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bureaucratic efficiency are typically found to be at odds (Sudnow 1967). A contrasting account of hospital rules governing disposition of the body in contemporary Ireland is even more sociological in its emphasis (Prior 1989). In another hospital study the ‘‘caring issue’’ has been seen as the main social problem. The selfhood of the dying person is found to be at risk since the hospital is essentially dedicated to efficiency (Kalish 1985b). However, studies suggest that an increasing proportion of deaths may now be occurring at home or under hospice care, which ‘‘mediates between the families and formal institutions that constitute the social organization of death and dying’’ (Marshall and Levy 1990; see also Bass 1985).

The Funeral. The funeral as a social institution has long been of sociological concern (cf.

Habenstein 1968). For example, a massive crosscultural study attests to its worldwide function in marking a major social transition (Habenstein and

Lamers 1963; Howarth 1996). Durkheim had emphasized its ceremonial role in facilitating social regrouping. Later sociologists have shown that elaborate and extravagant funeral rites may be more reflective of commercial interests than of human grief or mourning (Parsons and Lidz 1967).

The Bereaved Family. The now classic study

(Eliot 1932) of the economic consequences of death on the family stimulated a large literature that documents the general proposition that survi- vors—particularly significant others—require various types of social supports to ‘‘get through’’ the period of intense personal grief and the more publicly expressed mourning. In today’s societies, the time devoted to bereavement activities is generally shorter (Pratt 1981). This is consistent with Parsons’s (1963) position that in societies characterized by an ‘‘active’’ orientation, the bereaved are expected to carry out their grief work quickly and privately.

Social Stressors as ‘‘Causes’’ of Death. Sociologists and psychologists have investigated a range of individually experienced ‘‘social stressors’’ as causes of death, such as bereavement and retirement. The hypothesis that a bereaved spouse is at higher risk of death (the ‘‘broken heart’’ syndrome, or ‘‘death causes death’’) has been widely investigated but with no conclusive results. Similarly, retirees in some longitudinal studies have been

shown to experience excess mortality, whereas other investigations have reported opposite results. Retirement is a complex process, not a simple or single event, and the mortality impact of retirement is moot.

In an era in which nursing homes play an important role in the lives of many older people, the mortality consequences of relocation have come under critical scrutiny. Several studies have reported that the ‘‘warehousing’’ of the frail elderly results in increased mortality while in other studies feelings of security in the new ‘‘home’’ are shown to enhance a sense of well-being resulting in lower mortality. Similar caveats apply to macrolevel studies that attempt to relate such collectively experienced stressors as economic depressions, wars, and technological revolutions to trends in mortality. Advances in mathematical modelling and the increasing availability of large and relevant data sets make this problem an attractive area for continuing sociological research (see Riley 1983 for details and sources).

Self-Motivated Death. Durkheim’s studies of suicide spawned a wide, diverse, and sometimes confusing research literature. In most such studies social integration is the operative concept. If the theoretical relationship is believed to be unambiguous, the empirical relationship is far from tidy. The literature is vast and well beyond the reach of this review. Apart from suicide, it is a sociological truism that individuals are often socially motivated to influence the time of their own deaths. It has long been noted, for example, that both Thomas Jefferson and John Adams delayed their dying in order to participate in Independence Day celebrations. Several empirical studies have explored this so-called ‘‘anniversary effect’’ in which social events of significance are preceded by lower-than-expected mortality (Phillips and Feldman 1973). Such studies rest on Durkheim’s insight that if some people are so detached from society that they commit suicide, others may be so attached that they postpone their deaths in order to participate in social events of great significance (Phillips and Smith 1990). An example of the mortality impact of personal and local events is seen in studies of the ‘‘birthday dip.’’ One yearlong study, in a test area, coded all obituaries for birthdates. The results were striking. Fewer than 10 percent of the deaths occurred during the three months prior to the birth date, whereas nearly half

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were reported during the following three months.

Along similar lines, several sociological investigations have explored the proposition that some people die socially before they die biologically. These studies center on the notion of ‘‘levels of awareness’’ of death (Glaser and Strauss 1965).

When both the dying person and his or her significant others are cognizant of death as a soon-to-be- experienced event, the ensuing ‘‘open’’ awareness may enable them to negotiate various aspects of the final phase of life. Other research on ‘‘dying trajectories’’ involves certainties and uncertainties as to the time of death (Glaser and Strauss 1968).

‘‘The Right to Die.’’ As a final and critical example in this review of disparate empirical work, a basic and far-reaching question is being asked: Does the individual, in a society deeply committed to the preservation of life, have a ‘‘right’’ to die?

This has become one of the most profound, complex, and pressing issues of our time (Glick 1992). It involves the ‘‘rights’’ and wishes of the dying person, the ‘‘rights’’ and responsibilities of his or her survivors, the ‘‘rights’’ and obligations of attending physicians, and the ‘‘rights’’ and constraints of the law. The human side of such issues is producing a tidal wave of expressions of public interest in television documentaries, opinion surveys, editorials, pamphleteering, and radio talk shows. The issue of euthanasia is openly debated in leading medical journals, an unthinkable topic only a few years ago. Hospital rules, in which do not resuscitate (DNR) orders were written on blackboards then quickly erased, are being changed.

Certain aspects of the issue have reached the Supreme Court. A major book has proposed the rationing of medical resources (Callahan 1987).

Radical movements have sprung up that advocate active euthanasia and offer recipes for self-deliver- ance. Final Exit, the Hemlock Society’s handbook, was an instant best-seller (Humphry 1991). The costs of the last days of life have been dramatized, sometimes spoofed as a myth (Alliance for Aging Research 1996), and sometimes reported with great care (Congressional Research Service). Jack

Kevorkian, often referred to as ‘‘Dr. Death,’’ has become both hero and despised public enemy. In short, the problems and dilemmas inherent in the ‘‘management’’ of death have captured both popular and scientific attention (see various issues of the Hastings Center Reports). In both instances doctors and lawyers play ambiguous but critical

roles. It is, however, the ‘‘negotiation’’ that is of sociological interest. Norms designed to reduce the perplexities in wrenching decisions or to reassure the decision makers (including dying persons) are generally lacking (Wetle 1994). The need for relevant norms governing ‘‘the dying process’’ has been noted earlier (Riley and Riley 1986), and the main considerations have been specified (Logue 1989). The U. S. Office of Technology Assessment (1987) and the Hastings Center (1987) have issued medical and ethical guidelines, respectively, on the use of life-sustaining procedures. Many years ago sociologists developed research models for studying the social aspects of heroic operations and the treatment of nonsalvageable terminal patients (Fox and Swazey 1974; Crane 1975). Yet models necessary to the formation of norms capable of handling the ‘‘rights’’ and wishes of the various parties to the process of dying are still clearly needed. Furthermore, the conceptual problem of distinguishing between the two actors in the dying process, which the Minnesota Conference had emphasized, has not been resolved.

CURRENT ISSUES

With roots in these diverse studies, a set of three issue-laden topics cry out for more research and understanding: 1) dying individuals want a clearer voice in how their last days are to be treated; 2) policy questions are being raised that call attention to potential conflicts between the rights of individuals and the imperatives of society; and 3) programs and campaigns designed to reduce the difficulties of dying are demanding wide social action. These issues can be grouped under three shorthand labels: the living will; assisted suicide; and the quality of dying. While these issues are of great sociological interest, they are only now beginning to be framed in terms for sociological inquiry. The following discussions, consequently, rely largely on commission reports, conferences, public forums, social commentary in the media, brief reports in such journals as Omega, Issues in Law and Medicine, Journal of the American Geriatrics Society, Hospice Journal, and various unpublished materials.

The Living Will. As noted above, one of the most easily understood and practical developments in response to the dilemmas of dying in America is the ‘‘living will,’’ the so-called durable power of

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attorney, or some other form of advance directive.

These are quasi-legal instruments, signed by the patient, that instruct attending physicians (or surrogates) as to the patient’s preferred treatment at the end of life. Such directives are widely varied as to their specificity and the conditions of application, and it is currently impossible to know how many and what types of directives have been executed. There is, however, ample evidence that they are in widespread use. Simple do-it-yourself forms are available in stationery stores, and countless specialized directives have been developed to cover a wide variety of conditions and contingencies. But both the effectiveness and the ethics of such directives have become subject to wide debate: When and under what conditions is the withdrawal of food or fluids legally and medically permissible? When may guardians or surrogates act for incompetent patients? When does the constitutional right to privacy prevail? Under what conditions may the patient refuse treatment or take the initiative and disconnect respirators or tubes? When do oral directives, if ever, take precedence over written ones? The answers to such questions tend to be moot, although a broad legal doctrine has been promulgated that bears on the availability and use of advance directives. There must be ‘‘clear and convincing evidence’’ that the directive accurately reflects the patient’s precise intentions— or would in cases of incompetency. This legal dictum, however, has proved to be both burdensome and murky. The well-known Karen Anne Quinlan case is illustrative. This young woman

‘‘existed’’ in a persistent vegetative state for ten years while the legal process could determine whether Karen’s parents had met the ‘‘clear and convincing evidence’’ test (Karen’s parents had testified that they knew their daughter well enough to be certain that she would not wish to live in such circumstances). In another widely cited case, Nancy Cruzan ‘‘lived’’ in a similar state for seven years while the intricacies of the law were being debated. These and other such cases point to the need for more useful and practical evidentiary tests. The

Hastings Center published a special supplement titled ‘‘Advance Care Planning’’ in 1993.

In 1990, the Patient Self-Determination Act (PSDA) raised a set of new questions. The PSDA requires hospitals, nursing homes, and health providers to inform patients of their right to prepare a living will or some document of end-of-life

preferences. The significance of the PSDA was underscored by an occasionally distributed joint statement by the American Medical Association and the Harvard Medical School:

Modern medicine can keep one alive long after any reasonable prospect of mental, spiritual, or emotional life is gone. The only way for a person to retain autonomy in such a situation is to record his or her preferences for medical care before they are needed. (Published in The Harvard Health Letter and elsewhere.)

The force of the PSDA, however, has not been great and today it is generally believed that its lasting importance will be found in its power to enhance understanding of the still-developing and changing doctor-patient relationship. Indeed, the drama of that relationship has now been moved to a larger stage that involves both assisted suicide and the quality of dying.

Assisted Suicide. The role of law in cases where patients or their surrogates seek to control end-of-life decisions has always been debated. The early cases in the 1950s and 1960s had revolved around ‘‘informed consent.’’ This rule surfaced when medical treatments resulted in unanticipated negative consequences, and when it could be shown that the patient had not been informed of the risks. Not surprisingly, this rule led to more complicated ones and, during the 1970s, the increasing demand for patient control resulted in an implied ‘‘right’’ to die by refusing treatment. Of sociological interest, it was popular experience— not statutory law or court decisions—that was bringing about social change (see M. W. Riley 1978 for a theoretical statement). Nor was it long before demands for the ‘‘right’’ to receive treatments specifically designed to hasten death were seriously being discussed and in some states actually outlawed. As these events unfolded they have been reported by major news services, and analyzed by Hastings Center reports beginning in 1995.

In 1996 the U.S. Court of Appeals for the Ninth Circuit struck down a Washington state statute that had been passed specifically to deny such a right. The presiding judge included this noteworthy statement:

A competent, terminally ill adult, having lived nearly the full measure of his life, has a strong liberty interest in choosing a dignified and

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humane death rather than being reduced at the end of his existence to a childlike state of helplessness—diapered, sedated, incompetent.

The case was striking not only for its human interest but also because it invoked the guarantee of personal liberty in the Fourteenth Amendment to the U.S. Constitution. Shortly thereafter a New

York statute was struck down by the U.S. Court of

Appeals for the Second Circuit (Quill 1996), which had argued that if physicians were allowed to help people die it would put society on a slippery slope leading inevitably to abuse. The court pointed out, however, that physicians are not killers if they prescribe drugs to hasten death any more than they are killers when they discontinue life supports.

As expected, both cases were sent to the U.S. Supreme Court which has, at this writing, let stand state laws that prohibit any form of physicianassisted suicide. But the issue is far from settled. The Court’s decision concluded with this surprising statement by Chief Justice Rehnquist:

Throughout the nation, Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physicianassisted suicide. Our holding permits this debate to continue.

This statement was all the more remarkable since the chief justice, in his long opinion, rejected both the ‘‘liberty’’ and ‘‘due process’’ constitutional arguments, but came far short of putting the matter to rest. Indeed, continuing developments indicate that the question of physician-assisted suicide is not likely to go away soon. For example, the State of Oregon has passed two voter referenda, the most recent in 1998 with a 60 percent majority support which makes Oregon the only state (as of 1998) to permit, under strict conditions, physician-assisted suicide. The State of Michigan has rejected an Oregon-type statute and has finally convicted Dr. Kevorkian of second degree murder. Several other states are reported to be experimenting with alternatives that enhance the ‘‘right’’ of the individual to choose to die (for details of these developments see The Hastings Center reports). It may be that the law is overreaching its capacity to deal with such a basic and philosophical issue. The question is profound. Is there any logical (or sociological) difference between the right to refuse treatment designed to prolong

life and a parallel right to receive treatment designed to hasten death? Sociologists would ask: What is the distinction between the acceptance of death and its acceleration? Is the question so abstract that it defies empirical inquiry? Both the medical and legal answers to the issue are ambiguous and have been discussed in a book by a physician who publicly admitted helping a patient to die. Dr. Timothy Quill not only was the main plaintiff in the New York case, but he has become the leading medical voice on issues of assisted suicide. He writes with authority and sensitivity: ‘‘Death seems antithetical to modern medicine— no longer a natural and inevitable part of the life cycle, but a medical failure to be fought off, ignored, and minimized. The dark side of this desperate battle has patients spending their last days in the intensive care units of acute hospitals, tubes inserted into every body part, vainly trying to forestall death’s inevitability. No one wants to die, but if we have to, there must be a better way’’ (for an account of the issues see Quill 1996).

The Quality of Dying. Sociological concern with assisted suicide has been paralleled with concern for how people die. It had been hoped that the PSDA not only would make advance directives more effective, but would also bring about better communications between doctors and terminal patients. The act, however, was deemed a failure even before it was formally put in place. An impressive experiment, of great sociological interest, was designed to solve these basic issues. Funded and launched by the Robert Wood Johnson Foundation, it was the advance directive problem cast in research terms. The ‘‘Study to Understand Prognoses and Preferences in Risks of Treatment’’ carried such an unwieldy title that it was quickly shortened to the acronym SUPPORT (for a detailed account see The Hastings Center special supplement that carries the subtitle ‘‘The Lessons of SUPPORT’’ 1995). Five teaching hospitals were invited to participate in this multimillion dollar project. Phase One called for baseline data on the end-of-life experiences of some 9,000 dying patients. When the data were analyzed, the researchers were not surprised to find much to criticize in various regimens of hospital care. Their main

finding, however, was that doctors and attending nurses must attend not only to the physical comfort and pain management needs of patients but, more importantly, to their psychosocial needs.

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Phase Two, consequently, called for experimentation. The 9,000 cases were randomized and an experimental intervention consisting of a protocol designed to sensitize doctors to attend more closely to psychosocial needs was administered to onehalf of the cases and withheld from the other half, which had served as a control group. The experiment was continued for two years and expectations were high. Much to the chagrin of the study directors, when the two groups were compared, no differences were found! The experimental intervention showed no effects. This negative finding was so shocking that a number of evaluation panels were enlisted to reanalyze the data and scrutinize the research design. Their efforts, however, only served to corroborate the original analysis and Daniel Callahan (1995), then president of

The Hastings Center, concluded with this statement, ‘‘This painstaking scrutiny into how people die only goes to show how difficult it is to make the process any better. . . We thought that the care of dying patients could be set right by . . . some good talk between doctor and patient . . . we thought that we just needed reform . . . it is now obvious that we need a revolution’’ (Callahan 1995).

Callahan’s dramatic statement had the effect of nourishing a spate of organizations and proposals that had sprung up to improve the care of dying patients. For example ‘‘Project Death in America’’ (PDIA), centered at Sloan Kettering Hospital in New York was funded by the billionaire George

Soros; the ‘‘Center to Improve Care of the Dying’’ (CICD), based in the George Washington Medical

School and originally funded by the Retirement Research Foundation in 1995, enjoys wide institutional support and in 1997 launched a program for individual advocacy, ‘‘Americans for Better Care of the Dying’’ (ABCD); the American Board of Internal Medicine (ABIM) began publishing educational materials on techniques to improve care of the dying in 1996; and the American Medical Association (AMA) began alerting its members to the most recent developments in end-of-life care. And finally, the Robert Wood Johnson Foundation, which has long served as the collective voice for issues on dying, launched ‘‘Last Acts’’ in 1997, which is designed to involve the public through such participating organizations as the Institute of Medicine, the American Hospital Association, the Health Care Financing Administration, the National Hospice Organization, the Veterans Health

Administration, the American College of Physicians, and a host of specialized associations such as the American Pain Society, the American Cancer

Society, Choice in Dying, Partnership for Organ Donation, Memorial Societies of America, Wellness Councils of America, and on and on. Former First Lady Roslyn Carter, in a nationally broadcast speech, proclaimed that, ‘‘We need this coalition so that fewer people will die alone, in pain, and attached to machines, with the result that more people. . . can experience dying for what it ought to be. . . the last act in the journey of life.’’ The President of the Robert Wood Johnson Foundation was both optimistic and enthusiastic:

With all that is going on. . . we are seizing the moment, ‘‘Last Acts’’ will be much more than platitudes about a good death. . . it will undertake to improve care at the end of life. . .

If the campaign succeeds . . . we will find a significant decrease in the number of people dying in pain, an increase in referrals to hospice, more people dying at home outside the hospital, and fewer requests for physicianassisted suicide (1997).

If, however, the campaign does not live up to expectations, the foundation will work with the American Medical Association ‘‘on helping physicians to work with patients on advance care planning, and providing opportunities for physicians to increase their skills in palliative medicine and comfort care.’’ It is too early to estimate the longterm effects of this blizzard of efforts to improve the way people die, but it is not too early to predict that any improvements in the quality of dying based only on comfort care are likely to be short term. But change is in the air. Dying persons are pressing for more participation in when and how they die, and caregivers are coming under increasing criticism of the limitations of their caring regimens.

AN EVOLVING PERSPECTIVE

As indicated by this review of past research and current issues, the limitations of both legal and medical approaches to the problems of dying in contemporary society mean that the perspectives of sociology will be brought to bear. Perhaps future sociological attention will focus on the uniquely sociological principle that the dying process is not understandable in individual terms. This,

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in turn, provokes a series of predictions: Sociologists will focus on how dying persons are defined by their survivors and caregivers as well as on the sociological hypothesis that dying persons are more concerned for others than they are for themselves.

Sociologists will be required to disentangle the concatenation of forces that has produced today’s caregiving regimens in which terminal patients tend to be treated more as objects than as persons. Sociologists will be asked to explain how the process of socialization has seemingly been reversed, with the individual being figuratively stripped of years of social experience and defined as a nonperson. In effect, sociologists will be asked to explain the historical alchemy whereby dying persons themselves have been conned into believing that all they needed was palliation and comfort care.

REFERENCES

Alliance for Aging Research 1996 Uncovering the Facts about the Cost of the Last Year of Life. Washington, D.C.: AAR.

Baker, Paul M. 1990 ‘‘Socialization after Death: the Might of the Living Dead.’’ In Beth Hess and Elizabeth Markson, eds.,Growing Old in America. Rutgers: Trasaction Books.

Bass, David M. 1985 ‘‘The Hospice Ideology and Success of Hospice Care.’’ Research on Aging 7:1.

Blauner, Robert 1966 ‘‘Death and Social Structure.’’

Psychiatry 29:378–94.

Bowman, L. 1959 The American Funeral: A Study in Guilt, Extravagance, and Sublimity. Washington D.C.: Public Affairs Press.

Callahan, D. 1995 ‘‘Dying Well in the Hospital.’’ Hastings Center Report. Briarcliff Manor, N.Y.: Hastings Center.

——— 1987 Setting Limits; Medical Goals in an Aging Society. New York: Simon and Schuster.

Charmaz, K. C. 1980 Social Reality of Death. Reading, Mass.: Addison-Wesley.

Counts, D.A., and D.C. Counts 1985 Aging and Its Transformations: Moving Toward Death in Pacific Societies. Lanham, Md: University Press of America.

Crane, D. 1975 The Sanctity of Social Life: Physicians’ Treatment of Critically Ill Patients. New York: Russell Sage Foundation.

Eliot, T. 1932 ‘‘The Bereaved Family.’’ Special issue, The Annals160.

Fox, R.C., and T.P. Swazey 1981 ‘‘The Sting of Death in American Society.’’ Social Service Review. March:42–59.

——— 1980 ‘‘The Social Meaning of Death.’’ The Annals 447.

———1974 The Courage to Fail: A Social View of Organ Transplantation and Dialysis. Chicago: University of Chicago Press.

Fulton, R. 1994 ‘‘Society and the Imperative of Death.’’ In I. Corless et al., eds., Dying, Death and Bereavement. Boston: Jones and Bartlett.

——— 1965 Death and Identity. New York: John Wiley and Sons.

Fulton, R., and R. Bendiksen 1994 Death and Identity, 3rd ed. Philadelphia: The Charles Press.

Fulton, R., and G. Owen 1988 ‘‘Death and Society in Contemporary Society.’’ Omega 18(4).

Glaser, B.G., and A.L. Strauss 1965 Awareness of Dying. Chicago: Aldine.

——— 1968 Time for Dying. Chicago: Aldine.

Glick, H.R. 1992 The Right to Die: Policy Innovation and its Consequences. New York: Columbia University Press.

Habenstein, R.W. 1968 ‘‘The Social Organization of Death.’’The International Encyclopedia of the Social Sciences. New York: Macmillan and Free Press.

———, and M.W. Lamers 1963 Funeral Customs the World Over. Milwaukee: Bulfin.

Hastings Center 1987 Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying. Bloomington, Ind.: Indiana University Press.

Howarth, G. 1996 Last Rites: The Work of the Modern Funeral Director. Amityville N.Y.: Baywood Publishing Co.

Humphry, Derek 1991 Final Exit: the Practicalities of SelfDeliverance and Assisted Suicide. Eugene Oreg.: The Hemlock Society.

Kalish, R.A. 1985a Death, Grief and Caring Relationships. Monterey, Calif.: Brooks/Cole.

——— 1985b ‘‘The Social Context of Death and Dying.’’ In R.H. Binstock and E. Shanas, eds., Handbook of Aging and the Social Sciences. New York: Van Nostrand Reinhold Co.

Kearl, Michael C. 1989 Endings: A Sociology of Death and Dying. Oxford: Oxford University Press.

———, and A. Rinaldi 1983 ‘‘The Political Uses of the Dead as Symbols in Contemporary Civil Religions.’’

Social Forces61:3.

Kubler-Ross, E. 1969 On Death and Dying. New York:

Macmillan.

Lofland, L. 1978 The Craft of Dying: The Modern Face of Death. Beverly Hills, Calif.: Sage.

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Logue, B. 1989 Death Control and the Elderly: The Growing Acceptability of Euthanasia. Providence: Population Studies and Training Center, Brown University.

Mannheim, K. 1928, 1959 ‘‘The Problem of Generations.’’ In P. Keeskemeti, ed., Essays in Sociological Knowledge. London: Routledge and Kegan Paul.

Marshall, V.W. 1980 Last Chapters: A Sociology of Aging and Dying. Belmont Calif.: Wordsworth.

———, and J. A. Levy 1990 ‘‘Aging and Dying.’’ In R. H. Binstock and L. George, eds., Handbook of Aging and the Social Sciences, 3rd ed. San Diego: Academic Press.

Parsons, T. 1963 ‘‘Death in American Society: A Brief Working Paper.’’ American Behavioral Scientist.

———, and V. W. Lidz 1967 ‘‘Death in American Society.’’ In E.S. Shneidman, ed., Essays in Self Destruction. New York: Science House.

Phillips, D.P., and K.A. Feldman 1973 ‘‘A Dip in Deaths before Ceremonial Occasions: Some New Relationships between Integration and Mortality.’’ American Journal of Sociology 87.

———, and D.G. Smith 1990 ‘‘Postponement of Death Until Symbolically Meaningful Occasions.’’ Journal of the American Medical Association, vol. 203(14).

Pratt, L.V. 1981 ‘‘Business Temporal Norms and Bereavement Behavior.’’ American Sociological Review

4:317–333.

Prior, Lindsay 1989 The Social Organization of Death: Medical Discourses and Social Practices in Belfast. New York: St.Martin’s Press.

Quill, T.E. 1996 A Midwife through the Dying Process. Baltimore, Md.: The Johns Hopkins University Press.

Riley, J.W., Jr. 1983 ‘‘Dying and the Meanings of Death: Sociological Inquiries.’’ Annual Review of Sociology 9:191–216.

———1970 ‘‘What People Think about Death.’’ In O. G. Brim, Jr. et al., eds., The Dying Patient. New York: Russell Sage Foundation.

———1968 ‘‘Death and Bereavements.’’ In D.L. Sills, ed., International Encyclopedia of the Social Sciences. New York: Macmillan and Free Press.

Riley, M. W., and J.W. Riley, Jr. 1986 ‘‘Longevity and Social Structure: the Added Years.’’ Daedalus 115:51–75.

Sudnow, D. 1967 Passing On: The Social Organization of Dying. Englewood Cliffs, N.J.: Prentice-Hall.

U.S. Congress, Office of Technology Assessment 1987

Life-Sustaining Technologies and the Elderly. Washington D.C.: U.S. Government Printing Office.

Warner, W.L. 1959 The Living and the Dead. New Haven, Conn.: Yale University Press.

Wetle, T. 1994 ‘‘Individual Preferences and Advance Planning.’’Hastings Center Report. Briarcliff Manor, N.Y.: Hastings Center.

JOHN W. RILEY, JR.

DECISION-MAKING THEORY AND RESEARCH

Decision making must be considered in any explanation of individual behavior, because behaviors are based on decisions or judgments people have made. Thus, decision-making theory and research is of interest in many fields that examine behavior, including cognitive psychology (e.g., Busemeyer, Medin, and Hastie 1995), social psychology (e.g.,

Ajzen 1996), industrial and organizational psychology (e.g., Stevenson, Busemeyer, and Naylor 1990), economics (e.g., Lopes 1994), management (e.g., Shapira 1995), and philosophy (e.g., Manktelow and Over 1993), as well as sociology. This section will be an overview of decision-making theory and research. Several excellent sources of further information include: Baron (1994), Dawes (1997), Gilovich (1993), and Hammond (1998).

DECISION-MAKING THEORIES

Most decision-making theory has been developed in the twentieth century. The recency of this development is surprising considering that gambling has existed for millennia, so humans have a long history of making judgments of probabilistic events. Indeed, insurance, which is in effect a form of gambling (as it involves betting on the likelihood of an event happening, or, more often, not happening), was sold as early as the fifteenth and sixteenth centuries. Selling insurance prior to the development of probability theory, and in many early cases without any statistics for, or even frequencies of, the events being insured led to bankruptcy for many of the first insurance sellers (for more information about the history of probability and decision making see Hacking 1975, 1990; Gigerenzer et al. 1989).

Bayes’s Theorem. One of the earliest theories about probability was Bayes’s Theorem (1764/1958). This theorem was developed to relate the probability of one event to another; specifically, the

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probability of one event occurring given the probability of another event occurring. These events are sometimes called the cause and effect, or the hypothesis and the data. Using H and D (hypothesis and data) as the two events, Bayes’s Theorem is: P(H|D) = P(H)P(D|H)/P(D) [1] or P(H|D) = P(D|H)P(H)/[P(D|H)P(H)+P(D|−H)P(−H)] [2] That is, the probability of H given D has occurred is equal to [1] the probability of H occurring multiplied by the probability of D occurring given H has occurred divided by the probability of D occurring, or [2] the probability of D given H has occurred multiplied by the probability of H then divided by the probability of D given H has occurred multiplied by the probability of H plus the probability that D occurs given H has not occurred multiplied by the probability that H does not occur.

The cab problem (introduced in Kahneman and Tversky 1972) has been used in several studies as a measure of whether people’s judgments are consistent with Bayes’s Theorem. The problem is as follows: A cab was involved in a hit-and-run accident at night. Two cab companies, the Green and the Blue, operate in the city. You are given the following data: (a) 85 percent of the cabs in the city are Green and 15 percent are Blue. (b) a witness identified the cab as Blue. The court tested the reliability of the witness under the same circumstances that existed on the night of the accident and concluded that the witness correctly identified each one of the two colors 80 percent of the time and failed 20 percent of the time. What is the probability that the cab involved in the accident was Blue rather than Green? Using the provided information and formula [2] above, P(Blue Cab|Witness says ‘‘Blue’’) = P(Witness says ‘‘Blue’’|Blue Cab)P(Blue Cab)/[P(Witness says ‘‘Blue’’|Blue Cab)P(Blue Cab) + P(Witness says ‘‘Blue’’|Green Cab)P(Green Cab)] or P(Blue Cab|Witness says ‘‘Blue’’) = (.80)(.15)/[(.80)(.15)+(.20)(.85)] = (.12)/ [(.12)+(.17)] = .41

Thus, according to Bayes’s Theorem, the probability that the cab involved in the accident was Blue, given the witness testifying it was Blue, is 0.41. So, despite the witness’s testimony that the cab was Blue, it is more likely that the cab was Green (0.59 probability), because the probabilities for the base rates (85 percent of cabs are Green and 15 percent Blue) are more extreme than those for the witness’s accuracy (80 percent accuracy).

Generally, people will rate the likelihood that the cab was Blue to be much higher than .41, and often the response will be .80—the witness’s accuracy rate (Tversky and Kahneman 1982).

That finding has been used to argue that people often ignore base rate information (the proportions of each type of cab, in this case; Tversky and Kahneman 1982), which is irrational. However, other analyses of this situation are possible (cf. Birnbaum 1983; Gigerenzer and Hoffrage 1995), which suggest that people are not irrationally ignoring base rate information. The issue of rationality will be discussed further below.

Expected Utility (EU) Theory. Bayes’s Theorem is useful, but often we are faced with decisions to choose one of several alternatives that have uncertain outcomes. The best choice would be the one that maximizes the outcome, as measured by utility (i.e., how useful something is to a person). Utility is not equal to money (high-priced goods may be less useful than lower-priced goods), although money may be used as a substitute measure of utility. EU Theory (von Neumann and Morganstern 1947) states that people should maximize their EU when choosing among a set of alternatives, as in: EU = ([Ui * Pi]; where Ui is the utility for each alternative, i, and Pi is the probability associated with that alternative.

The earlier version of this theory (Expected Value Theory, or EV) used money to measure the worth of the alternatives, but utility recognizes people may use more than money to evaluate the alternatives. Regardless, in both EU and EV, the probabilities are regarded similarly, so people only need consider total EU/EV, not the probability involved in arriving at the total.

However, research suggests that people consider certain probabilities to be special, as their judgments involving these probabilities are often inconsistent with EU predictions. That is, people seem to consider events that have probabilities of 1.0 or 0.0 differently than events that are uncertain (probabilities other than 1.0 or 0.0). The special consideration given to certain probabilities is called the certainty effect (Kahneman and Tversky 1979). To illustrate this effect, which of these two options do you prefer? A. Winning $50 with probability .5 B. Winning $30 with probability .7 Now which of these next two options do you prefer? C. Winning

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$50 with probability .8 D. Winning $30 with probability 1.0

Perhaps you preferred A and D, which many people do. However, according to EU, those choices are inconsistent, because D does not have a higher EU than C (for D, EU = $30 = (1.0 * $30); for C, EU = $40 = (.8 * $50)). Recognize that A and B differ from C and D by a .3 increase in probability, and

EU prescribes selecting the option with the highest

EU. The certainty effect may also be seen in the following pair of options. E. Winning $1,000,000 with probability 1.0 F. Winning $2,000,000 with probability .5

According to EU, people should be indifferent between E and F, because they both have the same EU ($1,000,000 * 1.0 = $2,000,000 * .5).

However, people tend to prefer E to F. As the cliche goes, a bird in the hand is worth two in the bush. These results (choosing D and E) suggest that people are risk averse, because those are the certain options, and choosing them avoids risk or uncertainty. But risk aversion does not completely capture the issue. Consider this pair of options: G.

Losing $50 with probability .8 H. Losing $30 with probability 1.0

If people were risk averse, then most would choose H, which has no risk; $30 will be lost for sure. However, most people choose G, because they want to avoid a certain loss, even though it means risking a greater loss. In this case, people are risk seeking.

The tendency to treat certain probabilities differently from uncertain probabilities led to the development of decision-making theories that focused on explaining how people make choices, rather than how they should make choices.

Prospect Theory and Rank-Dependent Theories. Changing from EV to EU acknowledged that people do not simply assess the worth of alternatives on the basis of money. The certainty effect illustrates that people do not simply assess the likelihood of alternatives, so decision theories must take that into account. The first theory to do so was prospect theory (Kahneman and Tversky 1979).

Prospect theory proposes that people choose among prospects (alternatives) by assigning each prospect a subjective value and a decision weight (a value between 0.0 and 1.0), which may be functionally equal to monetary value and probability,

respectively, but need not be actually equal to them. The prospect with the highest value as calculated by multiplying the subjective value and the decision weight is chosen. Prospect theory assumes that losses have greater weight than gains, which explains why people tend to be risk seeking for losses but not for gains. Also, prospect theory assumes that people make judgments from a subjective reference point rather than an objective position of gaining or losing.

Prospect theory is similar to EU in that the decision weight is independent of the context.

However, recent decision theories suggest weights are created within the context of the available alternatives based on a ranking of the alternatives

(see Birnbaum, Coffey, Mellers, and Weiss 1992;

Luce and Fishburn 1991; Tversky and Kahneman

1992). The need for a rank-dependent mechanism within decision theories is generally accepted (Mellers, Schwartz, and Cooke 1998), but the specifics of the mechanism are still debated (see Birnbaum and McIntosh 1996).

Improper Linear Models. Distinguishing between alternatives based on some factor (e.g., value, importance, etc.) and weighting the alternatives based on those distinctions has been suggested as a method for decision making (Dawes 1979). The idea is to create a linear model for the decision situation. Linear models are statistically derived weighted averages of the relevant predictors. For example: L(lung cancer) = w1*age + w2*smoking + w3*family history, where L(lung cancer) is the likelihood of getting lung cancer, and wx is the weight for each factor. Any number of factors could be included in the model, although only factors that are relevant to the decision should be included. Optimally, the weights for each factor should be constructed from examining relevant data for the decision.

However, Dawes (1979) has demonstrated that linear models using equal weighting are almost as good as models with optimal weights, although they require less work, because no weight calculations need be made; factors that make the event more likely are weighted +1, and those that make it less likely are weighted −1.

Furthermore, linear models are often better than a person’s intuition, even when the person is an expert. Several studies of clinical judgment

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(including medical doctors and clinical psychologists) have found that linear models always do as well as, if not better than, the clinical experts (see Einhorn 1972). Similarly, bank loan officers asked to judge which businesses will go bankrupt within three years of opening was about 75 percent accurate, but a statistical model was 82 percent accurate (Libby 1976).

Arkes, Dawes, and Christensen (1986) demonstrated this point with people knowledgeable about baseball. Participants were asked to identify ‘‘which of. . . three players won the MVP [most valuable player] award for that year.’’ Each player’s season statistics were provided. One of the three players was from the World Series winning team, and subjects were told that 70 percent of the time the

MVP came from the World Series winning team, so if they were uncertain, they could use that decision rule.

Participants moderately knowledgeable of baseball did better than the participants highly knowledgeable, although the highly knowledgeable participants were more confident. The moderately knowledgeable group did better because they used the decision rule more. Yet, neither group did as well as they could have, if they had used the decision rule for every judgment. How a little knowledge can influence judgment will be further explained in the next section on how people make decisions.

DECISION PROCESSING

Decision theories changed because studies revealed that people often do not make judgments that are consistent with how the theories said they should be making judgments. This section will describe evidence about how people make judgments. Specifically, several heuristics will be discussed, which are short cuts that people may use to process information when making a judgment (Kahneman, Slovic, and Tversky 1982, is a classic collection of papers on this topic).

Availability. Consider the following questions: What is the first digit that comes to mind?, What is the first one-digit number that comes to mind?, and What is the first digit, such as one, that comes to mind? Kubovy (1977) found that the second statement, which mentions ‘‘1’’ in passing, resulted in more ‘‘1’’ responses than either of the other

two statements. The explanation is that mentioning ‘‘1’’ made it more available in memory. People are using availability, when they make a judgment on the basis of what first comes to mind.

Interestingly, the third statement, which mentions ‘‘1’’ in an explicit manner, resulted in fewer ‘‘1’’ responses than the first statement, which does not mention ‘‘1’’ at all. Kubovy suggests there are fewer ‘‘1’’ responses, because people have an explanation of why they are thinking of ‘‘1’’ following that statement (it mentions ‘‘1’’), so they do not choose it, because ‘‘1’’ has not been thought of at random. Thus, information must not only be available, but it must be perceived as relevant also.

Mood. Information that is available and may seem relevant to a judgment is a person’s present mood (for a review of mood and judgment research see Clore, Schwarz, and Conway 1994). Schwarz and Clore (1983) suggest that people will use their mood state in the judgment process, if it seems relevant to that judgment. They contacted people by phone on cloudy or sunny days, and predicted that people would be happier on the sunny days than on the cloudy days. That prediction was verified. However, if people were first asked what the weather was like, then there was no difference in people’s happiness on sunny and cloudy days. Schwarz and Clore suggested that asking people about the weather gave them a reason for their mood, so they did not use their mood in making the happiness judgment, because it did not seem relevant. Thus, according to Schwarz and Clore, people will use their mood as a heuristic for judgment, when the situation elicits actions from people as if they ask themselves, how do I feel about this?

Quantity and Numerosity. An effect that is also similar to availability was demonstrated in a series of experiments by Josephs, Giesler, and Silvera (1994). They found that subjects relied on observable quantity information when making personal performance judgments. They called this effect the quantity principle, because people seemed to use the size or quantity of material available to make their judgment. The experimenters had participants proofread text that was either attached to the source from which it came (e.g., a book or journal) or not, which was an unfamiliar task for the participants. They found that performance

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