people feel that others avoid them, for fear of getting it wrong.

Part B

Now watch this short clip in which Open University lecturer Dr Erica Borgstrom describes why language matters when we talk about end-of-life care or death and dying. As you watch the clip, note down some of the key points made by Dr Borgstrom that really made you think.

Download this video clip.Video player: k220_ol_act1_vid.mp4 >

Video 1 A Time to Live: Kevin

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Transcript

ERICA BORGSTROM

She's poorly? He's really unwell. She's palliative. These are phrases that I often hear when I'm doing research in palliative and end-of-life care, but what do they really mean?

As an anthropologist, it took me a while in my field work in hospitals, hospices, and care homes in England, to figure out that these phrases were code.

Code language can be really useful, if you want to keep information between certain groups of people only, but when talking about end-of-life care, it can actually, be quite unhelpful.

It can make it really unclear for the dying person and those around them, to know what's going on and what they might be able to do.

There's lots of examples of unclear language use in medicine, particularly in palliative and end-of-life care.

In England, people might use euphemisms to talk about death and dying because they think it might make it easier to talk about a difficult subject. But we know cross-culturally, that other places talk about death more openly and frankly. And that death isn't necessarily, a taboo not to be spoken about.

The language we use to talk about end-of-life care matters. It matters because it conveys the values we attribute to life and death.

For one of my latest projects, I'm looking at the language used when decisions have been made to provide no further medical intervention or treatment.

For example, there's the cliche that we say, there's nothing more that can be done. Now, this is often uttered at a time when palliative care teams might still be exploring alternative methods for symptom management and treatment.

There seems to be a contradiction then, between what we're saying and hearing and what people are actually doing.

Now, from my research experience, rarely, when there is an absence of medical treatment, is there actually, an absence of care. So why are we using language, or code, that might make us think otherwise?

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Discussion

Here are some key points that were identified by an OU academic:

phrases are code which can help control the flow of information
code language can make things unclear for some people to understand or follow
euphemisms in death and dying might be perceived as being an easier way to talk about a difficult subject matter
the use of code gives some indication of how taboo the subject is, or whether it’s a more open culture around death
language conveys our values about life and death.

This first activity shows that there is a lot of variation in our language and the words that we use to describe death and dying. It is important to remember that our language can convey our values and may reflect culture and wider society. Words do not necessarily directly reflect what is thought to be reality, but language can provide some clues about the openness, or otherwise, of society to the idea of death. The use of language is just one aspect of how death is expressed and understood, but language is something that is shared between groups in society and can provide a wider perspective than the individual expression of what death means to that person. Exploring how language connected with death and dying is used provides a brief glimpse of its power and its role in the social fabric of people’s lives.

2 Exploring Western ideas about ‘a good death’

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

What is a good death? If you were tasked with improving the experiences of dying or bereaved people, what would you aspire towards? This question may leave you wondering what makes one dying experience ‘good’, and another ‘bad’. You may speculate on what has shaped your own personal views concerning a ‘good death’ and how your perspective on a good death might differ from family and friends, or people in different communities or countries. And you may wonder whether any death can be inherently ‘good’.

The concept of the ‘good death’ has been central to the development of the modern hospice movement. It presents a view of death that is peaceful, gentle, and anticipated, free of unnecessary medical intervention. In many ways it connects with the natural birth movement. But the notion of a good death is one that needs to be explored in its social, historical and cultural context.

Figure 3 In this painting (‘The Triumph of Death’) by an anonymous painter from Sicily around 1445, Death is depicted as a skeleton on a skeletal horse who is picking off victims, which indicates ideas about the role of fate or luck in death and dying at this time.

Long description

Figure 4 Demonstrating how death is managed medically in the modern age, this image shows how the body is subject to scientific examination as part of an autopsy to understand cause of death.

Long description

The backlash to what has been described as the ‘medicalisation of death’ has been the modern hospice movement. Emerging from that movement was a new articulation of a good death. In their extensive reviews of the academic literature, Erica Borgstrom (2014) and Cottrell and Duggleby (2016) have suggested there are a number of key features that have become synonymous with ideas about a ‘good death’ in contemporary Western societies. These include:

awareness and acceptance of dying (viewed as a positive)
preparedness (getting one’s affairs in order)
comfort (minimisation of pain)
closure (addressing and resolving difficult issues)
peacefulness and dignity
presence of family and being in familiar home (or ‘home-like’) surroundings
personhood (a sense that an individual’s wishes and preferences have been accounted for)
timeliness (dying at an older age; and a dying process that is predictable, with an identifiable start and end point).

Central to all of these components is control – control over dying activities (like preparing for death); control over the time and place of death; and control of unpleasant symptoms.

Figure 5 Lack of control over their bodies forms the basis for the dark humour, focused on death, in the black comedy film Death Becomes Her in which Meryl Streep and Goldie Hawn play characters who take a magic potion that promises eternal youth but suffer unpleasant effects which they cannot control when their bodies physically die.

Long description

2.1 Preparing for death

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

In the next activity, you will explore personal perspectives on the end-of-life and preparing for death and the extent to which they draw on these contemporary components of a good death.

Activity 2 Preparing for death

Allow about 1 hour

Part A

Watch these three extracts from a BBC documentary A Time to Live, which explored the perspectives of people who had received a terminal prognosis. Although the interviewees were not specifically asked about their views on a good death, their interviews nonetheless reveal some interesting perspectives on the issue. For this activity, you will watch excerpts from three people: Kevin, Anita and Jolene.

As you watch the films, click the drop-down tabs to indicate if you have heard examples from the interviews that map onto the components of a good death outlined by Borgstrom (2014) and Cottrell and Duggleby (2016). You have the option of ‘no’ and ‘not sure’ as well.

Download this video clip.Video player: Video 1 A Time to Live: Kevin >

Video 1 A Time to Live: Kevin

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Transcript: Video 1 A Time to Live: Kevin

[MUSIC PLAYING]

[TEXT ON SCREEN

Introduction]

KEVIN

I’m Kevin. I’m 69 years old. And four months ago, I learned that I had incurable cancer.

INTERVIEWER

What sort of cancer?

KEVIN

It’s prostate cancer, which has spread to my bones.

[TEXT ON SCREEN

Background]

I believed I was indestructible. I think a lot of men do. I look in the mirror, and I see 18. And I think, why is my hair not brown? It must be the light that’s wrong. So I did have that male sense of I’m going to go on forever. Yeah, I did. Yeah.

My first wife died of cancer at the age of 49. But I only had a vague expectation that I would die one day. And what this gives you is clarity about that. Real clarity.

My wife was with me, and we wanted to know roughly how long we could expect that I would live. Because it’s so important, it felt at the time, and it’s right-- to know how long you have helps you develop the game plan for coping with it. If I had a three month diagnosis, I think I would be absolutely focused on the final stage, how I wanted to die, where I wanted to die, and those things I had to get sorted before that point arose. Whereas if you have more time than that, you will think about those things, but you will also have more time to enjoy the days that you have.

[TEXT ON SCREEN

Coping Mechanisms – Being Positive]

The first choice is that there is no point to being angry. There’s no point in being disappointed. What we’ve decided to do, talking about it, is we’re going to live each day as best as we can, take each day as a gift, and say, what can we do today. And not big things-- little things. Go for walks, enjoy getting a bird table, as we have, and watching the birds come. Doing things each day, and at the end of the day, say, hey, that was great, wasn’t it?

INTERVIEWER

Do you manage to laugh a lot?

KEVIN

Oh, absolutely. Absolutely. You have to laugh at yourself. You have to laugh at the vanities. You know I’ve got a chemo haircut now. I used to comb my hair very carefully, and I’ve given up on that.

You have to laugh at yourself and the situation, is find humour, because humour is warm, and humour feeds on yourself. What you, what I don’t want is any bitter, there is no room, there should be no room, for bitterness. Now, I’m saying that as a 69-year-old. And I do know if I was 19, I may feel differently. But I am not bitter about where I am. I’m grateful.

[TEXT ON SCREEN

Coping Mechanisms – Project Management]

If you said to me, did I want this project, I can think of other ones I’d rather have than project managing my own death. But the truth is, we all have, we’re all going to die. And I think we forget that in our lives, that every life ends. And to have the chance to organise and do things and make productive use of the time that’s left is a real, real privilege. And I’m grateful for that chance.

For somebody whose dad drop dead at 64, who went out the door to go down to the doctors to get a test result and he dropped dead in the high street, so my mother was never able to say goodbye, it’s a huge privilege to know that we’ve actually got some time. We don’t know how much time, but we’ve got some time to still enjoy things together, to put our lives as much where we want them to be as possible. It’s a real opportunity to live the rest of my life as positively as possible.

[TEXT ON SCREEN

Lifestyle]

You read all the stuff about diet, and I know that I could become a green tea-drinking vegan, and that might give me a little while longer. But I don’t want to change what I eat and what I drink and what we have fundamentally, because it’s part of who we are. And it’s part of the pleasure we take from everyday life.

So we might – I’m trying to eat a little less chocolate. And I’m trying not to eat blue cheese. And those other things which, at the margins, may make a difference. But the things that have got me to 69, there’s no point in junking them now in case it gave me another two months, because it’s given me the 69 years I’ve had. And that includes a glass of wine.

[LAUGHING]

INTERVIEWER

Good for you.

[TEXT ON SCREEN

Relationships – Wife]

KEVIN

I am on a journey. I’m hugely lucky I’ve got a supportive wife who’s on the journey with me for as long as she can be. But there’ll come a point where our destinations diverge, because I’m going to die and she’s not. And she’s going to have a life beyond. And I see my duty as her husband is to help her approach that new life as positively as she can.

I’ve organised a kind of a list of things that over the years I’ve done rather than she’s done. There’s a Word document of all of the things that I need to share with Jenny, and we’ve been through nearly all of them. So there won’t be anything that she’ll ever have to say, how did Kevin do that. And that gives me great comfort, because it means that I’m loving her till the last possible moment.

[TEXT ON SCREEN

Intensity]

When we both worked full time, essentially you worked in the week and you lived for the weekend. What we now do is we make every day matter. Since the diagnosis four months ago, we’ve actually had some of the best times of our life. And we’ve talked about it. We’ve said what a great day today was. We’ve never felt closer.

There’s an intensity about your life when you know it’s a finite one that you just, I guess, take for granted when you think you might live forever. If you’d said to me, would a dying person feel a new intensity, depending on my age, I probably would have found that unimaginable. I’d thought they’d have been sad and down and angry.

But that is not how I’m feeling. And I know it helps I’m 69, but even so, the gift of life is somehow reinforced when suddenly you’re reminded it’s finite.

End transcript: Video 1 A Time to Live: Kevin

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Video 2 A Time to Live: Anita

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Transcript: Video 2 A Time to Live: Anita

[MUSIC PLAYING]

[TEXT ON SCREEN

Introduction]

ANITA

I’m Anita. And two weeks before my 70th birthday, I was diagnosed with motor neuron disease. I always thought I was going to be that old lady of 100 that you always read about in the paper that’s parachuting out of a plane. That was my idea of myself.

[TEXT ON SCREEN

Coping Mechanisms – Being Positive]

My life isn’t about motor neuron disease.

INTERVIEWER

What’s it about?

ANITA

It’s about going out and having fun.

[LAUGHING]

INTERVIEWER

Good for you.

ANITA

That’s what it’s always been about. You know, as best as I can, without hurting anybody, I just want to live every minute of my life to its utmost.

INTERVIEWER

Is there anything about knowing that you’ve got a limited amount of time left that you think is a positive?

ANITA

Oh, there’s lots of positives.

[LAUGHS]

That means I can make plans for my end, that I can sort all my affairs out. I know that it’s going to happen.

You never know how you’re going to end up when you live alone. If I’d have lived to be 100, how would I have, what would have happened? I haven’t got that uncertainty now. I know I’m not going to. So I don’t have to worry about that.

INTERVIEWER

Is that quite a relief?

ANITA

Yes, absolutely, completely relief. It’s the quality of life that’s important, not the length of time you live. Obviously, we all want to live a wonderful, long life, full of quality for a long time. But if that’s taken away from you, if the length of time is taken away, you’ve absolutely got to make sure you’ve got the quality every day.

[TEXT ON SCREEN

Aloneness]

I’ve been alone now for seven years. So I suppose I’ve got used to it. I miss not having my husband here. We had each other to discuss problems. And so you’re on your own. You’ve got nobody to talk to about things. And you’ve got to make the decisions yourself. And that, I find hard.

I’m not worried about dying at all. That doesn’t bother me. We’ve all got to go. What I want to know is that I’m going to die with some sort of dignity. I would preferably like to choose when and how I die.

I’ve decided that I don’t want to see this disease through to the end, because it’s particularly horrible. In my opinion, it’s worse than cancer. Because my brain will remain as it is, while my body completely gives up in every way. And I will just be a blob in a bed, and I don’t want to be that.

Unfortunately, I cannot take an easy way out in this country, because it is against the law at present. So I am forced to look at other options.

INTERVIEWER

What have you decided then?

ANITA

I’ve decided that when the time comes, I will go to Switzerland. I don’t want to go, and I will have to go too early because I need to be fit enough to travel. But I haven’t got, I don’t see any other option. I really don’t see any other option. But I’m not happy about it.

INTERVIEWER

You’re not a rich woman, are you?

ANITA

No.

INTERVIEWER

So how have you managed to afford it?

ANITA

It’s taking every last penny. It will take every last penny I’ve got. My children are grown up. They’ve got families of their own. They’ve got lives of their own. They don’t need me. And I live on my own, and I’ve got not even any pets. So I feel sort of free to go. And I think those people that don’t go, don’t go because of the other person, or the children, or whatever keeps them there. There’s nothing to keep me here now.

So I don’t want my children to be upset. I want them to remember me as a person who enjoyed life, had a good time, and lived every minute of it. And then they’ll have happy memories hopefully. I hope they will.

[LAUGHS]

INTERVIEWER

Do you feel brave?

ANITA

No, not really. I’ve never felt brave. I just, no. It’s not hard. It’s not a hard thing I’m going to do. In fact, it’s harder for the people, for other people than it is for me. I’ve got the easy part.

INTERVIEWER

Why do you think it’s easy?

ANITA

All I’ve got to do is go on another trip, another airplane ride, drink a drink, off I go, wonderful. That is how we all want to go, isn’t it?

End transcript: Video 2 A Time to Live: Anita

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Video 3 A Time to Live: Jolene

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Transcript: Video 3 A Time to Live: Jolene

[MUSIC PLAYING]

[TEXT ON SCREEN

Denial and Hope]

JOLENE

I’m definitely, like definitely in a bit of happy denial. But I know it and I don’t really care. I’ve got to see a future. And even if that’s only in the form of dreaming that I’m old and grey, that’s fine by me.

Realistically, no, I won’t be old and grey and 80 years old. I know that that won’t happen. But actually, I can dream that. And I can believe that that will happen because that makes me feel better. I do kind of have my head in the clouds, because what I actually hope is unrealistic.

In some ways I think it’s quite healthy, because if I were to just admit to myself, like, oh, I’m going to die and I don’t know how long it’s going to be, I think I’d be worse off than I am now.

INTERVIEWER

Think you’d die quicker?

JOLENE

Yeah.

[MUSIC PLAYING]

[TEXT ON SCREEN

Sadness]

INTERVIEWER

Quite a lot of the people that we’ve interviewed are older. And quite a few of them have said in a funny way it’s a blessing, that it’s allowed them to get their house in order, it’s allowed them to do this. I think as a young person you don’t think of it--

JOLENE

No.

INTERVIEWER

[INAUDIBLE].

JOLENE

It’s not a blessing. It’s not something that I think, now I feel so differently about life because I’ve had this horrible experience which has changed me for the better. That’s not the case. If I could take it away tomorrow, I would. If I could change one thing about my life, it would be that I wouldn’t be going through this.

But I know I can’t. But I feel angry that I’m young and I felt like I was so able and had the whole world at my feet. And now I don’t have that. And I have, I guess, I have like a ditch that I’m trying not to fall down.

I think what makes me upset the most is the impact that it has on the people that you love, being ill, the impact that it has on your family. And I try so hard to be positive for my whole family and for my parents, my siblings, and everyone. But actually, it’s really unfair.

And I think it’s heartbreaking because they know that they can’t fix it for me. I think they find that really hard. Because I think as a parent, you probably, as a parent you probably just want to protect your children. And unfortunately, this whole situation is out of our control. And they can only do so much. And I think it’s really hard to see. You know it’s not only me that it affects being ill, but it’s my whole family.

[MUSIC PLAYING]

[TEXT ON SCREEN

Death and Dying]

I can’t explain to you how hard it is to feel like your life is going to be over before it’s begun. That’s really unfair. I definitely know that I’m going to keep fighting, but I know that eventually I won’t win. But if I admit that I’m not going to win, then I’ll lose sooner.

INTERVIEWER

That’s quite scary, that admission, isn’t it?

JOLENE

Yeah. Because ultimately, we all know that I’m living on borrowed time. That’s pretty hard to comprehend, but we all know it’s true.

INTERVIEWER

Breathe deeply.

JOLENE

Yeah, that’s a real tough one.

When I’m less well, I guess I’ll end up going and living at home with my mum back in Northampton. And I don’t really want to do that any time soon or by choice, because to me that’s the beginning of a downward spiral. I think once I’ve done that, whenever that might be, it could be three months, it could be three years from now, I kind of know that that’s the beginning of the end. So I’m going to stay standing on my two feet independently for as long as I can, I guess.

What I find really hard generally is knowing that I don’t have a future, realistically. It’s knowing that that’s been taken away from me. I feel a bit, I guess I feel kind of robbed of that. And I’m going to be 30 next year. But realistically, am I going to make 30? I can’t answer that.

End transcript: Video 3 A Time to Live: Jolene

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Video 3 A Time to Live: Jolene

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Discussion

The answers are collated here for comparison purposes:

Table 2 Example answers

Contemporary Western features of a good death	Kevin	Anita	Jolene
awareness of dying (viewed as a positive)	yes	yes	no
preparedness (getting one’s affairs in order)	yes	yes	not sure
comfort	not sure	not sure	not sure
closure	yes	yes	not sure
peacefulness and dignity	not sure	yes	not sure
presence of family and being in familiar surroundings	not sure	no	yes
personhood (a sense that an individual’s wishes and preferences have been accounted for)	not sure	yes	yes
timeliness – death at the ‘right’ time? A dying period that is predictable?	yes	not sure	no
control	yes	yes	no

Part B

Now draft some writing about the films you have just watched. Answer the three questions below. Write one paragraph of about 100 words for each question.

1. What similarities did you identify between the three films?

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2. What differences did you notice?

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3. Did anything surprise you about these films?

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Discussion

A student wrote the following answers:

I noticed that both Kevin and Anita valued that their diagnosis had given them time to get their affairs in order, and make preparations for their death. They both suggested that receiving a terminal diagnosis had enabled them to make the most of the life they have left. So the awareness of forthcoming death seemed to be a positive – perhaps even something quite transformational. Control over one’s destiny in the final stages of life seemed to be very important to all three people; they all seemed independent and headstrong, wanting to make decisions for themselves.
Jolene’s interview was very different in tone to Kevin and Anita. Awareness of her forthcoming death did not seem to be a positive for Jolene, and she had no interest in getting her affairs in order. This seemed to be a waste of precious life for Jolene. She also expressed anger, sadness and frustration that the end of her life was near, and that she had been ‘robbed’ of more time. I think age played a big part in how people responded to news of their terminal prognosis. How can a good death apply to someone so young?
I found Anita and Kevin’s interviews unexpectedly uplifting; I did not anticipate that before I watched them. I was perhaps a little surprised that the people on the film did not speak more about their forthcoming death, and how they envisaged this happening. Maybe people don’t want to talk about this when they know it’s coming? Perhaps it’s just too painful? I was also struck by the strong emotions in Jolene’s interview. How does that relate to ideas about a ‘good death’? It seemed that Jolene couldn’t see anything ‘good’ about her diagnosis, and I wondered what support there was for someone in her situation.

3 Assisted dying

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Figure 6 The debate on assisted dying is polarised and often features in the news media.

Long description

Assisted dying is currently not a feature of end-of-life care policy in the UK. The assisted dying debate is one that continues to divide opinions and is now regularly debated within the courts and parliaments. In countries that do allow it, it is offered alongside palliative and end-of-life care (e.g. the Netherlands).

Figure 7 In 2002, Terminally ill Diane Pretty (here with her husband Brian) lost her petition for her right to die. She took this to the European Court of Human Rights but the petition was denied.

Long description

Some people argue that if end-of-life care was better, people would then not want assisted dying because their pain and other symptoms, including psychological and social, would be managed. Others argue that even with such holistic care, some individuals may wish to choose when and how they die. However, research suggests that requests for assisted dying or euthanasia actually increase among people receiving hospice (i.e. end-of-life) care (Chapple et al., 2006; Lawton, 2000; Seale and Addington-Hall, 1995). A number of reasons for this have been suggested, including the greater openness of expression encouraged in hospices, the distress of witnessing other people’s deaths and wanting to avoid a similar experience, and the wish to remain physically independent and ‘in control’ (Chapple et al., 2006). In countries where assisted dying is legal, there is some evidence to suggest that not everyone who requests assisted dying follows through with the act (Warnes, 2014).

Before you look into the reasons for and against assisted dying in more detail, it is useful to understand the range of terminology that is used within this topic. As with end-of-life care, there are several terms used to describe a range of subtle differences. This is explained in Figure 8.

Figure 8 Different terminology relating to dying and end-of-life care.

Long description

Note how there are differences in these terms about who does the action, the intention of the action, and if the person who dies had a choice about the matter. In the media, there are often debates around legalising assisted dying. For example, assisted dying may be seen to some as more ethically defensible than prolonging a slow or painful death. Also some believe that it is an individual’s right to choose their death (personal autonomy) and achieve the death that they want at a time that they want which might allow them to have a dignified death (Rodgers, Booth, Norman, & Sowden, 2016). The debate about the right to die is often covered in the news media, such as when Paul Lamb (who was a paralysed former builder) and Jane Nicklinson (a widow of a man who had locked-in syndrome) lost their legal fight to allow disabled people the right to die. This issue was covered and reported in the news (ITV News. Hope remains despite Supreme Court rejection of right to die campaign, 2014). In the entertainment media, the UK TV drama Coronation Street has also included a storyline in which a long-standing character, Hayley Cropper, die in an assisted suicide (ITV News, Coronation Street shows controversial right to die scene, 2014).

In the next activity, you will be asked to watch a video featuring Actress and Activist Liz Carr who is speaking against legalising assisted dying.

Activity 3 A case against legalising assisted dying

Allow approximately 30 minutes.

Watch this video featuring British actress Liz Carr describe why she opposes legalising assisted dying:

Download this video clip.Video player: Video 4 >

Video 4

Skip transcript: Video 4

Transcript: Video 4

[TEXT ON SCREEN: Liz Carr talks to Tasmania about Euthanasia]

LIZ CARR

Hi. I'm Liz Carr. I'm an actor, a comedian, a disability rights activist, and I'm also a disabled person who opposes the legalisation of assisted suicide and euthanasia. And this is a message from me, here in Melbourne at the Melbourne International Comedy Festival, to all of my friends, all of our friends, Down Under.

Really, it's a message to implore you to be incredibly cautious about introducing medically or physician-assisted suicide into your state or your country. It's a scary thing for disabled people. Why? Many people say this has got nothing to do with disability. This is about mentally competent terminally ill people only.

But you know what? There is such a fine line between terminal illness and disability, both medically and in public perception, that we become one and the same. And that means then that assisted suicide is seen by the public, by the medical profession, as a compassionate, a rational solution even, to the problems of anyone who is ill and disabled.

We've discovered this in the UK, where in 2015, our Parliament got to debate for the first time in 16 years whether we should introduce this into our country. Now, it was a hard-fought-over law, first debated in the Lords, then debated in the Commons. Ultimately, the vote went this way: 330 MPs of all persuasions voted to oppose legalising physician-assisted suicide. Only 118 supported it.

Because ultimately, there is no proof - no proof - from the jurisdictions where it's been legalised, that vulnerable people, that people at risk, that the silent voices, the more silent voices of older, disabled and ill people will be heard and will be protected, or will not be protected, through these laws. And that's the thing - do we introduce a law for the benefit of the few at the risk to the many? We can't do that.

Most countries do not have capital punishment. Because even after a court case, investigations, there were miscarriages of justice. Now, we're talking about two doctors and a checklist deciding on whether somebody should be helped to end their life. That said, those same doctors will assess the person. Those same doctors will evaluate it afterwards.

It's no wonder that in the countries where it's been legalised, there's very little feedback on what actually happens. Because the same doctors that do it are the same doctors that feed back.

Anything can happen in that doctor's waiting room and that doctor's consultation room. And I'm not saying that doctors are bad people. Hell, I wouldn't be alive here. I love the medical profession. But the British Medical Association, the Australian Medical Association, do not support assisted suicide. And these are the people which will be licenced to help you to end your life, the very people.

So look, at a time where there are increasing pressures and cuts financially and rationing in terms of social care, and welfare, and health care for many different people, is this the right time to be introducing medically assisted suicide onto the menu of treatment options in your state or country? No.

And you know what? As long as we value certain lives differently - and we do - we value the lives of disabled and ill people and those who have greater dependence - we value those lives less. And as long as that's true, and as long as that's happening, we cannot enshrine that inequality in a law.

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Make a few notes about what problems or issues Liz Carr thinks that legalising assisted dying might raise.

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Discussion

Liz Carr argues that there is often a fine line between what people consider terminal illness and disability and that legalising forms of assisted dying may mean that people who are disabled may inadvertently be subject to subtle or direct coercion. Liz raises many points, including how there is no evidence to assure vulnerable people (older and disabled people) that their voices will be heard if assisted dying was legal. There is little or no evidence about how this is done successfully in places which have already legalised some forms of assisted dying. Liz highlights that assisted dying offers benefit for the few but is a risk to many (vulnerable) people. Liz also explains that in the cases of physician-assisted deaths, it is often the same doctors who assess the patient, who will carry out and evaluate whether the death was a good death – which doesn’t allow for much oversight. You may have written down other points.

3.1 Assisted dying legislation and policy

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Should individuals have the right to an assisted death? This question is central to debates about voluntary euthanasia and assisted suicide (both of which are forms of assisted dying). There are some situations where a dying person might conclude that theirs is a life ‘worth not living’. Arguably, only the person who is living that life can decide on its value to them, but they might not be able to end their life without assistance from someone else or they might be afraid of surviving the suicide attempt and end up worse off. On some occasions, the help of a relative or friend might be sought, while, on others, help might be requested from doctors involved in caring for the dying person.

At the time of writing (2018), health professionals, relatives and other people who help a dying person to end their own life in the UK run a serious risk of being prosecuted, but it is up to the discretion of the courts when the case is judged. Under the UK’s Suicide Act 1961, anyone who ‘aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide’ commits an offence and may be sentenced to up to 14 years in prison. People assisting in suicide can also be charged with attempted murder under certain circumstances (Fox, McHale & Murphy, 1997). When assisted suicide is alleged, the evidence that is available about the beliefs and intentions of the alleged ‘assistant’ is crucially important and is often what determines the outcome.

The case of Eleanor Samra

To understand the implications of this, here is a fictitious example.

Eleanor Samra lives with her daughter, Judith. Eleanor is virtually bedridden because of leg injuries sustained during recent falls. She also has bowel cancer which, her doctors say, will cause her to die quite soon. Although well cared for, she is understandably very unhappy and has, on several occasions, said to Judith (and to her other carers) that she doesn’t see any point in carrying on living, that she ‘feels like a burden’ and wishes that they’d ‘end it for her’. One evening, Eleanor asks Judith to get a box for her from the back of the wardrobe. While getting it out, Judith drops the box. The lid falls off, revealing several bottles of pills. On closer inspection, these turn out to be sleeping pills, which Eleanor – it seems – has been hoarding for some considerable time. Judith’s initial response is to throw the pills away. But after a lengthy and painful discussion with her mother, she is persuaded to leave the box on the bedside table, so that Eleanor can reach the pills easily and take them whenever she feels ready. Later that evening Eleanor takes a large overdose of the pills and dies in her sleep. In theory, Judith has probably broken the law, because she knew that her mother was contemplating suicide, knew that the pills would help her to kill herself, and intended the pills to help her mother’s suicide attempt. Successfully prosecuting Judith, however, might prove difficult in practice because of a lack of evidence. When similar cases have been brought to court, they have not necessarily attracted long sentences and have challenged the definition of ‘mercy killing’.

Carers and family members can come under very intense emotional pressure as a result of the distress and physical pain that they witness. The legislation acts as a means of protection for carers of dying people and also protects dying people from involuntary euthanasia. Moreover, legislation acts to protect people who may not be able to protect themselves. John Keown notes that, internationally, the main obstacle to legalising assisted dying, even if considered morally acceptable in some cases, is that it may be difficult to control (Keown, 2002). This is sometimes called the slippery slope argument, suggesting that once a practice is started for some people, it may begin to be used for other people who it was originally not intended for. This is of particular concern where consent (e.g. involuntary euthanasia) is not required or where there is the risk that someone may be pressured into opting for assisted dying. In the next activity, you will consider the slippery slope argument and your perspective on assisted dying.

Activity 4 The slippery slope

Allow approximately 30 minutes

Part A

Look at Figure 9 below representing the slippery slope argument. Using the slider button, choose a location on that slope that you think is appropriate for policy to take. For example, you may believe assisted dying should not be allowed at all (far left) or that it should be allowed for someone who is disabled.

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Figure 9 The slippery slope argument

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After you have made your selection, note down why you have placed your marker on that position of the slope. To aid your reflection, consider the following questions:

What did you consider in making your decision?
Do you think you may ever change your mind? Why or why not?
What implications do you think your position has for how you view end-of-life care?

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Discussion

Someone who previously completed this task marked that they would allow assisted dying for terminally ill people, but no one else. Here is a section of their reflections:

I think if a person is dying anyway, like within the next year, they should have a say about how much suffering they endure before death. Even with good end-of-life care, people may not wish to have pain (either physical or emotional) and their life is limited anyway. I realise this decision impacts others (like their family) and is not one to be taken lightly. I previously believed no one should have the ability to end their life when they wanted to, but having spoken to people who want to be able to die earlier and why they feel this way, I can sympathise with this. However, I think there needs to be very clear and strict safeguards in place, which I realise can be difficult to do legally, to protect others from being ‘forced to die’. We all value life differently but I don’t think others should be able to end someone’s life without their permission.
I think my position makes me realise that even if end-of-life care is really good, it still might not be enough for some people. One solution does not fit all. But this doesn’t mean that people who want assisted dying should not have access to good end-of-life care. I am not sure if I think assisted dying should formally be part of end-of-life care or something that is alongside of it.

The response above is just an example of one perspective on assisted dying. People will have different opinions about what policy should be about assisted dying. This will be influenced by their own beliefs about life and death, about the ethics and values that they believe in, and their own personal experiences.

While people will have differing viewpoints, the role of policy is to find a position that can be applied for the whole population. The current stance about assisted dying policy in the UK is one that promotes the ethical principle of ‘do no harm’ over personal autonomy.

4 Considering ethics in death and dying

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

In the previous sections of this OpenLearn course, you have considered whether it is wrong or right to let someone die, and evaluated your own personal opinion about assisted dying. These are ethical questions because they evaluate to what extent an action, event, or opinion is appropriate, right, or good in a particular context. The issues of a ‘good death’ and assisted dying have ethical dimensions in that they are commenting on the appropriateness of a situation or event. Ethical issues around death and dying are often talked about in terms of decision-making and actions. In this section, you will be given an introduction in how to recognise and discuss ethical issues.

It is important to realise that ethics is not the same as the law or professional codes (i.e. ethical standards professionals are expected to work within), although ‘doing the right thing’ or ‘doing good’ is a common feature of all of these. Ethics is specifically about the moral reasoning applied to a situation. A useful way to begin to recognise ethical issues, is to look at examples where questions are raised about what should happen. One of the first steps in studying ethics is to understand your own ethical perspective, which this next activity enables you to do.

Figure 10 A word cloud with words often associated with ethics and morals.

Long description

Activity 5 Considering ethical viewpoints

Allow approximately 30 minutes.

Part A

Consider the following statements in Table 3. State whether you agree or disagree and then write in the table why you chose this answer. If you are undecided, why are you undecided?

Table 3 Viewpoints

Statement	Agree or disagree, and why?
Dying people should always be told the truth.	Table 3 Viewpoints 1
End-of-life care is a human right.	Table 3 Viewpoints 2
Health care professionals should determine when a person has died.	Table 3 Viewpoints 3
Everything possible should be done to keep people alive.	Table 3 Viewpoints 4
People who are bereaved should talk about their emotions.	Table 3 Viewpoints 5

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Part B

Choose two of the statements above. Write one argument supporting each statement and one argument disagreeing with each statement.

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Discussion

Here’s an example of what some students have written in response to their selection about the statement that end-of-life care is a human right:

One student who agreed wrote ‘Everyone has the right to care throughout their life, including at the end-of-life.’

Another student, who chose disagree wrote ‘end-of-life care focuses on particular cultural understandings of what health, death, and care are, which are not necessarily universally agreed upon by all people. Saying it should be a right privileges certain ways of dying over others, and this may not be appropriate for an individual or the society in which they live in.’

Another responder found it they often wrote ‘it depends’ but then struggled to say exactly what would make it clearer for them to answer. For example, they were not sure under what circumstances they thought a dying person should not be told the truth, but nevertheless did not agree with the statement that they should always be told. This shows us that there is more to ethical decision making than just saying ‘it depends on the situation’ – there are principles and frameworks people use to guide their decisions.

It is important to remember that ethics is inherently a ‘grey area’ – there is always an element of debate on what is right.

Peter Singer has written extensively about end-of-life ethics. He argues that ethics requires people to move beyond being self-interested and engage with a level of objectively, for example by using agreed ethical principles (Singer, 2011). In other words, he believes that ethical principles provide standards that guide actions that should be applicable to all similar situations. Whatever your perspective, you need to be able to justify your position by providing a logical, coherent, and consistent account.

In some ways, ethical decision-making in the context of death and dying is different from choices in other areas of health and social care, not least because time is limited. However, the context of ethical decision-making at the end-of-life has much in common with other care situations. For example, the question about whether someone should be told all information about their health condition is not only an issue that comes up at the end-of-life. Uncertainty is often a feature of health and social care situations, and it might not be clear why something has occurred or how long it will last. Not knowing what might happen in the near future can make decision difficult. Health and social care professionals are also obliged to follow their own professional ethical codes of conduct, and these might conflict with their personal views or the views of others. Furthermore, individuals and their family members might not agree about what constitutes the best course of action in a given circumstance. People may also change their minds as events unfold. It is not uncommon for families and professionals to disagree, for example, about how much a dying person should be told about their condition and likely remaining lifespan. These complications, which include competing ethical perspectives, uncertainty, and disagreement about the value of information or action, as well as the emotional pain that is often associated with death and dying, all complicate the task of making ethical decisions in this context. Consequently, what is considered ‘right’ can vary depending on the situation and is often debatable.

If this introduction to ethical decision making has sparked your interest, you may be interested in learning more through a video drama and accompanying quiz on the challenges of making ethical decisions on behalf of others. You will have the opportunity to watch a series of events unfold and be intermittently asked what decisions you would make in each situation. So what would you do? Access this interesting interactive quiz activity here.

In this brief introduction to ethics, you should now be able to identify and recognise what constitutes an ethical dilemma in death and dying and how there might be different perspectives on what is right and wrong. In the next and final section, we will move on how people demonstrate grief both privately and publicly.

5 Exploring grief

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

This final section is focused grief and bereavement – particularly the social context of bereavement and grieving behaviour (social norms). In this section, you will explore the public dimensions of grief (such as by examining the deaths of celebrities) and the way in which grief is portrayed in popular culture (such as in film and music).

Figure 11 Artwork depicting grief and remembrance.

Long description

5.1 Public and private grief and popular culture

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Figure 12 This Japanese Silk painting is from 1086 shows mourning and grief has a long history. In this painting, a demon and lion grieve at the death of Buddha.

Long description

There may be differences between how grief is portrayed in the public sphere (in front of others) compared to the private sphere which can be interpreted as expressing internal feelings, thoughts and behaviour behind closed doors (Howarth, 2007).

Figure 13 Students and teachers in Heverlee, Belgium pay their respects at the school gates during a national day of mourning on March 12, 2012 to remember the 28 individuals who died in a school bus crash carrying many 11-12 year-olds who were returning from a skiing trip.

Long description

Distinguishing between public and private grief is important since it is a way of understanding the way people express grief. This is the focus of the next activity.

Activity 6 Private and public expressions of grief

Allow approximately 50 minutes.

Spend some time filling out the table columns, one which is marked public expression and the other private expression of grief. Make notes in the columns about:

a.Moments when you have observed people grieving in public: who were they grieving for, and how were they expressing grief?
b.What are some of the ways people might grieve more privately?

Table 4 Public and private expressions of grief

Public expression of grief	Private expression of grief
Table 4 Public and private expressions of grief 1	Table 4 Public and private expressions of grief 2
Table 4 Public and private expressions of grief 3	Table 4 Public and private expressions of grief 4

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Discussion

An OU academic who did this activity completed the table as follows:

Table 4 Example answer

Public expression of grief	Private expression of grief
The Bataclan attack in Paris in 2015 saw people come together and hold vigils while they lit candles, left flowers and messages as they cried openly in response to the event.	Engaging in silent prayer or personal memorials to those who have died might be a private expression of grief.
The suicide bombing at the Ariana Grande concert in Manchester in 2017, which resulted in the deaths of 22 fans and over 100 injuries, led to a tribute concert in which several well-known singers gathered to raise funds for the victims of the event.	Memory or reflection on important personal occasions might constitute private grief.
Many people witnessed the tragic fire at Grenfell Tower in London in the same year (2017), which showed a community shocked, saddened and in despair as people responded with donations of clothing for those who had lost their homes in the tower.	Eulogising to close friends and family is a common private expression of grief.

Is it so simple to discern between the private and public domain of grief? You may have observed more private outpourings of grief with people you know who have been bereaved or know that a piece of music acts as a ‘trigger’ for them as it reminds them of the deceased. In work with bereaved parents, Dr Kerry Jones reported that several parents discussed a particular piece of music which reminds them of the deceased. Others have talked about certain films which remind them of their own journey through grief.

5.2 Grief in popular culture

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Accounts of grief can be found throughout popular culture and within film, television, books and so on. The film ‘Manchester by the Sea’, released in 2017, stars Casey Affleck as a janitor whose life is turned upside down following the death of his brother. ‘Truly, Madly, Deeply’, a film from 1991 starring Julia Stevenson and the late Alan Rickman, demonstrates the complexity of the main character’s struggle with being composed in public and yet, privately with her therapist, both sad and angry. Superhero films such as Batman and Harry Potter (which explore parental death) and Astroboy (which reflects on the death of a child) also have grief as central themes throughout their narrative. In music, grief permeates throughout the lyrics of Eric Clapton’s song, ‘Tears in Heaven’, following the death of his four-year-old son.

Figure 14 The 2003 film Mystic River starring Sean Penn focuses on the themes of experiencing loss, grief and anger.

Long description

Activity 7 Grief in music and film

Allow approximately 30 minutes.

Think about some music that has lyrics and a film that reflects some aspect of grief or were motivated by bereavement. Make notes in the response boxes about what you found most powerful about the film or piece of music you have identified. What were the words used that struck a chord for you. What was it about a particular scene in a film? What was happening and to who?

Table 5 Music and film

Music	Film
Table 5 Music and film 1	Table 5 Music and film 2

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Discussion

There are an infinite number of films and pieces of music to draw on which represent grief and bereavement. One OU academic wrote:

Table 5 Music and film example answer

Music	Film
I recalled that pieces of music from funerals represented the age at which the person died and in what circumstances. Those that were used to reminisce about a very young child, were based on the meaning of the child attached to parents and the lyrics reflected the deep sense of loss. I have attended funerals where the music represented what mattered to the deceased when their favourite piece of music was played. I have also noted however, where this was frowned upon in a formal church setting where music played through a machine was seen as ‘dumbing down’ the genre of music that was traditionally played in a church. This was not an issue in crematorium type funerals. This enabled me to reflect upon other types of norms that determine and can affect the way in which people are expected to remember loved ones and represent more individualised ways to commemorate the deceased in keeping with more recent commemorative practices.	I thought about the film Manchester by the Sea and how the film is focused on death and grief. It made me realise that films about grief usually involve some ending that makes the viewer feel like there has been some development or acceptance of loss and that they have been on a journey. Often, there is some resolution or acceptance at the end of the journey. However, in life, this feeling may evade us or may be fleeting and we may not feel that the journey has ever come to any resolution. We may oscillate between more painful and less painful experiences of grief rather than any constant ‘acceptance’ or resolution.

Music

Film

I recalled that pieces of music from funerals represented the age at which the person died and in what circumstances. Those that were used to reminisce about a very young child, were based on the meaning of the child attached to parents and the lyrics reflected the deep sense of loss. I have attended funerals where the music represented what mattered to the deceased when their favourite piece of music was played. I have also noted however, where this was frowned upon in a formal church setting where music played through a machine was seen as ‘dumbing down’ the genre of music that was traditionally played in a church. This was not an issue in crematorium type funerals. This enabled me to reflect upon other types of norms that determine and can affect the way in which people are expected to remember loved ones and represent more individualised ways to commemorate the deceased in keeping with more recent commemorative practices.

I thought about the film Manchester by the Sea and how the film is focused on death and grief. It made me realise that films about grief usually involve some ending that makes the viewer feel like there has been some development or acceptance of loss and that they have been on a journey. Often, there is some resolution or acceptance at the end of the journey. However, in life, this feeling may evade us or may be fleeting and we may not feel that the journey has ever come to any resolution. We may oscillate between more painful and less painful experiences of grief rather than any constant ‘acceptance’ or resolution.

The way in which grief is portrayed in song and in film is often expressed as isolating and sad experiences. The common theme is also one of eventual acceptance although not necessarily severing ties with the deceased. Songs may not account for uncertainties such as multiple losses. You may have felt that grief is romanticised in song and reflect contemporary responses to bereavement. This represents a social norm. It is also possible to identify grief through newspaper stories and magazine articles. While the issues of death and dying might be considered taboo in some cultures, references to grief and bereavement in public and private are relatively common. Perhaps social expressions of grief and bereavement are more socially acceptable than talk of death and dying more directly.

Conclusion

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Congratulations on reaching the end of this free course, An introduction to death, dying and grief. You started the course by looking at how there are different understandings of death and you considered how language shapes and conveys our ideas and beliefs about death. You then moved on to examining a ‘good death’ in the West and the aspects of the experience that are important for it to be a good death. In Section 3, you considered the debate around assisted dying and learned about the complexity of the debate by considering your own personal values as well as others. In Section 4, you were introduced to ethical dilemmas and the challenge of navigating what is ‘right’ and ‘wrong’ in a consistent way. In the final section, you learned about private and public expressions of grief and bereavement and how popular culture can affect and influence expressions of grief.

We hope that you enjoyed learning about this complex and interesting subject. This OpenLearn course is an adapted extract from the Open University course K220 Death, dying and bereavement.

If you have been affected by the topics raised in this course, you can call Macmillan Cancer Support free of charge on 0808 808 00 00. You can also call Samaritans free from any phone on 116 123 (it will not appear on your phone bill), email jo@samaritans.org, or visit www.samaritans.org to find details of your nearest branch. The Motor Neurone Disease Association also provides support to people affected by motor neurone disease in England, Wales and NI - 03457 626262 or visit The Motor Neurone Disease Association

References

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

Borgstrom, E. (2014). Planning for death? An ethnographic study of choice and English end-of-life care (doctoral thesis). Available at: https://doi.org/ 10.17863/ CAM.16252 (Accessed 30 March, 2018).

Chapple, A., Ziebland, S., McPherson, A. and Herxheimer, A. (2006) ‘What people close to death say about euthanasia and assisted suicide: a qualitative study’, Journal of Medical Ethics, vol 32, no. 12, pp. 706–710.

Cottrell, L., & Duggleby, W. (2016). The “good death”: An integrative literature review. Palliative & Supportive Care, vol. 14, no. 6, pp. 686–712.

ITV News. Coronation Street shows controversial right to die scene, 2014. Available at: http://www.itv.com/ news/ 2014-01-20/ coronation-street-controversial-assisted-suicide-scene-hayley-cropper/ (Accessed 05 April 2018).

ITV News. Hope remains despite Supreme Court rejection of right to die campaign. Available at: http://www.itv.com/ news/ calendar/ 2014-06-25/ hope-remains-despite-supreme-court-rejection-of-right-to-die-campaign/ (Accessed 05 April 2018).

Fox, M., McHale, J. and Murphy, J. (1997) Health Care Law, Text, Cases, and Materials, in Fox, M., McHale, J., and Murphy, J. (eds), London: Sweet and Maxwell.

Howarth, G., 2007. Death and dying: A Sociological Introduction. Cambridge: Polity Press.

Keown, J. (2002) Euthanasia, Ethics and Public Policy: An Argument Against Legalisation. Cambridge: Cambridge University Press.

Lawton, J. (2000) The Dying Process: Patients’ experiences of palliative care. London, Routledge.

Rodgers, M., Booth, A., Norman, G., & Sowden, A. (2016). Research priorities relating to the debate on assisted dying: what do we still need to know? Results of a modified Delphi technique. BMJ Open, 6(6), e012213.

Seale, C. and Addington-Hall, J. (1995) ‘Euthanasia: the role of good care.’, Social Science & Medicine vol. 40, no. 5, pp. 581–587.

Singer, P. (2011). Practical Ethics. Cambridge: Cambridge University Press.

Warnes, S. (2014) How many people choose assisted suicide where it is legal? The Guardian. Available at https://www.theguardian.com/ news/ datablog/ 2014/ jul/ 18/ how-many-people-choose-assisted-suicide-where-it-is-legal (Accessed 20 October 2017).

Acknowledgements

The Open University — Fri, 17 Aug 2018 13:16:53 GMT

This free course was written by Rajvinder Samra in collaboration with Liz Tilley, Erica Borgstrom and Kerry Jones.

Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 Licence.

Grateful acknowledgement is made to the following sources for permission to reproduce material in this free course:

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