Legalizing assisted suicide--views of physicians in Oregon

Should Palliative Care Teams be Involved in Medical Assisted Dying?

Palliative care teams offer holistic care for patients experiencing serious illness and related suffering, nevertheless, there are times when clinicians are asked by patients for help to obtain assisted dying. Patients in a growing number of areas may be eligible to request medically administered or self-administered lethal medications to control the timing of death and palliative care practices, established to neither hasten nor postpone death, may be challenged when caring for patients asking for assisted dying. In this "Controversies in Palliative Care" article, we invite three experts to provide a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. These experts suggest palliative care teams should be and are involved in medical assisted dying, but how palliative care teams are involved may depend on type of assisted dying requested, team members' scope of practice, legal regulations, and institutional guidelines. Research is needed on many aspects of assisted dying and palliative care including improving evidence-based clinical guidelines, addressing the needs of families, and coping strategies for all involved. An international study comparing assisted dying practices within, and outside palliative care may inform policy helping to clarify whether the integration of palliative care in assisted dying improves end-of-life care. In addition to research, it is recommended that researchers and clinicians collaborate on the development of a clinical textbook on assisted dying and palliative care to support all palliative care team members, offering guidelines and recommendations for practice.

Physicians' Attitudes and Experiences with Medical Aid in Dying in Colorado: a "Hidden Population" Survey

BACKGROUND

Approximately 20% of the US population live in states where MAiD is a legal, though highly contentious, practice. Little generalizable data exists on the experiences of MAiD providers who comprise a small, and intentionally hidden, population.

OBJECTIVE

To examine the nature, extent, and consequences of physicians' participation in MAiD.

DESIGN

An anonymous, multi-wave, mailed survey (RR= 55%).

PARTICIPANTS

An enriched sample (n=583) of Colorado physicians caring for potential MAiD patients.

MAIN MEASURES

Physician willingness, preparedness, and participation in a continuum of MAiD activities. Other outcomes include the effects of providing MAiD and the barriers physicians face related to MAiD.

KEY RESULTS

Overall, 81.1% of respondents were willing to discuss MAiD with a patient, 88.3% to refer for MAiD, 46.3% to be a consultant, and 28.1% to be an attending. Fewer felt prepared to discuss MAiD (54.4%), provide a MAiD referral (62.8%), be a consultant (30.7%), or be an attending (18.0%). More than half of respondents (52.3%) had discussed MAiD with a patient, 27.3% provided a MAiD referral, 12.8% had been a MAiD consultant, and 8.5% had been a MAiD attending. Among MAiD consultants and attendings, 75% reported that their most recent MAiD case was emotionally fulfilling and professionally rewarding, though 75% also reported that it was time consuming and 46.9% reported that it was ethically challenging. Common barriers to physician participation in MAiD include lack of knowledge about MAiD (46.8%), the emotional (45.6%) and time (41.7%) investments, and ethical concerns (41.7%).

CONCLUSIONS

Many physicians in our sample are both willing and prepared to discuss MAiD with patients and to provide MAiD referrals. Fewer are prepared and willing to serve as an attending or consultant and fewer have provided these services. MAID consultants and attendings largely report the experience to be emotionally fulfilling and professionally rewarding, but all respondents reported multiple barriers to participation.

End-of-life decision making by Austrian physicians - a cross-sectional study

BACKGROUND

Austria has recently been embroiled in the complex debate on the legalization of measures to end life prematurely. Empirical data on end-of-life decisions made by Austrian physicians barely exists. This study is the first in Austria aimed at finding out how physicians generally approach and make end-of-life therapy decisions.

METHODS

The European end-of-life decisions (EURELD) questionnaire, translated and adapted by Schildmann et al., was used to conduct this cross-sectional postal survey. Questions on palliative care training, legal issues, and use of and satisfaction with palliative care were added. All Austrian specialists in hematology and oncology, a representative sample of doctors specialized in internal medicine, and a sample of general practitioners, were invited to participate in this anonymous postal survey.

RESULTS

Five hundred forty-eight questionnaires (response rate: 10.4%) were evaluated. 88.3% of participants had treated a patient who had died in the previous 12 months. 23% of respondents had an additional qualification in palliative medicine. The cause of death in 53.1% of patients was cancer, and 44.8% died at home. In 86.3% of cases, pain relief and / or symptom relief had been intensified. Further treatment had been withheld by 60.0%, and an existing treatment discontinued by 49.1% of respondents. In 5 cases, the respondents had prescribed, provided or administered a drug which had resulted in death. 51.3% of physicians said they would never carry out physician-assisted suicide (PAS), while 30.3% could imagine doing so under certain conditions. 38.5% of respondents supported the current prohibition of PAS, 23.9% opposed it, and 33.2% were undecided. 52.4% of physicians felt the legal situation with respect to measures to end life prematurely was ambiguous. An additional qualification in palliative medicine had no influence on measures taken, or attitudes towards PAS.

CONCLUSIONS

The majority of doctors perform symptom control in terminally ill patients. PAS is frequently requested but rarely carried out. Attending physicians felt the legal situation was ambiguous. Physicians should therefore receive training in current legislation relating to end-of-life choices and medical decisions. The data collected in this survey will help political decision-makers provide the necessary legal framework for end-of-life medical care.

Hospital and Health System Policies Concerning the California End of Life Option Act

Background: The End of Life Option Act (EOLOA) legalized physician aid in dying for competent, terminally ill Californians in 2016. The law allows clinicians, hospitals, and health systems to decide whether to participate. About 4 in 10 California hospitals permit the EOLOA, but little is known about their approaches and concerns. Objective: Describe hospital EOLOA policies and challenges. Design and Measurements: Survey study of hospitals in California, administered September 2017 to March 2018. We describe hospital policies concerning the EOLOA and perform thematic analysis of open-ended questions about challenges, including availability of providers, process of implementing EOLOA, experiences of distress by providers and patients, and questions about medications. Results: Of 315 hospitals surveyed, 270 (86%) responded. Every surveyed hospital had established a position on the EOLOA. Among hospitals permitting EOLOA, 38% required safeguards not required in the law, 87% provided for referral to another provider if the patient's physician did not participate, and 65% counseled staff, if needed. Among hospitals not permitting the EOLOA, nearly all allowed providers to follow patients choosing to pursue the EOLOA elsewhere and most permitted a provider to refer to another provider or system. Most hospitals expressed concerns about implementation of the EOLOA and interest in sharing promising practices. Conclusions: This survey of California hospitals demonstrates considerable heterogeneity in implementing the EOLOA. For many Californians, access to the EOLOA depends on where one receives medical care. Implementation would be improved by hospitals and health systems sharing promising practices.

Perceptions and intentions toward medical assistance in dying among Canadian medical students

Background

Medical assistance in dying (MAID) was legalized in Canada in 2016. As of July 2017, approximately 2149 patients have accessed MAID. There remains no national-level data on the perspectives of future physicians about MAID or its changing legal status. We provide evidence from a national survey of Canadian medical students about their opinions, intentions, and concerns about MAID.

Methods

From October 2016 to July 2017, we distributed an anonymous online survey to all students at 15 of Canada’s 17 medical schools. The survey collected data on respondent socio-demographic characteristics, features of their medical education, intentions for medical practice, and perspectives on MAID. We analyzed responses using univariate descriptive and stepwise multivariate logistic regression.

Results

In 1210 completed surveys, 71% of respondents reported being willing to provide MAID under a legal framework that permits it. Non-religious respondents reported greater willingness to participate in MAID than respondents of any religious affiliation (p < 0.001). Frequency of religious attendance was inversely associated with willingness to provide MAID (p < 0.001). Medical students born in Québec were more willing to provide MAID than respondents from other provinces (OR 2.21; p < 0.001). Age, sex, socioeconomic status, year of medical study, previous academic major, and rural/urban city of birth were not associated with willingness to provide MAID.

Conclusion

As the current class of medical students becomes the first cohort of new physicians to enter Canada’s changing medical and legal landscape around MAID, our findings inform the public debate by examining attributes associated with support or opposition to the practice.

Electronic supplementary material

The online version of this article (10.1186/s12910-019-0356-z) contains supplementary material, which is available to authorized users.

This moral coil: a cross-sectional survey of Canadian medical student attitudes toward medical assistance in dying

BACKGROUND

In February, 2015, the Supreme Court of Canada struck down the ban on medical assistance in dying (MAiD). In June, 2016, the federal government passed Bill C-14, permitting MAiD. Current medical students will be the first physician cohort to enter a system permissive of MAiD, and may help to ensure equitable access to care. This study assessed medical student views on MAiD, factors influencing these views, and opportunities for medical education.

METHODS

An exploratory cross-sectional survey was developed and distributed to medical students across all years of a three-year Canadian undergraduate medical program. The investigators administered the survey to participants during academic sessions from November to December, 2015. Analysis of the results included summary descriptive statistics, Pearson's chi-square test of independence to identify differences between participants by year of study, logistic regression to identify factors that influence students' stances on MAiD, and Wilcoxon signed rank test to measure changes in student support for MAiD and comfort discussing MAiD.

RESULTS

There were 405 participants for a response rate of 87%. The majority of students (88%) supported the Supreme Court's decision, 61% would provide the means for a patient to end their life, and 38% would personally administer a lethal medication. Students who were more willing to provide the means for MAiD found medical education/clinical experience and patient autonomy to be important contributors to their stances on MAiD. Those students who were less willing to provide the means for MAiD found religious/spiritual beliefs and teachings, as well as concern about potential negative consequences, to be important contributors to their stances on MAiD. Educational training desired by participants included medicolegal (91%), communication skills (80%), technical skills (75%), and religious (49%).

CONCLUSIONS

Medical students generally supported and would provide the means for MAiD to patients. They also indicated a desire for directed medical education on MAiD.

Attitudes Toward and Desire for Assisted Suicide among Persons with Amyotrophic Lateral Sclerosis

This study aimed at investigating attitudes toward assisted suicide among individuals with amyotrophic lateral sclerosis, and the differences in health status (illness severity and functional disability) and psychosocial adjustment (depression, perceived stress, social support, and coping) between those in favor of and those against assisted suicide. This study also aimed at describing the characteristics of terminally-ill individuals who acknowledge contemplating assisted suicide. Forty-four individuals diagnosed with amyotrophic lateral sclerosis were surveyed about their attitudes and the circumstances that would make them contemplate assisted suicide and filled out standardized measures of mood, stress, social support, coping, and illness status. Seventy percent of the sample found assisted suicide morally acceptable and 60% thought it should be legalized. In addition, 60% of patients agreed they could foresee circumstances that would make them contemplate assisted suicide, but only three (7%) indicated they would have requested it already if it had been legal. Willingness to contemplate assisted suicide was associated with reports of elevated levels of depressive symptoms and reports of hopelessness. Results highlight the need to assess psychological status carefully when terminally ill individuals begin contemplating assisted suicide or voice a request for it.

Attitudes, Sociodemographic Characteristics, and Actual End-of-Life Decisions of Physicians in Flanders, Belgium

Aim. To study the effect of sociodemographic and attitudinal determinants of physicians making end-of-life decisions (ELDs). Methods. The physicians having signed 489 consecutive death certificates in the city of Hasselt (Belgium) were sent an anonymous questionnaire regarding their ELDs and another on their attitudes toward voluntary euthanasia (EUTH) and physician-assisted suicide (PAS).Results.55% response rate. Nontreatment decisions occurred in 16.7% of all death cases; in 16%, there was potentially life-shortening use of drugs to alleviate pain and symptoms; in 4.8% of cases,death was deliberately induced by lethal drugs, including EUTH, PAS, and life termination without explicit request by the patient. In their attitudes toward EUTH and PAS, the 92 responding physicians clustered into 3 groups: positive and rule oriented, positive rule-adverse, and opposed. Cluster groupmembership, commitment to life stance, years of professional experience, and gender were each associated with specific ELD-making patterns.

The impact of the Rasouli decision: a Survey of Canadian intensivists

INTRODUCTION

In a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker (SDM) consent. How intensive care unit (ICU) physicians perceive this ruling is unknown.

OBJECTIVES

To determine physician knowledge of and attitudes towards the SCC decision, as well as the self-reported changes in practice attributed to the decision.

METHODS

We surveyed intensivists at university hospitals across Canada. We used a knowledge test and Likert-scale questions to measure respondent knowledge of and attitudes towards the ruling. We used vignettes to assess decision making in cases of intractable physician-SDM conflict over the management of patients with very poor prognoses. We compared management choices pre-SCC decision versus post-SCC decision versus the subjective, respondent-defined most appropriate choice. Responses were compared across predefined subgroups. We performed qualitative analysis on free-text responses.

RESULTS

We received 82 responses (response rate=42%). Respondents reported providing high levels of self-defined inappropriate treatment. Although most respondents reported no change in practice, there was a significant overall shift towards higher intensity and less subjectively appropriate management after the SCC decision. Attitudes to the SCC decision and approaches to disputes over end-of-life (EoL) care in the ICU were highly variable. There were no significant differences among predefined subgroups.

CONCLUSIONS

Many Canadian ICU physicians report providing a higher intensity of treatment, and less subjectively appropriate treatment, in situations of dispute over EoL care after the Supreme Court of Canada's ruling in Cuthbertson versus Rasouli.

The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland

OBJECTIVE

Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide.

METHOD

Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective.

RESULTS

The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p = 0.0577) and short-term prognosis with physical suffering (p = 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation.

SIGNIFICANCE OF RESULTS

The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.

Judging the quality of mercy: drawing a line between palliation and euthanasia

Clinicians frequently worry that medications used to treat pain and suffering at the end of life might also hasten death. Intentionally hastening death, or euthanasia, is neither legal nor ethically appropriate in children. In this article, we explore some of the historical and legal background regarding appropriate end-of-life care and outline what distinguishes it from euthanasia. Good principles include clarity of goals and assessments, titration of medications to effect, and open communication. When used appropriately, medications to treat symptoms should rarely hasten death significantly. Medications and interventions that are not justifiable are also discussed, as are the implications of palliative sedation and withholding fluids or nutrition. It is imperative that clinicians know how to justify and use such medications to adequately treat suffering at the end of life within a relevant clinical and legal framework.

Prevalence of formal accusations of murder and euthanasia against physicians

BACKGROUND

Little is known about how often physicians are formally accused of hastening patient deaths while practicing palliative care.

METHODS

We conducted an Internet-based survey on a random 50% sample of physician-members of a national hospice and palliative medicine society.

RESULTS

The final sample consisted of 663 physicians (response rate 53%). Over half of the respondents had had at least one experience in the last 5 years in which a patient's family, another physician, or another health care professional had characterized palliative treatments as being euthanasia, murder, or killing. One in four stated that at least one friend or family member, or a patient had similarly characterized their treatments. Respondents rated palliative sedation and stopping artificial hydration/nutrition as treatments most likely to be misconstrued as euthanasia. Overall, 25 physicians (4%) had been formally investigated for hastening a patient's death when that had not been their intention-13 while using opiates for symptom relief and six for using medications while discontinuing mechanical ventilation. In eight (32%) cases, another member of the health care team had initiated the charges. At the time of the survey, none had been found guilty, but they reported experiencing substantial anger and worry.

CONCLUSIONS

Commonly used palliative care practices continue to be misconstrued as euthanasia or murder, despite this not being the intention of the treating physician. Further efforts are needed to explain to the health care community and the public that treatments often used to relieve patient suffering at the end of life are ethical and legal.

Euthanasia: An Indian perspective

In our society, the palliative care and quality of life issues in patients with terminal illnesses like advanced cancer and AIDS have become an important concern for clinicians. Parallel to this concern has arisen another controversial issue-euthanasia or "mercy -killing" of terminally ill patients. Proponents of physician-assisted suicide (PAS) feel that an individual's right to autonomy automatically entitles him to choose a painless death. The opponents feel that a physician's role in the death of an individual violates the central tenet of the medical profession. Moreover, undiagnosed depression and possibility of social 'coercion' in people asking for euthanasia put a further question mark on the ethical principles underlying such an act. These concerns have led to strict guidelines for implementing PAS. Assessment of the mental state of the person consenting to PAS becomes mandatory and here, the role of the psychiatrist becomes pivotal. Although considered illegal in our country, PAS has several advocates in the form of voluntary organizations like "death with dignity" foundation. This has got a fillip in the recent Honourable Supreme Court Judgment in the Aruna Shaunbag case. What remains to be seen is how long it takes before this sensitive issue rattles the Indian legislature.

Concerns about end-of-life care and support for euthanasia

Popular support for euthanasia is known to vary according to sociodemographic characteristics. However, little is known about whether support is associated with concerns regarding the emotional, physical, and economic burdens of end-of-life care. This study used data from the 1998 General Social Survey, a national survey of community-dwelling adults. The outcome variable assessed the respondents' support for a doctor's right to end life in the setting of terminal illness. Independent variables assessed the following concerns: 1) concern about the emotional burden of end-of-life decision making for family members; 2) worry about the economic burden of terminal illness; 3) concern about pain at the end of life; 4) worry that lack of money or insurance will result in second-class end-of-life care; and 5) belief that their religious community will be helpful at the end of life. Multivariable logistic regression estimated the independent effect of these concerns on support for euthanasia, adjusting for sociodemographic characteristics. Of 786 respondents, 70.6% approved of euthanasia in the setting of terminal illness. In adjusted analyses, respondents with concerns about the emotional toll of decision making on family members, economic burden, and poor health care because of lack of insurance were significantly more likely to support euthanasia. Respondents with faith in the helpfulness of their religious community were less likely to support euthanasia. In conclusion, emotional and economic concerns about end-of-life care were associated with support for the right to euthanasia. Future work can evaluate whether alleviating these concerns may reduce the perceived desire for euthanasia by patients near the end of life.

Attitudes toward assisted death amongst Portuguese oncologists

BACKGROUND

The attitudes and practise of doctors concerning euthanasia and assisted suicide have been the subject of studies performed in many countries. However, these issues have not been studied properly in Portugal.

MATERIALS AND METHOD

This study is a survey of 450 Portuguese oncologists by postal means and personal contact.

RESULTS

The response rate was 33% (143). Only 13% would practise euthanasia with the present law in force forbidding such practise, and 24% would do so if it were legalised; 39% favoured its legalisation and 36% would like to have the option of euthanasia if they had a terminal disease. About assisted suicide, 15% would do it with the current law in force forbidding such action and 25% would do so if it were made legal; 32% favoured its legalisation and 24% would like to have that option if they had a terminal disease. There was one case of euthanasia and no cases of assisted suicide. The most important factor related with the acceptance of euthanasia and assisted suicide was religion, with non-practising Catholics accepting such practises more often than practising Catholics. The Portuguese oncologists have a very positive view on the potential role of palliative care in preventing many requests for euthanasia and assisted suicide.

CONCLUSION

Portuguese oncologists are mainly against the practise of euthanasia and assisted suicide and the number of requests is also relatively low; consequently, the number of episodes of assisted death is also apparently very low.

Physician-assisted suicide: a survey of attitudes among Swedish physicians

AIMS

To investigate the attitudes of Swedish physicians towards physician-assisted suicide.

DESIGN

A postal questionnaire on the respondent's opinion of physician-assisted suicide was sent to a randomly selected sample of physicians in Sweden. The respondents were given the opportunity of furnishing arguments of their own and of prioritizing arguments. They were also asked about possible influence on their own and patients' trust in the healthcare system if physician-assisted suicide was to be legally accepted.

PARTICIPANTS

1,200 physicians from six specialties, approximately 200 individuals each in: general practice, geriatrics, internal medicine, oncology, psychiatry and surgery.

SETTING

The study was commissioned by the Swedish Medical Society and its logo was printed on questionnaires and envelopes.

RESULTS

The total response rate was 74%, ranging between 63%-80% among the specialties. On average 34% were pro physician-assisted suicide, 39% against it and 25% were doubtful; 2% per cent did not respond to the question at all. Psychiatrists were significantly more accepting than oncologists, who were the most restrictive specialty. Older physicians (>50 years) provided a significantly more accepting attitude than younger ones (<or=51 years).

CONCLUSIONS

Despite the fact that the World Medical Association condemns physician-assisted suicide as unethical, the present survey indicates that there is no clear majority for or against physician-assisted suicide among Swedish physicians, and that significantly more elderly physicians have an accepting attitude towards physician-assisted suicide. There is a need for further research explaining the differences between the age groups as well as the variation between specialities.

Opinions concerning euthanasia, life-sustaining treatment and acceleration of death: results of an Italian Association of Medical Oncology (AIOM) survey

BACKGROUND

Advance directives, acceleration of death, euthanasia and 'life-sustaining treatment' have sparked much heated debate among the media, the public, doctors and political leaders. We evaluate the personal opinions of Italian Association of Medical Oncology (AIOM) members.

PATIENTS AND METHODS

A 30-item questionnaire was developed and delivered to all 1,832 AIOM members.

RESULTS

Six-hundred and eighty-five (37%) oncologists completed and returned the questionnaires. Sixty-three per cent felt culturally and psychologically prepared to face these issues. Fifty-four per cent believed that what had been decided while the patient enjoyed good health is no longer applicable in an advanced state of terminal illness. Thirty-nine per cent believed that doctors should abide by these directives, while 49% believed that this should be discussed on a case-by-case basis. Fourteen per cent of oncologists were favourable towards euthanasia and 42% only in particular circumstances. Fifty-six per cent had received at least one request for accelerating death: 15% consented, 50% discussed it with the patient and 31% refused.

CONCLUSION

Advance directives, euthanasia, accelerated death and life-sustaining treatment represent considerable challenges for Italian oncologists. Although prepared to face these issues, AIOM members ask for a debate within the medical world and for a shared judicial regulation.

To die, to sleep: US physicians' religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support

This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians' religious characteristics, ethnicity, and experience caring for dying patients.

Religious characteristics of U.S. physicians: a national survey

BACKGROUND

Patients' religious commitments and religious communities are known to influence their experiences of illness and their medical decisions. Physicians are also dynamic partners in the doctor-patient relationship, yet little is known about the religious characteristics of physicians or how physicians' religious commitments shape the clinical encounter.

OBJECTIVE

To provide a baseline description of physicians' religious characteristics, and to compare physicians' characteristics with those of the general U.S. population.

DESIGN/PARTICIPANTS

Mailed survey of a stratified random sample of 2,000 practicing U.S. physicians. Comparable U.S. population data are derived from the 1998 General Social Survey.

MEASUREMENTS/RESULTS

The response rate was 63%. Fifty-five percent of physicians say their religious beliefs influence their practice of medicine. Compared with the general population, physicians are more likely to be affiliated with religions that are underrepresented in the United States, less likely to say they try to carry their religious beliefs over into all other dealings in life (58% vs 73%), twice as likely to consider themselves spiritual but not religious (20% vs 9%), and twice as likely to cope with major problems in life without relying on God (61% vs 29%).

CONCLUSIONS

Physicians' religious characteristics are diverse and they differ in many ways from those of the general population. Researchers, medical educators, and policy makers should further examine the ways in which physicians' religious commitments shape their clinical engagements.

Physicians’ attitudes towards end-of-life decisions: a comparison between seven countries

In the context of an European collaborative research project (EURELD), a study on attitudes towards medical end-of-life decisions was conducted among physicians in Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland. Australia also joined the consortium. A written questionnaire with structured questions was sent to practising physicians from specialties frequently involved in the care of dying patients. 10,139 questionnaires were studied. Response rate was equal to or larger than 50% in all countries except Italy (39%). Apart from general agreement with respect to the alleviation of pain and symptoms with possible life-shortening effect, there was large variation in support--between and within countries--for medical decision that may result in the hastening of death. A principal component factor analysis found that 58% of the variance of the responses is explained by four factors. 'Country' explained the largest part of the variation of the standardized factor scores.

Medical house officers' attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide

In 2000, the authors surveyed 236 medical house officers in three internal medicine residency programs in Connecticut to assess attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide. The goal was to identify associations between these attitudes and training, demographic, and religious factors. The results of the study indicated that most medical house officers supported vigorous analgesia, the majority supported terminal sedation, but only a minority supported physician-assisted suicide. Some house officers' attitudes toward terminal sedation and assisted suicide may have been influenced by their religious commitments and the pressures of training.

Withholding and Withdrawing of Life Support

The developments in medicine in general and the technology of life support in particular have provided the means of maintaining organ function for prolonged periods of time. However, there are many situations where life-sustaining treatment in an intensive care unit (ICU) may lead to a death with lingering and suffering of the patient, as well as burdening their family. Although often equated, withholding and/or withdrawing life-prolonging treatments that allow the patient to die needs to be differentiated from the physician-assisted suicides and euthanasia that involve the active ending of life. There is a difference between an unintended but accepted consequence of forgoing therapy and an intended result of death from suicide or euthanasia. The present-day physicians view most patient deaths as an inevitable process secondary to disorders unresponsive to treatment and/or multiple organ dysfunction syndromes. The large majority of patients dying in ICUs today succumb not after cardiopulmonary resuscitation, but rather, after the forgoing of life-sustaining treatment. Such approach has frequently caused families, institutions, and conservators of patients to resort to judicial fiat for resolution.

The end of life decisions – should physicians aid their patients in dying?

Decisions pertaining to end of life whether legalized or otherwise, are made in many parts of the world but not reported on account of legal implications. The highly charged debate over voluntary euthanasia and physician assisted suicide was brought into the public arena again when two British doctors confessed to giving lethal doses of drugs to hasten the death of terminally ill patients. Lack of awareness regarding the distinction between different procedures on account of legal status granted to them in some countries is the other area of concern. Some equate withdrawal of life support measures to physician assisted suicide whereas physician assisted suicide is often misinterpreted as euthanasia. Debate among the medical practitioners, law makers and the public taking into consideration the cultural, social and religious ethos will lead to increased awareness, more safeguards and improvement of medical decisions concerning the end of life. International Human Rights Law can provide a consensual basis for such a debate on euthanasia.

Physicians' practices related to the use of terminal sedation: Moral and ethical concerns

Objective:Although terminal sedation (TS) has generally been seen as legal and ethically acceptable, ethical and moral issues remain. Little is known about the use of TS in general clinical practice and about how TS is viewed by physicians, given moral and ethical concerns. The objectives of this study are (1) to describe attitudes of physicians regarding terminal sedation; (2) to explore demographic characteristics, such as age, gender, subspecialty, and number of years in practice, that might be related to the use of TS; and (3) to compare physicians who have and have not used TS on the degree to which they view TS as moral and consistent with their professional and personal ethics.

Methods:An anonymous survey of New Jersey physicians was conducted at the University of Medicine and Dentistry of New Jersey–School of Osteopathic Medicine. A 39-item questionnaire assessing general opinions about, experiences with, and religious, moral, ethical attitudes toward TS and other end-of-life treatments was utilized.

Results:A majority of physicians (73%) had used TS for a patient. Most (93%) said there were circumstances under which they would use TS. With regard to questions about whether TS would be “immoral,” “would violate my religious beliefs,” “would violate my professional ethics” and “is inconsistent with the physician's role of preserving life,” approximately 55% of those who have used TS disagreed; for those who have not used TS, approximately 35% disagreed.

Significance of results:Professional education and opportunities for discussion appear necessary to help reconcile the conflicts raised in the use of this end-of-life treatment strategy.

Attitudes of people with disabilities toward physician-assisted suicide legislation: broadening the dialogue

This article presents the methods, findings, and implications of a participatory action research project that attempted to shed additional light on the debate over death with dignity (DWD) or physician-assisted suicide (PAS) legislation. In-depth, qualitative interviews with forty-five physically disabled residents of the San Francisco Bay Area, conducted by others with disabilities, revealed a wide breadth of opinions about and attitudes toward such legislation. For close to half of the participants, the desire for autonomy in making end-of-life decisions was a primary concern, yet fear that PAS legislation could violate this autonomy in various ways was a deep concern as well. Also reported were widespread accounts of disability-based discrimination and frequent expressions of fear about openly discussing positions that diverge from the official, publicly held opinions of disability leaders who oppose such legislation. The findings support those of a recent Harris poll demonstrating considerable diversity of opinion about PAS legislation among people with disabilities. The findings further suggest the need for additional research on the apparent disjunction between the diversity of attitudes held by those interviewed and the more unified position taken by many disability activists. Use of the study findings to promote greater dialogue within the community and to better position people with disabilities to take their place at the policy table also is discussed. In addition, the findings are seen as reinforcing the need for the public health community to become more engaged in this central ethical debate.

Attitudes of family physicians in Washington state toward physician-assisted suicide

CONTEXT

The topic of physician-assisted suicide is difficult and controversial. With recent laws allowing physicians to assist in a terminally ill patient's suicide under certain circumstances, the debate concerning the appropriate and ethical role for physicians has intensified.

PURPOSE

This paper utilizes data from a 1997 survey of family physicians (FPs) in Washington State to test two hypotheses: (1) older respondents will indicate greater opposition to physician-assisted suicide than their younger colleagues, and (2) male and rural physicians will have more negative attitudes toward physician-assisted suicide than their female and urban counterparts.

METHODS

A questionnaire administered to all active FPs obtained a 68% response rate, with 1074 respondents found to be eligible in this study. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas.

FINDINGS

One-fourth of the respondents overall indicated support for physician-assisted suicide. When asked whether this practice should be legalized, 39% said yes, 44% said no, and 18% indicated that they did not know. Fifty-eight percent of the study sample reported that they would not include physician-assisted suicide in their practices even if it were legal. Responses disaggregated by age-groups closely paralleled the group overall. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents. Even among those reporting support for physician-assisted suicide, many expressed reluctance about including it in their practices.

CONCLUSIONS

These findings highlight the systematic differences in FP attitudes toward one aspect of health care by gender, rural-urban practice location, and other factors.

Assisted suicide: factors affecting public attitudes

Public support for assisted suicide has been growing despite the ethical questions raised by members of the medical profession. Previous research suggests that age, gender, experience, and religiosity are factors affecting individuals' attitudes. This study examines the effect of demographic and ideological factors, as well as individuals' caregiving experiences, on attitudes toward assisted suicide. Random-digit-dialing procedures produced a sample of 156 residents of Denton, Texas, in March 1998. T-tests were conducted to measure significance, while gamma values were used to measure level of association and percent reduction in error. The data indicate that age, gender, and caregiving experience were not significant predictors of attitudes. Situational factors, including whether a physician or friend/family member should assist and whether a child or a terminally ill patient experiencing no pain should receive assistance, all were highly significant and positively associated with attitudes toward assisted suicide. Respondents were most likely to support physician-assisted suicide for individuals experiencing no pain. The data also indicated that the depth of commitment to the beliefs that suffering has meaning, that life belongs to God, and that physician-assisted suicide is murder, were highly significant and negatively associated with attitudes toward assisted suicide.

Gender and physician-assisted suicide: an analysis of the Kevorkian cases, 1990-1997

This study examines the seventy-five suicide cases Dr. Jack Kevorkian acknowledged assisting during the period between 1990-1997. Although these cases represent a range of regional and occupational backgrounds, a significant majority are women. Most of these individuals had a disabling, chronic, nonterminal-stage illness. In five female cases, the medical examiner found no evidence of disease whatsoever. About half of the women were between the ages of forty-one and sixty, and another third were older adults. Men's conditions were somewhat less likely than women's to be chronic and nonterminal-stage. The main reasons for the hastened death mentioned by both the person and their significant others were having disabilities, being in pain, and fear of being a burden. The predominance of women among Kevorkian's assisted suicides contrasts with national trends in suicide mortality, where men are a clear majority. It is possible that individuals whose death was hastened by Kevorkian are not representative of physician-assisted suicide cases around the country, because of Kevorkian's unique approach. Alternatively, the preponderance of women among Kevorkian's assisted suicides may represent a real phenomenon. One possibility is that, in the United States, assisted suicide is particularly acceptable for women. Individual, interpersonal, social, economic, and cultural factors encouraging assisted suicide in women are examined.

Doctor assisted suicide: an analysis of public opinion of Michigan adults

Michigan public opinion on Doctor Assisted Suicide (DAS) was assessed in January 1997 (N=603). Asked if they would consider DAS for themselves, two-thirds would if being kept alive by machine or were experiencing chronic pain; one-half would if they experienced a loss in mobility or independence, became a burden to others, or were diagnosed with a terminal disease; and one-third would if they were incontinent or going to a nursing home. A series of demographic and attitudinal comparisons were made for support for the concept of DAS and as a hypothetical consideration for oneself. The highest support for the concept of DAS was found among the following: men eighteen to twenty-four years old, some college education, $35-60,000/year income, Caucasian, Democrat, liberal, Protestant, and frequent church attendee. The highest self-consideration of DAS was found among the following: men, fifty to fifty-five years old, post-graduate education, $35-60,000/year income, Caucasian, Democrat, liberal, Protestant, and infrequent church attendee.

Potential psychodynamic factors in physician-assisted suicide

A number of assumptions underlying the debate over physician-assisted suicide (PAS) deserve closer scrutiny. It is often implicitly assumed that decisions as to the competency of the patient to request PAS can be accurately made, and that the treating physician's values and intrapsychic conflicts can be successfully separated from the decision to accede to or reject the patient's request. This article argues that in such an emotionally-laden decision, such factors may play a significant role, and that even were PAS to gain widespread acceptance, ignoring them may lead to errors in classifying patients either as appropriate or inappropriate for PAS.

Could adequate palliative care obviate assisted suicide?

Physician views regarding the relationship between palliative care and physician-assisted suicide (PAS) are poorly understood. This survey of Connecticut physicians (n = 2,805; 40% response rate) found physicians nearly evenly divided on the question of whether there is a role for PAS in systems where adequate palliative care is available (42% no, 41% yes, 17% uncertain). These groups differ significantly on numerous personal and practice characteristics (all p < .001), as well as perceptions of various risks of PAS (p < .001). Written comments by 152 respondents provide further insights. Views on the respective roles of palliative care and PAS are highly discordant, challenging the development of clinical standards for end-of-life care.

Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: a nationwide survey

PURPOSE

To clarify the frequency of practice of sedation therapy for terminally ill cancer patients and to identify physicians' attitudes toward sedation.

METHODS

Questionnaires were mailed to 1,436 Japanese oncologists and palliative care physicians with a request to report their practice of and attitudes toward palliative sedation therapy.

RESULTS

A total of 697 physicians returned questionnaires (response rate, 49.6%). Use of mild, intermittent-deep, or continuous-deep sedation for physical and psychologic distress was reported by 89% and 64%, 70% and 46%, and 66% and 38%, respectively. In vignettes in which physicians were asked whether they would use sedation for a patient with refractory dyspnea or with existential distress, 14% and 15%, respectively, chose continuous-deep sedation as a strong possibility. Those physicians less confident with psychologic care and with higher levels of professional burnout were more likely to choose continuous-deep sedation. In vignettes in which they were asked whether they use sedation for a patient with depression or delirium, 39% and 31%, respectively, considered psychiatric treatment to be a strong possibility, and 42% and 50% regarded continuous-deep sedation as a potential treatment option. Physicians less involved in caring for the terminally ill and less specialized in palliative medicine were significantly less likely to choose psychiatric treatment.

CONCLUSION

Sedation is frequently used for severe physical and psychologic distress of cancer patients. Physicians' clinical experiences with the terminally ill and their levels of professional burnout influence the decisions. Training and education for physicians in regard to end-of-life care and valid clinical guidelines for palliative sedation therapy are necessary.

Ethical dilemmas in participatory action research: a case study from the disability community

Participatory action research (PAR) is a collaborative approach to inquiry for education and social change that is gaining increasing prominence in health education. This case study explores the use of PAR by and with a community of people with disabilities in addressing a polarizing issue in that community: death with dignity or physician-assisted suicide legislation. Following a brief review of the debate within the community about this issue and the goals, methods, and findings of this project, the authors examine four key ethical challenges. These are dilemmas in issue selection when the community is deeply divided over a problem area, inclusion and exclusion in study team makeup and sample selection, insider/outsider issues, and how best to use findings in ways that can unite and strengthen the community. The implications of these issues for health educators and others engaged in community-based PAR efforts are presented.

Opinions and practices of medical rehabilitation professionals regarding prayer and meditation

OBJECTIVE

To assess the attitudes and practices of professionals in the field of physical medicine and rehabilitation (PM&R) regarding prayer and meditation.

DESIGN

A national mail survey that included questions about the use of a number of complementary and alternative therapies.

PARTICIPANTS

The survey was mailed to 7,479 physicians, nurses, physical therapists, and occupational therapists who specialize in PM&R, and 1221 (17%) returned completed surveys.

RESULTS

Although the majority of respondents endorsed prayer as a legitimate health care practice, there was greater belief in the benefits of meditation. Older respondents were more likely to recommend meditation to their patients and more likely to meditate themselves. Gender differences that were observed in opinions and practices are better interpreted as differences in professional specialty. In general, nurses and occupational therapists responded more positively toward meditation and prayer than did physicians and physical therapists. Personal use of a technique was the strongest predictor of professional behaviors. Attitude was a stronger predictor of professional use or referral for prayer than meditation, but correlations between attitude and behavior were generally weak for both techniques. Despite their acceptance of these techniques, the vast majority of rehabilitation professionals did not refer their patients for meditation or religious consultation.

CONCLUSIONS

Although there were significant relationships among beliefs, and personal and professional behaviors regarding these techniques, a large part of the variance in professional behaviors was not accounted for by age, gender, opinion, or personal behavior, indicating that other influences exert a stronger effect on professional practice decisions.

Physicians' voices on physician-assisted suicide: looking beyond the numbers

Most empirical research examining physician views on physician-assisted suicide (PAS) has used quantitative methods to characterize positions and identify predictors of individual attitudes. This approach has generated limited information about the nature and depth of sentiments among physicians most impassioned about PAS. This study reports qualitative data provided by 909 physicians as part of a larger survey (N = 2,805) regarding attitudes toward and experiences with PAS and palliative care. Emergent themes illustrate important clinical, social, and ethical considerations in this area. The data illustrate the diverse and ardent responses that PAS evokes among certain physicians. The role of physicians' personal values is central to discussions about legalization of PAS. Polarized views such as those expressed by physicians in this study are not likely to be reconciled, thereby constraining the development of public policy regarding PAS.

Euthanasia and physician-assisted suicide in Scandinavia--with a conceptual suggestion regarding international research in relation to the phenomena

This article analyses and compares recent research on Scandinavian physicians' attitudes towards, as well as their practice of, euthanasia and physician-assisted suicide. The studies discussed are quite dissimilar in their design, resulting in considerable difficulties as far as comparability is concerned. Such difficulties are common in these fields of research. As an intended contribution to the amendment of future research, we suggest what we take to be detailed and precise definitions of the terms euthanasia and physician-assisted suicide for use internationally. Our definitions, or interpretations, basically draw on the Dutch experience and understanding of these terms. The Dutch approach implies that acts of abstention from life-prolonging treatment, i.e., withholding and withdrawing treatment, and pain and symptom treatment that theoretically could shorten life (including terminal sedation) are to be considered 'normal medical practice'. Furthermore, death is seen as having natural causes in all of these acts. That, however, is not the case with euthanasia and physician-assisted suicide. When a physician performs either of these acts, he or she is required to state 'unnatural death' in the patient's death certificate. Our conceptual suggestions do not address the ethical status of the various medical decisions that are made with regard to the death of patients; our aim is conceptual clarity only. As far as euthanasia and physician-assisted suicide in Scandinavia is concerned, even though comparisons prove difficult, we do think some observations may be made: physicians from Norway, Denmark and Sweden display differences in both attitude and practice concerning these phenomena. Norwegian physicians are most restrictive with regard to attitude. Danish and Swedish physicians display a more liberal attitude, the latter being the most liberal. These findings did not fit the physicians' practice. Danish physicians have performed euthanasia and physician-assisted suicide more often than Norwegian physicians. Swedish physicians, even though they are the most liberal when it comes to attitude, appear never to have performed euthanasia and very seldom physician-assisted suicide.

The intention to hasten death: a survey of attitudes and practices of surgeons in Australia

OBJECTIVE

To determine attitudes among surgeons in Australia to assisted death, and the proportion of surgeons who have intentionally hastened death with or without an explicit request.

DESIGN

Anonymous, cross-sectional, mail-out survey between August and November 1999

PARTICIPANTS

683 out of 992 eligible general surgeons (68.9% response rate).

MAIN OUTCOME MEASURES

Proportion of respondents answering affirmatively to questions about administering excessive doses of medication with an intention to hasten death.

RESULTS

247 respondents (36.2%; 95% CI, 32.6%-39.9%) reported that, for the purpose of relieving a patient's suffering, they have given drugs in doses that they perceived to be greater than those required to relieve symptoms with the intention of hastening death. More than half of these (139 respondents; 20.4% of all respondents; 95% CI, 17.4%-23.6%) reported that they had never received an unambiguous request for a lethal dose of medication. Of all respondents, only 36 (5.3%; 95% CI, 2.9%-6.1%) reported that they had given a bolus lethal injection, or had provided the means to commit suicide, in response to an unambiguous request.

CONCLUSIONS

More than a third of surgeons surveyed reported giving drugs with an intention to hasten death, often in the absence of an explicit request. However, in many instances, this may involve the use of an infusion of analgesics or sedatives, and such actions may be difficult to distinguish from accepted palliative care, except on the basis of the doctor's self-reported intention. Legal and moral distinctions based solely on a doctor's intention are problematic.

Synthesis of research and evidence on factors affecting the desire of terminally ill or seriously chronically ill persons to hasten death

Review of empirical studies indicates that suicide is more common in persons suffering from some physical illnesses (e.g., epilepsy, head injuries, Huntington's Chorea, gastrointestinal diseases, AIDS, and cancer), but other chronic diseases and disabilities have not been linked to increased suicide risk (e.g., blindness, senile dementia, multiple sclerosis, and other physical handicaps). The timing of increased suicide risk varies in different illnesses from early presymptomatic stages to the terminal phase. Difficulties in reliably determining when someone is “terminally ill” and problems of the competence of persons with a poor prognosis complicate empirical investigations of euthanasia, assisted suicide, and the desire to hasten death. The role of family and caregivers in end of life decisions needs further clarification. Researchers have found that pain and suffering and quality of life variables may be linked to the desire to die prematurely, particularly in cancer patients. Others find that clinical depression is a major factor. But, since depression is often present, we do not know why a small minority of depressed patients desire and choose to hasten death. Support for alternative hypotheses is examined, including the role of pre-morbid suicidality and depression, individual differences in coping strategies and indirect consequences of the illness. There is a need to clarify links between attitudes, which is the major variable studied, and actual behaviors and decisions. Furthermore, we need theoretical and empirical links between studies of suicide, which is linked to clinical depression and characterized by ambivalence and studies of euthanasia, which is often depicted as rational and with little ambivalence. Evaluative research should be conducted to determine if interventions to reduce the desire for a premature death by suicide, euthanasia, or assisted suicide are effective. In the light of this review, we present several considerations for those involved in proposing changes in public policy concerning euthanasia and assisted suicide.

Uncertainty and opposition of medical students toward assisted death practices

To explore medical students' views of assisted death practices in patient cases that describe different degrees and types of physical and mental suffering, an anonymous survey was administered to all students at one medical school. Respondents were asked about the acceptability of assisted death activities in five patient vignettes and withdrawal of life support in a sixth vignette. In the vignettes, actions were performed by four possible agents: the medical student personally; a referral physician; physicians in general; or non-physicians. Of 306 medical students, 166 (54%) participated. Respondents expressed opposition or uncertainty about assisted death practices in the five patient cases that illustrated severe forms of suffering which were secondary to amyotrophic lateral sclerosis, treatment-resistant depressive and somatoform disorders, antisocial and sexually violent behavior, or AIDS. Students supported the withdrawal of life support in the sixth vignette depicting exceptional futility secondary to AIDS. Students were especially opposed to their own involvement and to the participation of non-physicians in assisted death activities. Differences in views related to sex, religious beliefs, and personal philosophy were found. Medical students do not embrace assisted death practices, although they exhibit tolerance regarding the choices of medical colleagues. How these attributes of medical students will translate into future behaviors toward patients and peers remains uncertain. Medical educators must strive to understand the perspectives of physicians-in-training. Expanded, empirically informed education that is attuned to the attitudes of medical students may be helpful in fulfilling the responsibility of imparting optimal clinical care skills.

A comparison of characteristics of Kevorkian euthanasia cases and physician-assisted suicides in Oregon

PURPOSE

The sociodemographic and clinical characteristics of Kevorkian euthanasia cases were compared with Oregon physician-assisted suicide (PAS) cases and U.S. mortality data.

DESIGN AND METHODS

Two hundred variables were coded from medical examiner reports on all 69 Kevorkian euthanasia cases who died and were autopsied by the Oakland County Medical Examiner. Data on the 43 Oregon PAS cases in the first two years and U.S. mortality data were obtained from published sources.

RESULTS

Only 25% of patients euthanized by Kevorkian were terminally ill as compared to 100% of Oregon PAS cases. PAS cases were significantly more likely to have cancer (72%) than euthanasia cases (29%). Women and those who were divorced or had never married were significantly more likely to seek euthanasia than would have been predicted by national mortality statistics.

IMPLICATIONS

Gender and marital status appeared to influence decisions to seek an assisted death, and research on the role of these factors in end-of-life decision making is merited.

Epidemiology and psychiatric morbidity of suicidal ideation among the elderly

This study investigates the epidemiology and psychiatric morbidity of the wish to be dead, suicidal ideation, and suicidal intent in a group of elderly persons (> 70 years). A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview GMS-A and various other self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R and clinical judgment. In a cross-section of this population, we found the following prevalence rates: At the time of the study, 14.7% of the elderly community had symptoms of tiredness of life, 5.4% wished to die, and 1% showed suicidal ideation or gestures. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as suffering from psychiatric disorders and 50-75% showed symptoms fulfilling the criteria of at least one specific psychiatric diagnosis. Further, logistic regression analysis showed a significant influence of major depression and specific DSM-III-R diagnosis on suicidality in old age. Our conclusion is that suicidal ideation in the elderly is usually a sign of a mental illness warranting diagnosis and treatment rather than assisted suicide.

Views of United States physicians and members of the American Medical Association House of Delegates on physician-assisted suicide

OBJECTIVE

To ascertain the views of physicians and physician leaders toward the legalization of physician-assisted suicide.

DESIGN

Confidential mail questionnaire.

PARTICIPANTS

A nationwide random sample of physicians of all ages and specialties, and all members of the American Medical Association (AMA) House of Delegates as of April 1996.

MEASUREMENTS

Demographic and practice characteristics and attitude toward legalization of physician-assisted suicide.

MAIN RESULTS

Usable questionnaires were returned by 658 of 930 eligible physicians in the nationwide random sample (71%) and 315 of 390 eligible physicians in the House of Delegates (81%). In the nationwide random sample, 44.5% favored legalization (16.4% definitely and 28.1% probably), 33.9% opposed legalization (20.4% definitely and 13.5% probably), and 22% were unsure. Opposition to legalization was strongly associated with self-defined politically conservative beliefs, religious affiliation, and the importance of religion to the respondent (P <.001). Among members of the AMA House of Delegates, 23.5% favored legalization (7.3% definitely and 16.2% probably), 61.6% opposed legalization (43.5% definitely and 18.1% probably), and 15% were unsure; their views differed significantly from those of the nationwide random sample (P <.001). Given the choice, a majority of both groups would prefer no law at all, with physician-assisted suicide being neither legal nor illegal.

CONCLUSIONS

Members of the AMA House of Delegates strongly oppose physician-assisted suicide, but rank-and-file physicians show no consensus either for or against its legalization. Although the debate is sometimes adversarial, most physicians in the United States are uncertain or endorse moderate views on assisted suicide.