Attitudes Towards Euthanasia | Literature Review

Introduction

This literature review is based upon people’s attitudes towards Euthanasia, which comes from the Greek meaning ‘good death’ and in English means the killing of one person by another to relieve the suffering of that person and Physician Assisted Suicide (PAS), which is described as; a medical professional aiding a person who is incapable of the act themselves to commit suicide, (NHS, 2010). For this literature review, a literature search was performed using the Cochrane library, Science Direct, EBSCOhost and Sage using the key words:

• Assisted suicide
• Euthanasia
• Opinions
• Attitude
• United Kingdom
• Public
• Right to Die
• Assisted Dying

Most of these words (with the exception of Assisted Suicide and Assisted Dying) were used in each of the search engines individually and also used to form sentences, however, the only electronic databases that gave this search the information it required was Sage. This provided a substantial amount of journals, a lot of the others used were subscription based or a fee was required, but from the free to use information two of the most relevant to the subject I wished to perform the review on were chosen. The two papers were chosen from surveys and studies performed in the United Kingdom, because it was decided to research what the thoughts and feelings of medical professionals were in a place where this practice was presently illegal. Use in the literature search, but this was difficult to come by. The titles of the three journals are: ‘Legalisation of Euthanasia or Physician Assisted Suicide: Survey of Doctors’ Attitudes’, and Opinions of the Legalised of Physician Assisted Suicide. Despite not inputting the word ‘physician’ into the search engine, a lot of the searches came up with types of journals which mention this anyway.

This review will critically evaluate the information in the journals and will be compared with each other, discussing the disadvantages of the surveys and the advantages. The review will also include the various research methods used in the research.

The Literature Review

The first paper reviewed is in English by Clive Seale, PhD, from the Centre for Health Sciences, Barts and The London School of Medicine and Dentistry, London and is called ‘The legalisation of Euthanasia or Physician-Assisted Suicide: Survey of Doctors’ Attitudes’. The protocol was to determine what doctors’ opinions about the legalisation of medically assisted dying (which includes the terms, euthanasia and physician-assisted suicide (PAS)) were and this was done in comparison with the opinions of the general public of the UK. The methodology was to send out structured questionnaires with a series of questions using qualitative methods and then analyse the results in a quantitative manner. In 2007, Binley’s database (http://www.binleys.com) was used to send questionnaires to 8857 currently working medical practitioners all over the UK, this was broken down into 2829 (7%) GPs, 443 (43%) neurologists, 836 (21% of these were doctors) specialists in the care of the elderly, 462 (54% of these were also doctors) specialists in palliative medicine and 4287 workers in other hospital based specialities. This is quite a large sample to use and covers a wide range of specialities. It is not clear in what month in 2007 these questionnaires were sent out but follow-up letters were sent to non-respondents between November 2007 and April 2008 to enquire as to why they did not respond, in which 66 doctors in all responded with the most common reason being lack of time to complete the survey. Overall the response rate was 42.1% with specialists in palliative medicine being the most responsive with 67.3% of people returning their questionnaire, along with specialists in the care of the elderly (48.1%) neurologists (42.9%) other hospital specialties (40.1%) and GPs (39.3%). Despite the large sample of people, 42.1% of replies are quite disappointing, although it is a very emotive subject.

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The questions consisted of personal questions such as age, gender, grade, ethnic origin, and speciality of the respondent and, on average, the number of deaths attended. They were all asked four questions about their attitude towards euthanasia and assisted suicide, in order to obtain the questionnaire in full the author of the survey invited people to contact him. An email was sent: Appendix (a) and a reply was received the next day: Appendix (b). Previous surveys regarding this subject were performed in the Netherlands, Oregon (USA) and Belgium majority support from the medical profession has been important in passing permissive legislation in these countries.

The keywords used in this study were assisted dying; euthanasia; physician-assisted suicide; right to die and terminal care. The distribution of questionnaires meant that the methodology used was right as it was discreet and reached a lot of people in a short amount of time, the only danger with this method was that the medical professionals did not have to respond which was shown in the return response of 42.1% there was no financial or other incentive as this would go against all ethical considerations. Ethical approval for this study was granted by the South East Research Ethics Committee. The results showed that those who were specialists in palliative medicine were more opposed to euthanasia or PAS being legalised than the other specialities, although this could be down to the higher response rate in this area. Those that expressed their religious beliefs were more opposed to the legalisation also. The study showed that the most widely held view was that British doctors do not support legalising assisted dying in either euthanasia or PAS; this differs from the British Social Attitudes (BSA) survey which has tracked changes in public opinion since 1984, and is the most consistent source of data (http://www.britsocat.com).

The second paper reviewed is ‘Survey of doctors’ opinions of the legalisation of physician assisted suicide’ by William Lee, Annabel Price, Lauren Rayner and Matthew Hotopf from the Institute of Psychiatry. King’s College, London. The protocol is similar to the first paper in that they were looking at practitioners’ opinions on euthanasia and PAS. The article begins by saying that there is wide support among the general public for assisted dying but not so much for those who care for the dying. The methodology was to send out a postal survey of a 1000 senior consultants and medical practitioners were selected randomly from the commercially available ‘Informa Healthcare Medical Directory (2005/2006), retired doctors were excluded from the survey. Questionnaire were sent firstly in February 2007, 12 weeks later, in May, non-respondents were contacted and then six weeks later they were telephoned, it was discovered that that some of the possible contributors had moved, died or retired. This information was adjusted to take this into account. The authors completed separate univariable (a single variable) and multivariable (containing more than one variable) predicting the outcomes using polytomous methods which would allow two outcomes to be predicted together.

The response rate to the survey was 50% once the exclusions were accounted for, which is higher than the first paper and still gave a lot of date to work with. Included in the survey the authors included a brief outline of the Assisted Dying for the Terminally Ill Bill (2006) 32% of the doctors who responded had read some of the Bill. Gender, speciality and years in post had no effect on opposition or support for a new law. An interesting point noted is that the views of doctors who do not care for the dying tally with the general publics view, so there is some correlation there with 66% of those who never cared for the dying supporting a change in the law. The outcome of interest for the authors was to what level practitioners agreed with the statement: “The law should not be changed to allow assisted suicide”.

A second outcome of interest was the level of agreement with the statement “I would be prepared to prescribe a fatal drug to a terminally ill patient who was suffering unbearably, were that course of action to become legal”. (Hotopf, et. al. 2007:3). The findings of this questionnaire can be found in Appendix (c). Both of these questions were determined using five-point Likert-type scales, used commonly in questionnaires, following this were converted into three-point scales comprising of ‘agree’, ‘neither agree nor disagree’ and ‘disagree’ with a change in law. The survey shows that senior doctors are split abut their views regarding a change in the law; fewer are in favour than the general public in the United Kingdom. These findings have been noted in the US, as well as Canada, Finland and the Netherlands as well as the UK. Ethical permission was gained from the Institute of Psychiatry, King’s College London Research Ethics Committee.

Comparisons and Conclusions

There are many comparisons between the two papers, for example, both sent out questionnaires to their target group, who were specialists in certain fields. However, the first paper surveyed over double the amount of people the second paper did but got less replies. Both studies were done in the same year but it is difficult to tell who started theirs first as the date for first paper is unknown other than it was performed in 2007. The second survey is far more in depth that the first one, and it suggests that qualitative research is needed to understand doctors’ views better whereas the first paper did not state which the preferred method was. The second paper suggests that doctors who oppose a change in the law comes from an ‘over-optimistic’ credence in their ability to relieve the suffering of the dying. (Hotopf, et.al. 2007). It is possible to argue against this though and the knowledge and experience of patients who are dying influences views about PAS. Both compare the attitudes between the general public and the specialist doctors and note a big difference between them. On the whole both papers conducted a thorough and precise survey but there is room for further research and investigation.

References

Hotopf, L, Lee, W, Price, A, and Rayner, L. (2009) ‘Survey of Doctors’ Opinions of the Legalisation of Physician-Assisted Suicide’, Bio-Med Central, [Online], Available from: http://www.biomedcentral.com/content/pdf/1472-6939-10-2.pdf [Accessed: 22nd April 2010].

NHS (2010) Euthanasia and assisted suicide [Online], London. Available from: http://www.nhs.uk/Conditions/Euthanasiaandassistedsuicide/Pages/Definition.aspx [Accessed 22nd April 2010].

Seale, C. (2009) ‘Legalisation of Euthanasia or Physician-Assisted Suicide: Survey of Doctors’ Attitudes’, Palliative Medicine, [Online], Available from: http://pmj.sagepub.com/cgi/content/abstract/23/3/205 [Accessed 22nd April 2010].

Papers used in Literature Search:

Hotopf, L, Lee, W, Price, A, and Rayner, L. ‘Survey of Doctors’ Opinions of the

Legalisation of Physician-Assisted Suicide’.

Seale, C ‘Legalisation of euthanasia or physician-assisted suicide: survey of doctors’ attitudes’.

Appendix

(a)

—–Original Message—–

From: Katy Marsland (08111890) [mailto:k.marsland@students.lincoln.ac.uk]

Sent: 26 April 2010 19:25

To: c.seale@qmul.ac.uk

Subject: A Questionnaire request.

Dear Sir,

I am at the University of Lincoln and am doing a literature review for my

degree in Health and Social care involving your survey on the Legalisation

of Euthanasia or Physician-Assisted Suicide: Survey of Doctors’ Attitudes,

and was wondering if it were possible for you to forward me a copy of the

questions in order to aid my review?

Many thanks in advance

Katy Marsland

Reply:

Here is the questionnaire. Clive

(b)

END OF LIFE DECISIONS IN MEDICAL PRACTICE: CONFIDENTIAL ENQUIRY

PLEASE TICK THE BOXES TO INDICATE YOUR ANSWERS

THANK YOU FOR YOUR ASSISTANCE 

General Background Questions

Your age

 under 35 years of age

 36 to 45 years of age

 46 to 55 years of age

 56 to 65 years of age

 over 65 years of age

Your gender

 male

 female

Your medical specialty

 General practice

 Palliative medicine

 Neurology

 Elderly Care

 Other, please specify

Grading of your post

 Consultant

 Specialist registrar

 Associate specialist / staff grade

 SHO / HO / F1 / F2

 GP principal

 GP registrar

Please indicate the number of deaths, on average, for which you would be the treating or attendant doctor in the normal course of your duties

Answer only one of (a), (b) or (c). (Please give the most accurate estimate you can)

(a)_______________per week

(b)_______________per month

(c)_______________per year

Have you been the treating or attendant doctor in the case of a death in the last 12 months?

 yes

 no – Please go to question 30, on page 7

SPACE FOR COMMENTS ONCE YOU HAVE FINISHED THIS QUESTIONNAIRE

Once you have completed this questionnaire, you can use this space to provide any clarifications to your answers or make other points

PLEASE TRY TO RECALL AS CAREFULLY AS POSSIBLE THE MOST RECENT DEATH WITHIN THE LAST 12 MONTHS FOR WHICH YOU WERE ACTING AS THE TREATING OR ATTENDANT DOCTOR, AND ANSWER ALL OF THE QUESTIONS 1 TO 29 FOR THAT PARTICULAR DEATH

It is, of course, impossible to do justice to all the finer nuances of decisions concerning the end of life in a short questionnaire. But please indicate those answers which approach the actual circumstances of this death as closely as possible.

1

Sex of the deceased

 male

 female

2

Age of the deceased

(please estimate if unsure)

 under 1 year

 1-9 years

 10-19 years

 20-29 years

 30-39 years

 40-49 years

 50-59 years

 60-69 years

 70-79 years

 80-89 years

 90 years and over

3

Place of death

 hospital

 hospice

 care home

 deceased’s own home

 other (please specify)

4

Cause of death

*This does not mean the mode of dying,

such as heart failure, asphyxia, asthenia,

etc: it means the disease, injury, or

complication which caused death

1a Disease or condition directly leading to death*

1b Other disease or condition, if any, leading to 1 (a)

1c Other disease or condition, if any, leading to 1 (b)

2 Other significant conditions contributing to the death but not related to the disease or condition causing it

5

With respect to this death, when was your first contact with the patient?

 before or at the time of death: go to Question 6

 after death: go to question 30, on page 7

6

How long had you known this patient?

 more than six months

 one to six months

 one to four weeks

 between one day and one week

 less than 24 hours

Medical actions

7a

7b

7c

Concerning this death, did you or a colleague:

withhold a treatment* (or ensure that this was done)?

withdraw a treatment* (or ensure that this was done)?

use any drug to alleviate pain and/or symptoms?

(please tick as many answers as apply)

* IN THIS STUDY ‘TREATMENT’ INCLUDES CARDIO-PULMONARY RESUSCITATION (CPR), ARTIFICIAL FEEDING AND/OR HYDRATION

 no

 yes (please specify treatments withheld)

…………………………………………………………….

 no

 yes (please specify treatments withdrawn)

…………………………………………………………….

 no

 yes, morphine or another opioid

 yes, benzodiazepine

 yes, other drug

8a

8b

In withholding a treatment, did you or your colleague consider it probable or certain that this action would hasten the end of the patient’s life?

In withdrawing a treatment, did you or your colleague consider it probable or certain that this action would hasten the end of the patient’s life?

 no

 yes

 no treatment withheld

 no

 yes

 no treatment withdrawn

9a

9b

Concerning the drugs used to alleviate symptoms, (Questions 7c), were these administered

knowing this would probably or certainly hasten the end of life?

partly intending to end life?

 no

 yes

 no drugs used to alleviate symptoms

 no

 yes

 no drugs used to alleviate symptoms

10a

10b

In withholding a treatment, did you or your colleague have the explicit intention of hastening the end of life?

In withdrawing a treatment, did you or your colleague have the explicit intention of hastening the end of life?

 no

 yes

 no treatment withheld

 no

 yes

 no treatment withdrawn

11a

11b

Was death caused by the use of a drug prescribed, supplied or administered by you or a colleague with the explicit intention of hastening the end of life (or of enabling the patient to end his or her own life?)

If yes, who administered this drug (i.e. introduced it into the body)?

 no

 yes

 the patient

 you or another health care colleague

 a relative

 someone else

NOTE: IF YOU ANSWERED ‘NO’ TO ALL THE QUESTIONS ON THIS PAGE, GO TO QUESTION 23

Decision making

NOTE: QUESTIONS 12 TO 22 REFER THE LAST-MENTIONED ACT OR OMISSION, THAT IS, THE LAST ‘YES’ THAT YOU TICKED ON THE PREVIOUS PAGE (QUESTIONS 7 TO 11)

12

Which were the most important reasons for the last-mentioned act or omission?

(please tick all that apply_

 patient had pain

 patient had other symptoms

 request or wish of the patient

 request or wish of relatives

 expected further suffering

 no chance of improvement

 treatment would have been futile

 further treatment would have increased suffering

 other (please specify below)

……………………………………………………………….

13

In your estimation, how much was the patient’s life shortened by the last mentioned act or omission?

 more than six months

 one to six months

 one to four weeks

 between one day and one week

 less than 24 hours

 life was probably not shortened at all

14

Did you or a colleague discuss the last-mentioned act or omission with the patient?

 yes, at the time of performing the act/omission

or shortly before: go to Question 15

 yes, some time beforehand: go to Question 15

 no, no discussion: go to Question 19

15

At the time of this discussion, did you consider the patient had the capacity to assess his/her situation and make a decision about it?

 yes

 no

16

Did this discussion include the (probable or certain) hastening of the end of the patients’ life by this last-mentioned act or omission?

 yes

 no

17

Was the decision concerning the last mentioned act or omission made in response to an explicit request from the patient?

 yes, upon an oral request

 yes, upon a written request

 yes, upon both an oral and a written request

 no: go to Question 21

18

At the time of this request, did you consider the patient had the capacity to assess his/her situation and make a decision about it?

 yes: go to Question 21

 no: go to Question 21

ONLY ANSWER QUESTIONS 19 and 20 IF YOUR ANSWER TO QUESTION 14 WAS ‘NO, NO DISCUSSION’

19

Did you consider the patient had the capacity to assess his/her situation and make a decision about it?

 yes

 no

20

Why was the last mentioned act or omission not discussed with the patient?

(Please fill in as many answers as apply)

 patient was too young

 the last mentioned act or omission was clearly the best

one for the patient

 discussion would have done more harm than good

 patient was unconscious

 patient had significant cognitive impairment

 patient was suffering from a psychiatric disorder

 other, please elaborate at the end of the questionnaire

21

Did you or a colleague discuss with anybody else the (possible) hastening of the end of the patient’s life before it was decided to take the last mentioned act or omission?

(Please fill in as many answers as apply)

 with one or more medical colleagues

 nursing staff /other caregivers

 by partner/relatives of the patient

 someone else

 nobody

22

Which were the most important reasons for the last-mentioned act or omission?

(please tick all that apply)

 patient had pain

 patient had other symptoms

 request or wish of the patient

 request or wish of relatives

 expected further suffering

 no chance of improvement

 further treatment would have been futile

 further treatment would have increased suffering

 other (please specify below

………………………………………………………………

NOTE: QUESTIONS FROM HERE ONWARDS SHOULD BE ANSWERED WHETHER OR NOT YOU ANSWERED ‘YES’ TO ANY OF THE ACTS OR OMISSIONS MENTIONED ON PAGE 3 (QUESTIONS 7 TO 11)

23

Was an explicit request to hasten the end of the patient’s life made by any of the following?

(Please tick all that apply)

 partners/relatives of the patient

 nursing or other care staff

 someone else

 no explicit request

24

As far as you know, did the patient ever express a wish for the end of his/her life to be hastened?

 yes, clearly: go to Question 25

 yes, but not very clearly: go to Question 25

 no: go to Question 26

25

Did the patient’s wish for this outcome reduce or disappear over time?

 no

 yes, in response to care provided

 yes, other reason

26

The treatment during the last week was mainly

aimed at:

 recovery

 prolonging life

 support during the dying process

27

Which caregivers were involved in the care for the patient during the last month before death (beside yourself and as far as you know)?

(please tick all that apply)

Of those not involved, which ones might have helped?

Involved

Not involved and

might have helped

general practitioner





specialist in pain relief





palliative care team





psychiatrist /

psychologist





nursing staff





social care worker





spiritual caregiver





volunteer





family member





28a

28b

28c

28d

Was the patient continuously and deeply sedated or kept in a coma before death?

Which medication was given for sedation?

(please tick as many answers as apply)

At what time before death was continuous sedation of the patient started?

Which were the most important reasons for this sedation?

(please tick all that apply)

 yes

 no: go to Question 29a

 midazolam

 other benzodiazepine

 morphine or another opioid

 other type of medication

……. hours before death

……. days before death

……. weeks before death

 patient had intractable pain

 patient had intractable psychological distress

 patient had other intractable symptoms

 request or wish of the patient

 request or wish of relatives

 other (please specify below

……………………………………………………………

29a

29b

29c

Did the patient receive morphine or another opioid during the last 24 hours before death?

How much time before death was the administration of morphine or another opioid started?

Which figure best illustrates the dosage of morphine or another opioid during the last 3 days before the patient’s death?

 yes

 no go to Question 30

……. hours before death

……. days before death

……. weeks before death

 No increase

 Gradual increase

 Strong increase last day

Attitudes and beliefs

Questions 30 and 31 are about voluntary euthanasia (that is, when someone ends the life of another person at their request), worded in the same way as those used in surveys of general public opinion.

30

30a

30b

First, a person with an incurable and painful illness, from which they will die – for example, someone dying of cancer.

Do you think that, if they ask for it, a doctor should ever be allowed by law to end their life, or not?

And do you think that, if this person asks for it, a doctor should ever be allowed by law to give them lethal medication that will allow the person to take their own life?

 Definitely should be allowed

 Probably should be allowed

 Probably should not be allowed

 Definitely should not be allowed

 Definitely should be allowed

 Probably should be allowed

 Probably should not be allowed

 Definitely should not be allowed

31

31a

31b

Now, how about a person with an incurable and painful illness, from which they will not die.

Do you think that, if they ask for it, a doctor should ever be allowed by law to end their life, or not?

And do you think that, if this person asks for it, a doctor should ever be allowed by law to give them lethal medication that will allow the person to take their own life?

 Definitely should be allowed

 Probably should be allowed

 Probably should not be allowed

 Definitely should not be allowed

 Definitely should be allowed

 Probably should be allowed

 Probably should not be allowed

 Definitely should not be allowed

32

Religion: what is your religion?

 None

 Christian (including Church of England, Catholic,

Protestant and all other Christian denominations)

 Buddhist

 Hindu

 Jewish

 Muslim

 Sikh

Any other religion, please write in

33

Religion: would you describe yourself as:

 extremely religious

 very religious

 somewhat religious

 neither religious nor non-religious

 somewhat non-religious

 very non religious

 extremely non religious

 can’t choose

34

What is your ethnic group?

Choose ONE section from A to E, then tick the appropriate box to indicate your ethnic group

A White

 any White background

B Mixed

 White and Black Caribbean

 White and Black African

 White and Asian

 Any Other Mixed background, please write in

C Asian or Asian British

 Indian

 Pakistani

 Bangladeshi

 Any Other Asian background, please write in

D Black or Black British

 Caribbean

 African

 Any Other Black background, please write in

E Chinese or other ethnic group

 Chinese

 Any Other, please write in

To clarify any answers or to make further comments, please use the space on page 1.

Thank you for your help with this important survey.

Now that you have finished the questionnaire, to ensure the anonymity of your answers you will need to do two things.

Place the completed questionnaire in the reply-paid envelope, seal it and post it as soon as possible

Post the reply-paid response notification card with your name on it if you wish to avoid receiving follow-up reminders.

These two items will be received by different people in different locations and kept separate. It will not be possible to link your questionnaire with your name.

This questionnaire has been sent to a random sample of 10,000 doctors. It will not be possible for the researchers or anyone else to use your replies to discover your identity or the identity of the patient on whose care you have reported.

We understand that recalling events of this nature can be a distressing experience. If you wish to talk to someone about your feelings concerning end-of-life care, the Confidential Counselling Helpline of the British Medical Association can assist you. Their number is: 0645 200 169

(c)

Euthanasia and Assisted Suicide in the United Kingdom

A Research Proposal

Part B

By Katy Marsland 08111890

University of Lincoln

Hand in Date: 4th May 2010

(1,352 Words)

Julie Burton

NUR2002M-0910 research Methods

2009/2010

Table of Contents: Page

Title 26

Research Questions 27

Aims of Project 28

Initial Literature Review 29-30

Methodology 31

Ethical Considerations and Practical Constraints 32

Timetable for Dissertation Research 33-34

References 35

A Research Proposal

1. Title:

Euthanasia and Assisted Suicide in the United Kingdom.

2. Research Questions

Should Euthanasia and Assisted Suicide be made legal? What are the arguments for and against policy change in the United Kingdom? Which section of society is most supportive of a change in the law? Which section is most opposed and why?

3. Aims of Project

This research aims to investigate, using secondary data, whether a change in the law is needed to clarify the position of euthanasia and assisted suicide in the United Kingdom, and whether this should be made legal just for those who are terminally ill or for