“The correlates of attitudes toward euthanasia” revisited

Abstract

In a 1979 Social Biology article, B. K. Singh found religious affiliation to be an insignificant variable for the prediction of euthanasia and suicide attitudes. Reanalysis of this same data indicated that religious affiliation, coded as a discrete variable, Catholic vs. non‐Catholic, was masking existing differences among religious denominations. Using a chi‐square partitioning analysis comparing Jewish, Catholic, Protestant, and Non Religion categories indicated significant differences between Protestant and a combined category of Non Religion‐Jews for both euthanasia and suicide attitudes. Future efforts to predict euthanasia and suicide attitudes should include religious affiliation as dummy variable instead of an artificially dichotomized variable.     

Correlates of attitudes toward euthanasia

Abstract

Data from a national survey conducted in 1977 were examined to identify correlates of attitudes toward euthanasia and suicide for terminally ill persons. The results indicated that race, religious participation, and attitudes toward freedom of expression were directly associated with such attitudes. It was also found that regional variations in such attitudes could be explained by the degree of urbanization of geographic regions.     

End-of-life issues as perceived by Lebanese judges

Objectives: to assess the attitudes of judges in Beirut, Lebanon, regarding end-of-life issues such as assisted suicide and withholding or withdrawing life-sustaining treatment.
Subjects and Methods: 85% of all currently acting and in-training judges and public prosecutors in Beirut (N =135) were surveyed using a mailed questionnaire that assessed attitudes toward intervention in five hypothetical cases. The associations of attitudes, on a scale from least to most 'sympathetic' toward assisting those who desire to end their lives, were measured by a variety of personal, social and professional variables.
Results: younger individuals, and those who have not yet been formally appointed as judges, were significantly more sympathetic to withdrawal or withholding of life-sustaining devices when patients or their proxies requested it, and more in support of assisted suicide. Gender, religious denomination, religious practice, and personal experience with prolonged illness leading to death among close friends or family, were generally not significant predictors of respondents' attitudes. Years of experience as a judge correlated strongly with age and may have contributed to its predictive effect.
Discussion and conclusions: a relatively more sympathetic attitude among younger judges, many of them women, and among trainees, may reflect a historical evolution in younger age-groups in Lebanon today. A survey of opinions in the public may help reach a more conclusive understanding in this regard. In any case, judges in Lebanon will remain important partners in the debate, as they will continue to be the final interpreters of the letter of the law in end-of-life issues.     

ATTITUDES TOWARDS EUTHANASIA AND ASSISTED SUICIDE: A COMPARISON BETWEEN PSYCHIATRISTS AND OTHER PHYSICIANS

Euthanasia and physician assisted‐suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist's involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician‐assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables.     

Attitudes of cancer patients, family caregivers, oncologists and members of the general public toward critical interventions at the end of life of terminally ill patients

Background:

Whereas most studies have focused on euthanasia and physician-assisted suicide, few have dealt comprehensively with other critical interventions administered at the end of life. We surveyed cancer patients, family caregivers, oncologists and members of the general public to determine their attitudes toward such interventions.

Methods:

We administered a questionnaire to four groups about their attitudes toward five end-of-life interventions — withdrawal of futile life-sustaining treatment, active pain control, withholding of life-sustaining measures, active euthanasia and physician-assisted suicide. We performed multivariable analyses to compare attitudes and to identify sociodemographic characteristics associated with the attitudes.

Results:

A total of 3840 individuals — 1242 cancer patients, 1289 family caregivers and 303 oncologists from 17 hospitals, as well as 1006 members of the general Korean population — participated in the survey. A large majority in each of the groups supported withdrawal of futile life-sustaining treatment (87.1%–94.0%) and use of active pain control (89.0%–98.4%). A smaller majority (60.8%–76.0%) supported withholding of life-sustaining treatment. About 50% of those in the patient and general population groups supported active euthanasia or physician-assisted suicide, as compared with less than 40% of the family caregivers and less than 10% of the oncologists. Higher income was significantly associated with approval of the withdrawal of futile life-sustaining treatment and the practice of active pain control. Older age, male sex and having no religion were significantly associated with approval of withholding of life-sustaining measures. Older age, male sex, having no religion and lower education level were significantly associated with approval of active euthanasia and physician-assisted suicide.

Interpretation:

Although the various participant groups shared the same attitude toward futile and ameliorative end-of-life care (the withdrawal of futile life-sustaining treatment and the use of active pain control), oncologists had a more negative attitude than those in the other groups toward the active ending of life (euthanasia and physician-assisted suicide).As more attention turns to when and how the lives of terminally ill patients end in the clinical setting, debate about the issues of euthanasia and physician-assisted suicide grows.^1–5 Euthanasia has been discussed in Europe and the United States for more than a century, and the public has become more accepting of it.^4–10 Announcing its first-ever ruling in favour of an unconscious patient’s right to die with dignity, the Korean Supreme Court recently ruled that doctors of an elderly woman in a persistent vegetative state remove the artificial respirator from her on the basis of her presumed wishes.¹¹ A public debate aimed at legalizing withdrawal of futile life-sustaining treatment, exposure to stories of dying patients in the mass media, and the court’s decision may have led to a greater awareness of, and sensibility toward, the rights of terminally ill patients. In 2000, only 16.5% of 535 Korean oncologists surveyed said that they would prescribe morphine for severe cancer pain, and more than half of 655 patients who had pain said they had inadequate pain management.¹²Although much has been written about attitudes toward how the general public would choose to die in the clinical setting,^4,13 most studies have focused on only euthanasia and physician-assisted suicide.^14–18 We conducted a large survey to examine attitudes among cancer patients, family caregivers, oncologists and members of the general public toward critical interventions at the end of life of terminally ill patients.     

Comparison of members of pro‐ and anti‐abortion organizations in Missouri

Abstract

Comparisons were made between members of Missouri Citizens for Life (MCL) and of the Abortion Rights Alliance (ARA) of Missouri. ARA members were more educated, urbanized, and had fewer children. MCL members were predominantly Catholic, and compared to ARA members, highly religious. ARA members were more inclined to favor equality of the sexes, especially in their approval of the ERA. ARA members were politically more liberal and more committed to free speech for social deviants. MCL members were much more committed to a conservative approach to matters of personal morality. MCL members regarded suicide and euthanasia as more objectionable than did their ARA counterparts, but they were also more militaristic.     

Nine demographic factors and their relationship to attitudes toward abortion legalization

The 1967 Gallup Poll on attitudes toward abortion legislation taken for the Population Council was studied by multivariate analysis of 9 demographic factors: age, family income, occupation of household head, race, section of the country, sex, city size, education and religion. The poll was taken in two waves that totaled 6,065 cases (after weighting for a representative sample and elimination of "don't know" and "no answer" responses). The question asked for approval or disapproval of the legalization of abortion for the four "hard" reasons: mother's health, rape, incest, or expected child deformity. The analysis revealed that age, family income, occupation of household head, race, section of the country, and sex did not in themselves have an effect on attitudes towards abortion legalization, though they sometimes were an influence in combination with other variables. Significant statistical correlations were found between approval of abortion legalization and increasing city size and higher educational level. Abortion approval also increases along a religious scale from Jewish-Protestant-Catholic. The most significant theoretical conclusion of the study was that 6 of the 9 factors were not influential on abortion attitudes and the remaining 3 did not have strong predictive-explanatory power as expected. Re-examination of the causes of abortion attitudes is needed.     

Moral and religious influences on the amniocentesis decision

Abstract

As early as 1973 Fletcher documented moral problems families encountered as they struggled with the decision of whether or not to have amniocentesis. In this study we asked 202 women accepting and 50 women rejecting amniocentesis extensive questions about religious beliefs, behaviors, and beliefs about abortion. Members of small Protestant denominations were the most conservative. Catholics and other Protestants were intermediate with smaller differences between these middle groups. Those respondents claiming no religion or one of a non‐Christian denomination were the most liberal. Net predictors of acceptance of amniocentesis included respondents’ support for laws permitting abortion for medical reasons, negative responses about belief in the sanctity of life, having insurance, and the respondents’ political affiliation. Education and religious attendance were the most consistent net predictorsof moral attitudes. We concluded that the amniocentesis decision is influenced by many religious beliefs but is not completely determined by these.     

Abortion in Canada: religious and ideological dimension's of women's attitudes

This paper examines a number of demographic and sociocultural factors (e.g., age, marital status, family size, religion, religious assiduity, sex-role ideology) as predictors of women's attitudes toward abortion, using data from the Canadian Fertility Survey of 1984. The findings suggest that women's abortion attitudes are to a greater extent based on ideological positions. It appears that anti-abortion stance affects those women who are religious, presumably by increasing the relationship between their general sex-role ideological stances and abortion attitudes. Abortion attitudes also vary according to a woman's education, her size, and province/region of residence.     

Attitudes toward genetic testing in patients at risk for HNPCC/FAP and the German population

Adequate knowledge regarding hereditary diseases and genetics, as well as personal attitudes toward gene tests, are major determinants of optimal utilization of genetic testing. In the present study, we aimed to explore the general attitudes toward genetic testing in a sample representative of the German general population (n = 2,076) and to compare the attitudes of persons at risk for hereditary non-polyposis colorectal cancer/familial adenomatous polyposis (HNPCC/FAP) (n = 36) who had attended a university genetic counseling service, with a matched general population sample. We administered a subset of a questionnaire previously used in a Finnish study (Jallinoja et al., 1998). The 12 statements pertain to approval, disapproval, and concern for genetic testing. Overall, the results reveal high approval of genetic testing in the German population and in at-risk persons. In accordance with other studies, we find that the attitudes of individuals for whom hereditary disease is a salient issue of personal relevance and the attitudes of the general public are very similar. Only a few significant differences between these two samples emerged, indicating that at-risk persons hold a more favourable view of the testing. One intriguing finding was the high rate of "don't know" responses, especially in the general population sample. Compared to results from Finland, approval of genetic testing is lower in the German population, and endorsement of "don't knows" is remarkably higher. We argue for increased attention to the issue of attitude change after genetic counseling and for the need of comparative cross-cultural research on attitudes toward gene technology.     

Risk aversion and religious behaviour: Analysis using a sample of Danish twins

Economics offers an analytical framework to consider human behaviour including religious behaviour. Within the realm of Expected Utility Theory, religious belief and activity could be interpreted as an insurance both for current life events and for afterlife rewards. Based on that framework, we would expect that risk averse individuals would demand a more generous protection plan which they may do by devoting more effort and resources into religious activities such as church attendance and prayer, which seems to be in accordance with previous empirical results. However, a general concern regards the problems of spurious correlations due to underlying omitted or unobservable characteristics shaping both religious activities and risk attitudes. This paper examines empirically the demand for religion by analysing the association between risk attitudes on the one hand, and church attandance and prayer frequency on the other controlling for unobservable variables using survey data of Danish same-sex twin pairs. We verify the correlation between risk preferences and religion found previously by carrying out cross-sectional analyses. We also show that the association between risk attitudes and religious behaviour is driven by the subgroup of individuals who believe in an afterlife. In addition, when re-analysing our results using panel data analyses which cancel out shared factors among twin pairs, we find that the correlation found between risk aversion and religious behaviour is no longer significant indicating that other factors might explain differences in religious behaviour. Caution is needed in the interpretation of our results as the insignificant association between risk aversion and religious behaviour in the panel data analyses potentially might be due to measurement error causing attenuation bias or lack of variation within twin pairs rather than the actual absence of an association.     

Alberta euthanasia survey: 1. Physicians' opinions about the morality and legalization of active euthanasia.

OBJECTIVE: To ascertain the opinions of a sample of Alberta physicians about the morality and legalization of active euthanasia, the determinants of these opinions and the frequency and sources of requests for assistance in active euthanasia. DESIGN: Cross-sectional survey of a random sample of Alberta physicians, grouped by site and type of practice. SETTING: Alberta. PARTICIPANTS: A total of 2002 (46%) of the licensed physicians in Alberta were mailed a 38-item questionnaire in May through July 1991; usable responses were returned by 1391 (69%). RESULTS: Of the respondents 44% did believe that it is sometimes right to practice active euthanasia; 46% did not. Moral acceptance of active euthanasia correlated with type of practice and religious affiliation and activity. In all, 28% of the physicians stated that they would practice active euthanasia if it were legalized, and 51% indicated that they would not. These opinions were significantly related to sex, religious affiliation and activity, and country of graduation. Just over half (51%) of the respondents stated that the law should be changed to permit patients to request active euthanasia. Requests (usually from patients) were reportedly received by 19% of the physicians, 78% of whom received fewer than five. CONCLUSIONS: This survey revealed severely disparate opinions among Alberta physicians about the morality of active euthanasia. In particular, religious affiliation and activity were associated with the polarized opinions. The desire for active euthanasia, as inferred from requests by patients, was not frequent. Overall, there was no strong support expressed by the physicians for the personal practice of legalized active euthanasia. These data will be vital to those involved in health education and public policy formation about active euthanasia in Alberta and the rest of Canada.     

Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey

Background

Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal.

Methods

We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007.

Results

The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient’s explicit request, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids.

Interpretation

Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.Euthanasia and physician-assisted suicide are heavily debated issues in medical practice. In recent years, three European countries (Belgium and the Netherlands in 2002, and Luxemburg in 2009) and two US states (Oregon in 1997 and Washington State in 2009) decriminalized euthanasia and physician-assisted suicide under formal conditions.^1–5 Canada is among a number of countries where the debate over legalization has flared up, with a proposed bill reaching Parliament and a pro-euthanasia proposal by the Quebec College of Physicians.⁶Understandably, the issue of euthanasia triggers much emotion and can be fraught with speculative arguments. Opponents of euthanasia often argue that legalizing the procedure will lead to a rise in the use of life-ending drugs without a patient’s explicit request, especially in vulnerable patient groups.^7–10 Thus far, however, no indications of this have been found in studies of physician-assisted deaths before and after legalization in Belgium and the Netherlands.^9,11,12 In Belgium, the percentage of deaths in which life-ending drugs were used remained stable, and the proportion without an explicit request from the patient decreased.¹² Other studies have shown that euthanasia, physician-assisted suicide and the use of life-ending drugs without explicit patient request are not confined to countries where physician-assisted death is legal.^13–16In addition to knowing the overall occurrence of physician-assisted death, it is equally important for an adequately informed, empirically based debate to know its performance in vulnerable patient groups and the care put into the decision and performance. In light of legalization and its alleged effects on the use of life-ending drugs without patient request, it is also important to map similarities and differences between euthanasia and the use of life-ending drugs without explicit patient request. In this article, we report our investigation of demographic and clinical characteristics associated with physician-assisted deaths in Flanders, Belgium; the involvement of the patient, relatives and other caregivers in the decision-making process; reasons for the decisions; aspects of the treatment trajectory; and details of the performance in terms of drug use and the people administering the life-ending drugs.     

Cancer patients’ attitudes towards euthanasia and physician-assisted suicide: The influence of question wording and patients’ own definitions on responses

Objectives: The aims of this study were to: (1) investigate patients' views on euthanasia and physician-assisted suicide (PAS), and (2) examine the impact of question wording and patients' own definitions on their responses. Design: Cross-sectional survey of consecutive patients with cancer. Setting: Newcastle (Australia) Mater Hospital Outpatients Clinic. Participants: Patients over 18 years of age, attending the clinic for follow-up consultation or treatment by a medical oncologist, radiation oncologist or haematologist. Main Outcome Measures: Face-to-face patient interviews were conducted examining attitudes to euthanasia and PAS. Results: 236 patients with cancer (24% participation rate; 87% consent rate) were interviewed. Though the majority of participants supported the idea of euthanasia, patient views varied significantly according to question wording and their own understanding of the definition of euthanasia. Conclusions: Researchers need to be circumspect about framing and interpreting questions about support of 'euthanasia', as the term can mean different things to different people, and response may depend upon the specifics of the question asked.     

On euthanasia: exploring psychological meaning and attitudes in a sample of Mexican physicians and medical students

Euthanasia has become the subject of ethical and political debate in many countries including Mexico. Since many physicians are deeply concerned about euthanasia, due to their crucial participation in its decision and implementation, it is important to know the psychological meaning that the term 'euthanasia' has for them, as well as their attitudes toward this practice. This study explores psychological meaning and attitudes toward euthanasia in 546 Mexican subjects, either medical students or physicians, who were divided into three groups: a) beginning students, b) advanced students, and c) physicians. We used the semantic networks technique, which analyzed the words the participants associated with the term 'euthanasia'. Positive psychological meaning, as well as positive attitudes, prevailed among advanced students and physicians when defining euthanasia, whereas both positive and negative psychological meaning together with more ambivalent attitudes toward euthanasia predominated in beginning students. The findings are discussed in the context of a current debate on a bill proposing active euthanasia in Mexico City.     

Effect of sex on annual variations in plasma LH and FSH levels in prepubertal subjects

We studied, from 1977 to 1979, 61 females and 72 males (aged 6 to 10 years) in order to demonstrate the occurrence of FSH and LH circannual variations. The data were fitted a cosine function by least square method in order to describe any rhythm and to estimate its parameters:mesor, amplitude, acrophase. Our data suggest that in prepubertal age the behaviour of FSH secretion is different in two sexes, but without circannual rhythm. LH instead shows a statistically significant circannual rhythm in both groups, without differences in mean levels between the two sexes.     

The Health Policy Attitudes of American Medical Students: A Pilot Survey

Background

Relatively little is known about American medical student’s attitudes toward caring for the uninsured, limiting physician reimbursement and the role of cost-effectiveness data in medical decision-making. We assessed American medical student’s attitudes regarding these topics as well as demographic predictors of those attitudes, and compared them to practicing physicians.

Methods and Findings

A survey instrument was explicitly designed to compare medical student attitudes with those previously reported by physicians. Between December 1st 2010 and March 27th 2011 survey responses were collected from more than 2% of the total estimated 2010–2011 US medical student population enrolled at 111 of 159 accredited US medical schools within the 50 United States (n = 2414 of possible 98197). Medical students were more likely to object to reimbursement cuts, and more likely to object to the use of cost effectiveness data in medical decision making than current physicians according to the literature. Specialty preference, political persuasion, and medical student debt were significant predictors of health policy attitudes. Medical students with anticipated debt in excess of $200,000 were significantly less willing to favor limiting reimbursement to improve patient access (OR: 0.73 [95% confidence interval (CI): 0.59–0.89]), and significantly more likely to object to using cost effectiveness data to limit treatments (OR 1.30, 95% CI 1.05–1.60) when compared to respondents with anticipated debt less than $200,000.

Conclusions

When compared to physicians in the literature, future physicians may be less willing to favor cuts to physician reimbursements and may be more likely to object to the use of cost effectiveness data. Political orientation, specialty preference and anticipated debt may be important predictors of health policy attitudes among medical students. Early career medical providers with primary care ambitions and those who anticipate less debt may be more likely to support healthcare cost containment.     

Influence of the "Rijeka model" of bioethics education on attitudes of medical students towards death and dying--a cross sectional study

The aim of this study was to assess attitude towards euthanasia, and the influence of socio-demographic data and death education carried out through the "Rijeka model" of bioethics education for the first-year medical students of the School of Medicine, University of Rijeka, Croatia. The cross-sectional study was conducted in the academic year 20031 2004. 124 (61% female) participants were surveyed by using an anonymous questionnaire before and after training. Catholics (p = 0.003) and students from areas with populations of less than 50,000 inhabitants (p = 0.001) had significantly negative attitude towards euthanasia than others before the course, yet no differences were found following this training. Attitude towards euthanasia was significantly positive after the course (p = 0.005). All items in the questionnaire, except "Croatia should legalise euthanasia", received more positive scores after the course. Death education carried through the "Rijeka model" of bioethics education has changed attitudes of medical students towards a more positive perception of euthanasia.