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

Attitude of nurses towards euthanasia: a cross-sectional study in Iran

Background:

Nurses play a major role in providing end-of-life care, and euthanasia is considered to be one of the most important ethical challenges that care providers can face.

Aim:

To assess the nurses' attitude towards euthanasia in Iran.

Methods:

The cross-sectional study included nurses who worked in intensive and critical care, as well as dialysis units of a teaching hospital affiliated to Zahedan University of Medical Sciences, who were selected by the census sampling technique. Data were collected using a two-part questionnaire encompassing the demographic characteristics of nurses and the 20-item Euthanasia Attitude Scale.

Results:

The overall score of nurses' attitudes towards euthanasia, ranging from one to five, was 2.71±0.45, indicating a negative attitude and opposition towards euthanasia. Alongside this, the results demonstrated that there was no significant relationship between demographic characteristics and nurses' attitudes toward euthanasia.

Conclusion:

In general, nurses in Iran oppose euthanasia. This can be attributed to the context of religious beliefs and culture in Iran as an Islamic country.

National Survey of Medical Choices in Caring for Terminally ill Patients in Italy, a Cross-Sectional Study

Aims and background

In Italy, euthanasia and assisted suicide remain illegal but have been the subject of constant debate. Such discussions, however, seem to take relatively little account of physicians' views and attitudes.

Methods and study design

We used an anonymous questionnaire to survey the attitudes and practices concerning euthanasia and the care of terminally ill patients of 5000 Italian physicians from among the approximately 20,000 members of seven of the most important Italian scientific societies. They were asked to complete an anonymous questionnaire consisting of 15 items, which also collected demographic and professional information.

Results

The response rate was 23.5%, and 855 questionnaires were returned. The respondents (75% males) had a median age of 51 years and 47% practiced medicine in a hospital or university setting. The survey showed that the attitude of Italian physicians towards caring for terminal patients is generally against the practice of euthanasia insofar as 84% and 87%, respectively, would, on a theoretical basis, be unwilling to prescribe or administer lethal drugs. Only 1.2-2% of the physicians declared that they had resorted at least once to active euthanasia practices consisting of the prescription and/or direct administration of lethal drugs during their professional lives, and 0.5–0.9% during the previous year. The main factor significantly influencing the opinions and behaviors of the physicians was religion.

Conclusions

To our knowledge, this is the first Italian survey investigating the opinions and practices on euthanasia of a large sample of physicians from all over the country, belonging to various medical specialties. Our findings confirm the considerable influence of religion on physician's opinions and practice concerning end-of-life care.

Intending, hastening and causing death in non-treatment decisions: a physician interview study

PURPOSE

To explore how physicians analyse their non-treatment decisions in light of the concepts of hastening, causing and intending the patient's death.

METHODS

Sixteen Norwegian physicians from relevant specialties were interviewed and the results analysed by systematic text condensation, a qualitative analysis framework.

RESULTS

The physicians' chief dilemma in non-treatment decisions was the attempt to achieve the proper balance for the level of treatment at life's end. Respondents framed their challenges in medical and not ethical terms. They treated the concepts of intending, hastening and causing the patient's death as alien to their practical deliberations and, for many, irrelevant to the moral appraisal of their end-of-life practices.

CONCLUSIONS

The core concepts of traditional medico-ethical analyses of end-of-life decision-making do not map the practical terrain well. Research on physician intentions must be designed and interpreted in light of this.

Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care

BACKGROUND

In recognition of the ongoing discussion on euthanasia and physician-assisted suicide, the Board of Directors of the European Association for Palliative Care commissioned this white paper from the palliative care perspective.

AIM

This white paper aims to provide an ethical framework for palliative care professionals on euthanasia and physician-assisted suicide. It also aims to provide an overview on the available evidence as well as a discourse of ethical principles related to these issues.

DESIGN

Starting from a 2003 European Association for Palliative Care position paper, 21 statements were drafted and submitted to a five-round Delphi process

PARTICIPANTS

A panel with 17 experts commented on the paper in round 1. Board members of national palliative care or hospice associations that are collective members of European Association for Palliative Care were invited to an online survey in rounds 2 and 3. The expert panel and the European Association for Palliative Care board members participated in rounds 4 and 5. This final version was adopted as an official position paper of the European Association for Palliative Care in April 2015.

RESULTS

Main topics of the white paper are concepts and definitions of palliative care, its values and philosophy, euthanasia and physician-assisted suicide, key issues on the patient and the organizational level. The consensus process confirmed the 2003 European Association for Palliative Care white paper and its position on the relationship between palliative care and euthanasia and physician-assisted suicide.

CONCLUSION

The European Association for Palliative Care feels that it is important to contribute to informed public debates on these issues. Complete consensus seems to be unachievable due to incompatible normative frameworks that clash.

[Medical students' attitudes towards legalisation of euthanasia and physician-assisted suicide]

BACKGROUND

We wished to investigate prevailing attitudes among future doctors regarding legalisation of euthanasia and physician-assisted suicide. This issue is important, since any legalisation of these practices would confer a completely new role on doctors.

MATERIAL AND METHOD

Attitudes were identified with the aid of a questionnaire-based survey among medical students in their 5th and 6th year of study in the four Norwegian medical schools.

RESULTS

Altogether 531 students responded (59.5% of all students in these cohorts). Of these, 102 (19%) were of the opinion that euthanasia should be legalised in the case of terminal illness, 164 (31%) responded that physician-assisted suicide should be permitted for this indication, while 145 (28%) did not know. A minority of the respondents would permit euthanasia and physician-assisted suicide in other situations. Women and those who reported that religion was important to them were less positive than men to permitting euthanasia or physician-assisted suicide.

INTERPRETATION

In most of the situations described, the majority of the students in this survey rejected legalisation. Opinions are more divided in the case of terminal illness, since a larger proportion is in favour of legalisation and more respondents are undecided.

Dying cancer patients' own opinions on euthanasia: an expression of autonomy? A qualitative study

INTRODUCTION

Deliberations on euthanasia are mostly theoretical, and often lack first-hand perspectives of the affected persons.

METHOD

Sixty-six patients suffering from cancer in a palliative phase were interviewed about their perspectives of euthanasia in relation to autonomy. The interviews were transcribed verbatim and analysed using qualitative content analysis with no predetermined categories.

RESULTS

The informants expressed different positions on euthanasia, ranging from support to opposition, but the majority were undecided due to the complexity of the problem. The informants' perspectives on euthanasia in relation to autonomy focused on decision making, being affected by (1) power and (2) trust. Legalization of euthanasia was perceived as either (a) increasing patient autonomy by patient empowerment, or (b) decreasing patient autonomy by increasing the medical power of the health care staff, which could be frightening. The informants experienced dependence on others, and expressed various levels of trust in others' intentions, ranging from full trust to complete mistrust.

CONCLUSIONS

Dying cancer patients perceive that they cannot feel completely independent, which affects true autonomous decision making. Further, when considering legalization of euthanasia, the perspectives of patients fearing the effects of legalization should also be taken into account, not only those of patients opting for it.

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.

Would physician-assisted suicide jeopardize trust in the medical services? An empirical study of attitudes among the general public in Sweden

AIM

To investigate the attitudes among the Swedish population towards physician-assisted suicide, with special regard to the possible effects on trust in the medical services of physician-assisted suicide being allowed.

DESIGN

A postal questionnaire about physician-assisted suicide under certain conditions and its possible influence on trust in the medical services was distributed to 1206 randomly selected individuals living in the county of Stockholm. Two reminders were distributed, followed by a short version of the questionnaire containing only the question about the attitude towards physician-assisted suicide.

RESULTS

The total response rate was 51%, a short-version reminder adding another 7%. Of all participants, 73% were in favour of physician-assisted suicide, 12% were against, and 15% were undecided. They believed that their trust in the medical services would increase (38%) or not be influenced at all (45%) if physician-assisted suicide were to be allowed. However, 75% of those who were against physician-assisted suicide believed that their trust would decrease. As compared to those reporting high trust in medical services (n = 492), those with low trust (n = 97) stated that their trust would increase, 36% (confidence interval (CI) = 35-37%) vs. 49% (95% CI = 39-59%). Thirty-three per cent (95% CI = 28-38%) of the younger respondents (<50 years), and 43% (95% CI = 37-49%) of the older respondents believed that their trust would increase.

CONCLUSIONS

We found no evidence for the assumption that trust in the medical services would be unambiguously jeopardized if physician-assisted suicide were to be legalized. Only among the minority who opposed physician-assisted suicide did a majority of respondents report that their trust would decrease.

[Tuition in palliative medicine. Does it have an impact on future physicians' attitudes toward active euthanasia?]

BACKGROUND

The aim of this study was to examine the attitude of medical students with or without tuition in palliative medicine towards active euthanasia and whether this changes during the course of the study period.

METHODS

A questionnaire was developed with 13 items (focus groups, preliminary tests) which takes knowledge and attitude into consideration. Students in the 2nd (2CS) and 6th (6CS) clinical semesters at 2 universities with (U1) and without (U2) palliative medicine as a compulsory subject were included.

RESULTS

The initial approval rate for active euthanasia was high for students in 2CS at both universities (U1 and U2), remained stable for U2 and sank clearly for U1. At U1 the number of students who would consider active euthanasia for themselves was greatly reduced but only slightly for U2. Of all the students, 40.9% of U2 and 22.5% of U1 were of the opinion that they could practice active euthanasia on patients. The majority admitted to being frightened to have responsibility for incurable patients. Of the students in 6CS, only 12.2% from U1 and 7.1% from U2 considered themselves sufficiently prepared to be responsible for terminally ill patients.

CONCLUSIONS

The results of this questionnaire demonstrated a clear influence of tuition in palliative medicine on the rejection attitude of students towards active euthanasia, however, the attitude proactive euthanasia was still high. The results indicate that tuition in palliative medicine must be modified and substantially intensified.

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.

Physician-assisted death. Opinions of a sample of Mexican physicians

BACKGROUND

There is insufficient information on what Mexicans think of physician-assisted death, a problem that is currently being discussed in our legislative bodies. This paper discusses the findings among a sample of physicians.

METHODS

The sample was formed by 2097 physicians from several specialties employed by a Mexican government health system, distributed throughout the country. Each physician received a structured questionnaire exploring what they thought of two different scenarios related to physician-assisted death: 1) intolerable suffering of patients; and 2) persistent vegetative state (PVS). Questions included data on several personal characteristics of the respondents and two open-ended questions asking the reasons why they answered the main questions as they did.

RESULTS

There was an overall response rate of 47.3%. Approximately 40% agreed with physicians helping terminally ill patients request to die because of intolerable suffering caused by incurable diseases, whereas 44% said no and the rest were undecided. This was statistically different from the answers to the scenario where the relatives of a patient in a PVS ask their physician to help him or her die, where 48% of respondents said yes, and 35% said no. The main reasons to say yes in both scenarios were respect for patients or family autonomy and to avoid suffering, whereas those opposed cited other ethical and mainly religious considerations.

CONCLUSIONS

The variable with the highest probability to approve both scenarios was of a legal nature, whereas strong religious beliefs were against accepting physician-assisted death. The group was evenly divided with approximately 40% each between those for and against the idea of helping die a patient and approximately 20% were undecided.

Confusion between euthanasia and other end-of-life decisions: influences on public opinion poll results

BACKGROUND

Public opinion polls indicate that a majority of Canadians are in favour of euthanasia. However, there have been many criticisms of the validity of these findings. The objective of this study was to assess public opinion towards euthanasia while controlling for possible threats to validity indicated in the literature review.

METHODS

A telephone public opinion poll was conducted in 2002 with a representative sample of the general population of Quebec (n = 991; response rate = 49.8%). Respondents were asked about their support for euthanasia and treatment withdrawal and, for comparison, were asked a previously used question on euthanasia (Gallup) which has been criticized for methodological problems. Respondents were also asked to distinguish between euthanasia and other end-of-life decisions in hypothetical scenarios.

RESULTS

Eleven percent more people supported euthanasia with the Gallup question than the question developed in this study. Support for euthanasia (69.6%) was less prevalent than for treatment withdrawal (85.8%). Respondents who failed to distinguish between euthanasia and treatment withdrawal or withholding treatment in hypothetical scenarios were more likely to support euthanasia in public opinion poll questions. Furthermore, there is a significant relationship between opinions about the acceptability of euthanasia and inaccurate knowledge of the nature of euthanasia.

INTERPRETATION

Public opinion polls on euthanasia must be interpreted in the light of the wording of the question. Education of the population concerning euthanasia and other end-of-life decisions may be considered to be an important prerequisite to engage in public debate concerning the legalization of euthanasia.

Attitudes toward euthanasia among Swedish medical students

Attitudes toward euthanasia differ between individuals and populations, and in many studies the medical profession is more reluctant than the general public. Our goal was to explore medical students' attitude toward euthanasia. A questionnaire containing open-ended questions was answered anonymously by 165 first- and fifth-year medical students. Data were analysed using qualitative content analysis with no predetermined categories. The students' arguments opposing euthanasia were based on opinions of 1. euthanasia being morally wrong, 2. fear of possible negative effects on society, 3. euthanasia causing strain on physicians and 4. doubts about the true meaning of requests of euthanasia from patients. Arguments supporting euthanasia were based on 1. patients' autonomy and 2. the relief of suffering, which could be caused by severe illnesses, reduced integrity, hopelessness, social factors and old age. There are several contradictions in the students' arguments and the results indicate a possible need for education focusing on the possibility of symptom control in palliative care and patients' perceived quality of life.

Relatives' perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands

This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most patients (79%) had spoken about their wishes concerning medical end-of-life decisions to be made at a later date. Hopeless suffering, loss of dignity, and no prospect of recovery were the most prevalent reasons for explicitly requesting EAS. According to the relative, in 92% of patients EAS had contributed favourably to the quality of the end of life, mainly by preventing or ending suffering.

Should People Die a Natural Death?

In the article the concept of natural death as used in end-of-life decision contexts is explored. Reviewing some recent empirical studies on end-of-life decision-making, it is argued that the concept of natural death should not be used as an action-guiding concept in end-of-life decisions both for being too imprecise and descriptively open in its current use but mainly since it appears to be superfluous to the kind of considerations that are really at stake in these situations. Considerations in terms of the quality of life cost of the intervention in relation to the quality and length of life benefits of the same intervention. In referring to the concept of natural death we risk to blur these considerations and end up in difficult distinctions between what is a natural and non- or un-natural death, a distinction which it is argued is of no real moral interest.

Attitudes towards, and wishes for, euthanasia in advanced cancer patients at a palliative medicine unit

BACKGROUND

Most studies on attitudes towards euthanasia and physician-assisted suicide (PAS) have been conducted in healthy populations. The aim of this study is to explore and describe attitudes towards, and wishes for, euthanasia/PAS in cancer patients with short life expectancy.

METHOD

Semi-structured interviews with 18 cancer patients with a life expectancy of less than nine months. All patients were recruited from an inpatient palliative medicine unit.

RESULTS

Patients holding a positive attitude towards euthanasia/PAS do not necessarily want euthanasia/PAS for themselves. Wishes are different from requests for euthanasia/PAS. Fear of future pain and a painful death were the main reasons given for a possible wish for euthanasia/PAS. Worries about minimal quality of life and lack of hope also contributed to such thoughts. Wishes for euthanasia/PAS were hypothetical; they were future oriented and with a prerequisite that intense pain, lack of quality of life and/or hope had to be present. Additionally, wishes were fluctuating and ambivalent.

CONCLUSION

The wish to die in these patients does not seem to be constant. Rather, this wish is more appropriately seen as an ambivalent and fluctuating mental 'solution' for the future. Health care providers should be aware of this when responding to utterances regarding euthanasia/PAS.

Medical end-of-life decisions in Norway

AIM

Previous studies indicate that Norwegian physicians hold conservative attitudes towards ethically controversial end-of-life decisions. The present study was undertaken to explore whether in Norway euthanasia may be hidden under labels such as death after analgesic injections and withholding or withdrawing treatment.

METHODS

A postal questionnaire containing 76 questions on ethical, collegial and professional autonomy issues was sent to a representative sample of 1616 active physicians in Norway in 2000.

RESULTS

83% responded. A total of 8.1% had terminated life-prolonging treatment based on the resource situation, while 53.5 and 40.1% respectively had stopped life prolonging treatment due to the wish of the patient and the wish of the patient's relatives. Although not significantly, anaesthesiologists more often reported to have stopped treatment due to resource considerations. One percent of the physicians reported to have shortened a patient's life intentionally (other than stopping futile treatment). All of these were men. Logistic regression showed no effect when gender, age and specialty were analysed simultaneously. 10.6%, and male more often than female physicians, had had experience of unintentional patient death in relation to pain treatment. Anaesthesiologists had had experiences of death following an analgesic injection no more than other specialists.

CONCLUSIONS

Only a small minority of Norwegian physicians has committed euthanasia. However, patient death has occurred following ethically questionable decisions such as withdrawal of treatment based on resource considerations and requests from the family.