Multi-Ethnic Attitudes Toward Physician-Assisted Death in California and Hawaii

Maybe for unbearable suffering: Diverse racial, ethnic and cultural perspectives of assisted dying. A scoping review

BACKGROUND

Assisted dying, also commonly known as euthanasia and physician-assisted suicide, is legal in many countries. Interest in assisted dying is growing due to evolving societal understandings of a good death and a desire for choice. Ethico-legal perspectives are well-known, but as societies become more heterogenous, a greater understanding of the perspectives of people from diverse racial, ethnic, and cultural backgrounds is needed.

AIM

To explore perspectives of people from diverse racial, ethnic and cultural backgrounds about assisted dying.

DESIGN

Scoping review with narrative synthesis. The protocol was registered with Open Science Framework.

DATA SOURCES

Medline, CINAHL Complete, PsycINFO and ProQuest Dissertations & Theses Global were searched from inception to May 2023. Citations were independently assessed against inclusion and exclusion criteria.

RESULTS

Of the 17 included studies, perspectives of assisted dying were presented according to religion, religiosity, spirituality, race, ethnicity and ancestry. Perspectives were diverse, presenting more as a spectrum, with multiple intersections and interconnections. Support and/or opposition for assisted dying differed according to cultural attributes, but even amongst those with similar cultural attributes, perspectives differed according to life experiences and notions of suffering.

CONCLUSION

Perspectives on assisted dying are dynamic and evolving. Even where assisted dying is legalised, individual's cultural attributes contribute to unique perspectives of assisted dying as an end-of-life option. Thus, understanding a person's culture, beliefs, expectations and choices in illness, treatment goals and care is fundamental, extending beyond what may be already considered as part of clinician-patient care relationships and routine advance care planning.

Self-destruction or surrender? Religiosity and active versus passive euthanasia

Previous research suggests that people, especially religious people, are more opposed to active euthanasia, such as a lethal injection, than to passive euthanasia, such as withdrawing life support. The current research proposes a possible explanation for this finding-that active euthanasia is viewed as interfering with the natural course of life and death, but passive euthanasia is viewed as allowing it to take place. Two studies yielded results consistent with this hypothesis and found that how people think about the natural course of life and death substantially explained the greater opposition to active euthanasia among more religious people.

Attitudes toward the Legalization of Euthanasia or Physician-Assisted Suicide in South Korea: A Cross-Sectional Survey

This study aimed to investigate the general South Korean public attitudes toward the legalization of euthanasia or physician-assisted suicide (EAS) and examine the reasons underpinning these attitudes. From March–June 2021, we conducted a cross-sectional survey of a representative national sample of 1000 South Koreans aged 19 years or older. Three in four participants (76.4%) expressed positive attitudes toward the legalization of EAS. Participants who agreed with this legalization reported “meaninglessness of the rest of life” and “right to a good death” as their main reasons. Participants who disagreed with the legalization of EAS reported “respect for life”, “violation of the right to self-determination”, “risk of abuse or overuse”, and “violation of human rights” as theirs. In the multivariate logistic regression analyses, participants with poor physical status (adjusted odds ratio [aOR]: 1.41, 95%; confidence interval [CI]: 1.02–1.93) or comorbidity (aOR: 1.84, 95%; CI: 1.19–2.83) showed positive attitudes toward the legalization of EAS. In summary, most of the general South Korean population regards the legalization of EAS positively, especially participants with poor physical status or comorbidity.

Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial

INTRODUCTION

Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes.

METHODS AND ANALYSIS

The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites.

ETHICS AND DISSEMINATION

Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results.

TRIAL REGISTRATION NUMBER

NCT04347629.

The Attitude of Iranian Critical Care Nurses Toward Euthanasia: A Multicenter Cross-sectional Study

Today, one of the major ethical challenges facing the world's health care system, and in particular nurses in the intensive care unit, is euthanasia or death out of pity. The aim of this study was to investigate the attitude of Iranian nurses in the intensive care unit toward euthanasia. This was an analytical cross-sectional study using census sampling. The data collection tool was the Euthanasia Attitude Scale. A total of 206 nurses working in the intensive care unit in 4 hospitals in the Mazandaran province of Iran were included in this study. The mean of total Euthanasia Attitude Scale score in intensive care unit nurses was 2.96. The mean euthanasia dimensions were ethical consideration, practical considerations, treasuring life, and naturalistic beliefs, 3.03, 2.92, 2.98, and 2.99, respectively. There was significant but low negative correlation between age and total Euthanasia Attitude Scale score, ethical considerations, and practical considerations. Male nurses exhibited significantly higher Euthanasia Attitude Scale scores, specifically in regard to ethical and practical considerations compared with female nurses. The most Iranian nurses in the intensive care unit had a negative attitude toward euthanasia for patients in the later stages of the disease. However, this opposition was less than similar studies in Iran in the past.

Barriers to Access: A Feminist Analysis of Medically Assisted Dying and the Experience of Marginalized Groups

In this article, I argue that a holistic strategy is needed to ascertain how implicit bias, on the part of health-care providers, and structural impediments work together to produce significant barriers to access to medical assistance in dying for marginalized groups-particularly those experiencing intersecting or interlocking forms of identity-based oppressions. In doing so, I also make the case that this kind of primary, patient-centered, and institutional research could benefit from the insights of critical feminism and materialist feminist theory by highlighting and challenging inequalities, opening up debate, and exploring new forms of knowledge production. It also offers a way to shape future research of medical assistance in dying, as it relates specifically to the study of how overlapping forms of structural and interpersonal marginalization (e.g., implicit bias), inclusive of race, gender, class, ethnicity, dis/ability, sexuality, and so on are expressed and experienced.

Expanded definitions of the 'good death'? Race, ethnicity and medical aid in dying

The range of end-of-life options is expanding across North America. Specifically, medical aid in dying (AID), or the process by which a patient with a terminal illness may request medical assistance with hastening death, has recently become legal in eight jurisdictions in the United States and all of Canada. Debates about AID often rely on cultural constructions that define some deaths as 'good' and others as 'bad'. While research has found commonalities in how patients, family members and health care providers define good and bad deaths, these constructions likely vary across social groups. Because of this, the extent to which AID is seen as a route to the good death also likely varies across social groups. In this article, we analyse qualitative data from six focus groups (n = 39) across three racial and ethnic groups: African American, Latino and white Californians, just after a medical AID law was passed. We find that definitions of the 'good death' are nuanced within and between groups, suggesting that different groups evaluate medical AID in part through complex ideas about dying. These findings further conversations about racial and ethnic differences in choices about end-of-life options.

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.

Comparison of attitudes towards five end-of-life care interventions (active pain control, withdrawal of futile life-sustaining treatment, passive euthanasia, active euthanasia and physician-assisted suicide): a multicentred cross-sectional survey of Korean patients with cancer, their family caregivers, physicians and the general Korean population

OBJECTIVES

This study determined attitudes of four groups-Korean patients with cancer, their family caregivers, physicians and the general Korean population-towards five critical end-of-life (EOL) interventions-active pain control, withdrawal of futile life-sustaining treatment (LST), passive euthanasia, active euthanasia and physician-assisted suicide.

DESIGN AND SETTING

We enrolled 1001 patients with cancer and 1006 caregivers from 12 large hospitals in Korea, 1241 members of the general population and 928 physicians from each of the 12 hospitals and the Korean Medical Association. We analysed the associations of demographic factors, attitudes towards death and the important components of a 'good death' with critical interventions at EoL care.

RESULTS

All participant groups strongly favoured active pain control and withdrawal of futile LST but differed in attitudes towards the other four EoL interventions. Physicians (98.9%) favoured passive euthanasia more than the other three groups. Lower proportions of the four groups favoured active euthanasia or PAS. Multiple logistic regression showed that education (adjusted OR (aOR) 1.77, 95% CI 1.33 to 2.36), caregiver role (aOR 1.67, 95% CI 1.34 to 2.08) and considering death as the ending of life (aOR 1.66, 95% CI 1.05 to 1.61) were associated with preference for active pain control. Attitudes towards death, including belief in being remembered (aOR 2.03, 95% CI 1.48 to 2.79) and feeling 'life was meaningful' (aOR 2.56, 95% CI 1.58 to 4.15) were both strong correlates of withdrawal of LST with the level of monthly income (aOR 2.56, 95% CI 1.58 to 4.15). Believing 'freedom from pain' negatively predicted preference for passive euthanasia (aOR 0.69, 95% CI 0.55 to 0.85). In addition, 'not being a burden to the family' was positively related to preferences for active euthanasia (aOR 1.62, 95% CI 1.39 to 1.90) and PAS (aOR 1.61, 95% CI 1.37 to 1.89).

CONCLUSION

Groups differed in their attitudes towards the five EoL interventions, and those attitudes were significantly associated with various attitudes towards death.

The Views of Clergy Regarding Ethical Controversies in Care at the End of Life

CONTEXT

Although religion often informs ethical judgments, little is known about the views of American clergy regarding controversial end-of-life ethical issues including allowing to die and physician aid in dying or physician-assisted suicide (PAD/PAS).

OBJECTIVE

To describe the views of U.S. clergy concerning allowing to die and PAD/PAS.

METHODS

A survey was mailed to 1665 nationally representative clergy between 8/2014 to 3/2015 (60% response rate). Outcome variables included beliefs about whether the terminally ill should ever be "allowed to die" and moral/legal opinions concerning PAD/PAS.

RESULTS

Most U.S. clergy are Christian (98%). Clergy agreed that there are circumstances in which the terminally ill should be "allowed to die" (80%). A minority agreed that PAD/PAS was morally (28%) or legally (22%) acceptable. Mainline/Liberal Christian clergy were more likely to approve of the morality (56%) and legality (47%) of PAD/PAS, in contrast to all other clergy groups (6%-17%). Greater end-of-life medical knowledge was associated with moral disapproval of PAD/PAS (adjusted odds ratio [AOR], 1.51; 95% CI, 1.04-2.19, P = 0.03). Those reporting distrust in health care were less likely to oppose legalization of PAD/PAS (AOR 0.93; 95% CI, 0.87-0.99, P < 0.02). Religious beliefs associated with disapproval of PAD/PAS included "life's value is not tied to the patient's quality of life" (AOR 2.12; 95% CI, 0.1.49-3.03, P < 0.001) and "only God numbers our days" (AOR 2.60; 95% CI, 1.77-3.82, P < 0.001).

CONCLUSION

Most U.S. clergy approve of "allowing to die" but reject the morality or legalization of PAD/PAS. Respectful discussion in public discourse should consider rather than ignore underlying religious reasons informing end-of-life controversies.

How California Prepared for Implementation of Physician-Assisted Death: A Primer

Physician-assisted death is now legal in California, and similar laws are being considered in many other states. The California law includes safeguards, yet health care providers will face practical and ethical issues while implementing physician-assisted death that are not addressed by the law. To help providers and health care facilities in California prepare to provide optimal care to patients who inquire about physician-assisted death, we brought together experts from California, Oregon, and Washington. We convened a conference of 112 stakeholders in December 2015, and herein present their recommendations. Themes of recommendations regarding implementation include (1) institutions should develop and revise physician-assisted death policies; (2) legal physician-assisted death will have implications for California's culturally and socioeconomically diverse population, and for patients from vulnerable groups; (3) conscientious objection and moral distress for health care providers must be considered; and (4) palliative care is essential to the response to the law. The expert conference participants' insights are a valuable guide, both for providers and health care facilities in California planning or revising their response, and for other jurisdictions where physician-assisted death laws are being considered or implemented.

Preferences for care towards the end of life when decision-making capacity may be impaired: A large scale cross-sectional survey of public attitudes in Great Britain and the United States

Background

There is continuing public debate about treatment preferences at the end of life, and the acceptability and legal status of treatments that sustain or end life. However, most surveys use binary yes/no measures, and little is known about preferences in neurological disease when decision-making capacity is lost, as most studies focus on cancer. This study investigates changes in public preferences for care towards the end of life, with a focus on measures to sustain or end life.

Methods

Large-scale international public opinion surveys using a six-stage patient vignette, respondents chose a level of intervention for each stage as health and decision-making capacity deteriorated. Cross-sectional representative samples of the general public in Great Britain and the USA (N = 2016). Primary outcome measure: changes in respondents’ preferences for care, measured on a four-point scale designed before data collection. The scale ranged from: maintaining life at all costs; to intervention with agreement; to no intervention; to measures for ending life.

Results

There were no significant differences between GB and USA. Preference for measures to sustain life at all costs peaked at short-term memory loss (30.2%, n = 610). Respondents selecting ‘measures to help me die peacefully’ increased from 3.9% to 37.0% as the condition deteriorated, with the largest increase occurring when decision-making capacity was lost (10.3% to 23.0%). Predictors of choosing ‘measures to help me die peacefully’ at any stage were: previous personal experience (OR = 1.34, p<0.010), and older age (OR = 1.09 per decade, p<0.010). Negative predictors: living with children (OR = 0.72, p<0.010) and being of “black” race/ethnicity (OR = 0.45, p<0.001).

Conclusions

Public opinion was uniform between GB and USA, but markedly heterogeneous. Despite contemporaneous capacitous consent providing an essential legal safeguard in most jurisdictions, there was a high prevalence of preference for “measures to end my life peacefully” when decision-making capacity was compromised, which increased as dementia progressed. In contrast, a significant number chose preservation of life at all costs, even in end stage dementia. It is challenging to respect the longstanding values of people with dementia concerning either the inviolability of life or personal autonomy, whilst protecting those without decision-making capacity.

High hypothetical interest in physician-assisted death in multiple sclerosis

OBJECTIVE

To assess the opinions of persons with multiple sclerosis (MS) regarding physician-assisted death (PAD).

METHODS

We surveyed participants in the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry regarding PAD. For each of 5 hypothetical situations, respondents indicated whether they definitely would, probably would, probably would not, or definitely would not consider PAD. They also reported their sociodemographics, disability status using Patient-Determined Disease Steps, depression status, pain status, religiosity, and degree of social support. Using multivariable logistic regression models, we evaluated the factors associated with an individual reporting that he or she would definitely or probably consider PAD in each situation.

RESULTS

Of 7,534 respondents, 6,011 (79.8%) were female, and 6,884 (92.9%) were white. Their mean (SD) age was 59.9 (10.2) years. Fifty percent of respondents reported at least moderate disability. Of the 6,792 respondents who responded to any of the PAD questions, 6,400 responded to all questions. Of these, 458 (7.1%) indicated that they would definitely consider PAD in all of the situations listed, while 1,275 (19.9%) indicated that they definitely would not consider PAD in any of the situations listed. If experiencing unbearable pain, 4,383 (65.3%) of respondents would definitely or probably consider PAD. On multivariable analysis, religiosity, social support, depression, pain, disability, sex, and race were associated with considering PAD in some or all of the situations presented.

CONCLUSIONS

Depending upon the situation, a large proportion of persons with MS would consider PAD. The association of depression with considering PAD emphasizes the importance of diagnosing and treating depression.