Article Text

Veterinary surgeons' attitudes towards physician-assisted suicide: an empirical study of Swedish experts on euthanasia
  1. Henrik Lerner1,
  2. Anna Lindblad2,
  3. Bo Algers3,
  4. Niels Lynöe2
  1. 1Centre for Applied Ethics, Linköping University, Linköping, Sweden
  2. 2Centre for Healthcare Ethics, Karolinska Institute, Stockholm, Sweden
  3. 3Department of Animal Environment and Health, Swedish University of Agricultural Sciences, Skara, Sweden
  1. Correspondence to Dr Henrik Lerner, Centre for Applied ethics, Linköping University, SE-58183 Linköping, Sweden; henrik.lerner{at}


Aim To examine the hypothesis that knowledge about physician-assisted suicide (PAS) and euthanasia is associated with a more restrictive attitude towards PAS.

Design A questionnaire about attitudes towards PAS, including prioritisation of arguments pro and contra, was sent to Swedish veterinary surgeons. The results were compared with those from similar surveys of attitudes among the general public and physicians.

Participants All veterinary surgeons who were members of the Swedish Veterinary Association and had provided an email address (n=2421).

Main outcome measures Similarities or differences in response pattern between veterinary surgeons, physicians and the general public.

Results The response pattern among veterinary surgeons and the general public was almost similar in all relevant aspects. Of the veterinarians 75% (95% CI 72% to 78%) were in favour of PAS, compared with 73% (95% CI 69% to 77%) among the general public. Only 10% (95% CI 5% to 15%) of the veterinary surgeons were against PAS, compared with 12% (95% CI 5% to 19%) among the general public. Finally, 15% (95% CI 10% to 21%) of veterinarians were undecided, compared with 15% (95% CI 8% to 22%) among the general public. Physicians had a more restrictive attitude to PAS than the general public.

Conclusions Since veterinary surgeons have frequent practical experience of euthanasia in animals, they do have knowledge about what euthanasia really is. Veterinary surgeons and the general public had an almost similar response pattern. Accordingly it seems difficult to maintain that knowledge about euthanasia is unambiguously associated with a restrictive attitude towards PAS.

  • Attitudes towards physician-assisted suicide
  • knowledge about euthanasia
  • veterinary surgeons
  • demographic surveys/attitudes
  • attitudes toward death
  • care of the dying patient

Statistics from


Attitudes towards euthanasia and physician-assisted suicide (PAS) among the general public seem to have changed during the last quarter of a century. The public sentiment in favour of PAS has grown.1 Even among patients close to death a majority think that PAS or euthanasia should become a legal option.2 Even though the general population is in favour of PAS and euthanasia, some studies have shown that even a rather large group of physicians, under certain conditions, find that PAS might be an option for patients at the end of life.3–6 But nevertheless it is clear that the general public is more in favour of physician-assisted suicide (PAS) than physicians are. In contrast to patients close to death, physicians who are taking care of patients in the end of life tend to be restrictive towards PAS and euthanasia; and these physicians are also more restrictive compared with physicians who do not have such experiences.3 4 Palliative care physicians in particular maintain that their goal is to help suffering patients to live as long as possible, and neither to shorten or prolong life; and they think that if patients' suffering is adequately alleviated, patients will not request euthanasia or PAS. Palliative care physicians might maintain the viewpoint that less experienced physicians and the general public do not know what they are actually reasoning about when dealing with end of life issues. Accordingly, some physicians even argue that it is not necessary to take the general public's opinions seriously.7

Apart from physicians, veterinary surgeons might be a professional group who understand what euthanasia means in practice—at least for suffering animals.8 There are similarities between veterinary surgeons and physicians even if the patients differ. Both veterinary surgeons and physicians have a basic training in physiology, pharmacology and pathology and they also share certain ethical principles,9 for example at least the principles of beneficence and non-maleficence. Their common goal is to prevent disease, to promote the health and well-being of their patients, and to provide treatment when possible. When no treatment options remain, both physicians and veterinary surgeons are supposed to alleviate suffering. However, the means of alleviating suffering differ. In human patients, palliative measures might be provided, and if the symptoms are refractory then sedation therapy may be offered. Animal patients rarely receive sedation therapy, as veterinary surgeons usually euthanise animals in such situations.10 But sometimes animal owners are so attached to their companion animal that they are not able to understand or accept that it is dying; in such cases sedation therapy has been provided to companion animals.

Another important difference is that veterinary surgeons are sometimes requested to euthanise a healthy animal if the owner, for some reason, prefers it. When PAS is considered for human patients in for example Oregon, a precondition is that the patient is suffering from a terminal illness and is judged to have less than half a year left to live. Euthanising a healthy animal is a controversial issue for veterinary surgeons, but euthanising a suffering and untreatable animal patient is not only considered as ethical defensible – it is illegal not to offer such an animal euthanasia as many national animal welfare laws prohibit unnecessary suffering.11

Even though there are both similarities and discrepancies between the ethics of physicians and veterinary surgeons, it is difficult to maintain that veterinary surgeons have no experiences of euthanasia. We have studied veterinary surgeons' attitudes to PAS, using the same questionnaire as the one applied in similar studies on the attitudes of Swedish physicians and the general public.4 5 The aim was to study veterinary surgeons attitudes to PAS and to compare it with the attitudes of physicians and the general public.

Material and methods

The present study was conducted during the period August to September 2009. The web-based survey included all veterinary surgeons who were members of the Swedish Veterinary Association and had provided an email address. This gave a total of 2421, which was approximately 80% of all veterinary surgeons in Sweden.

The questionnaire was similar to those used among physicians and the general public during spring 2007.4 5 It consisted of four parts: (1) the main question about attitude towards a physician prescribing a lethal dose of pharmaceuticals on a competent patient's request, given that certain criteria were met (see box 1); (2) arguments pro/contra PAS, among which respondents were asked to prioritise the most important one; (3) trust in the medical services if PAS should be allowed; (4) background variables.

Box 1

The participants were asked whether they found it acceptable for a physician to prescribe a lethal dose of pharmaceuticals on a competent patient's request, given that these listed criteria were met

  • The prescription of a lethal drug must be legally accepted by the authorities.

  • The patient must be at the end of life and regard his/her suffering as unbearable.

  • The patient must be decision-competent and well-informed about alternative palliative measures.

  • The patient must be asking for physician-assisted suicide by him/herself and there must be no influence from others.

  • The patient must be capable of administering the drug by him/herself.

  • The patient must not be suffering from any treatable psychiatric disorder.

  • The treating physician must have known the patient for a considerable period of time.

  • A second physician must verify that the listed criteria are fulfilled.

The results are presented as proportions with a 95% CI. A comparison is made with a similar study of the attitudes to PAS among the general public and physicians.4 5


The response rate among veterinary surgeons was 47% (n=1126). No skewness in age or sex was detected when the respondents were compared with the total group of recipients.

A majority of the veterinary surgeons, 75% (95% CI 72% to 78%), were in favour of PAS, 10% (95% CI 4% to 15%) against it and 15% (95% CI 10% to 21%) were undecided (figure 1). There were no significant differences in age or sex between respondents reporting as being pro, contra or undecided about PAS.

Figure 1

The proportions in favour of, against and undecided on physician-assisted suicide (PAS) among veterinary surgeons (present study), the general public5 and physicians4.

Those reporting in favour of PAS mainly prioritised the arguments “the aim is to minimise suffering, not to shorten the patient's life” and “respect for patient autonomy”. Among those against PAS, the most prioritised arguments were “patients who perceive themselves as burdens may experience pressure to ask for PAS”, “patients' trust in physicians may be put at risk” and “the principle of non-maleficence should override the principle of autonomy”. Those reporting being undecided chose a position in between, prioritising almost the same arguments except for “the principle of autonomy should precede the principle of non-maleficence” (see table 1).

Table 1

Prioritisation of arguments in relation to the respondents' attitudes to physician-assisted suicide (PAS)

A majority of the veterinarians, 79%, had trust in healthcare. About half of those who were in favour of PAS (n=794), 47% stated that their trust would increase if PAS was legalised, 51% claimed that there would be no difference and 2% stated that trust would decrease. Among those who were against PAS (n=89), 73% stated that their trust would decrease if PAS was allowed, 19% that it would have no influence and 8% that trust would increase. Finally, among those who were undecided (n=145), 43% thought trust would decrease, 46% that it would not be influenced and 11% that trust would increase.


Main outcome

The present study indicates that a large majority of the responding veterinary surgeons were in favour of PAS under the given criteria. These results are similar to those derived from the general population using the same questionnaire. The response pattern concerning trust is also similar. The only difference between veterinary surgeons and the general public was how the “respect for autonomy” and the “minimise suffering” arguments were prioritised. The general public tended to stress the “respect for autonomy” argument and the veterinary surgeons the “minimise suffering” argument. The response pattern in all other relevant respects was similar.

However, these results differ significantly from those of the physicians. When prioritising the different arguments there were significant differences too: the “respect for autonomy” argument was significantly expressed more frequently among physicians than veterinary surgeons. Like the general public, physicians did not underline “minimising suffering” to the same degree as veterinary surgeons.

Paternalistic approach and respecting autonomy

When veterinary surgeons provide euthanasia to a suffering animal they should solely consider whether or not it is in the best interest of the animal patient. Since the animal patient is not regarded as an autonomous individual, there is no autonomy to respect and the approach is typical for soft paternalism. The ambition of minimising suffering is quite in accordance with the beneficence and non-maleficence principles; and stressing these principles opens up a paternalistic patient–healthcare provider relationship. Possibly some veterinary surgeons might have endorsed these principles even when considering human patients.

When PAS and euthanasia is considered in human patients—in the countries where the procedures are legal—a common denominator is that the patients should be at the end of life, be suffering unbearably, be competent and request the measure him/herself. Respecting the patients' autonomy is essential for human patients, which is reflected in the response pattern of the physicians. There is, however, one situation where there might be some similarities between veterinary surgeons and physicians regarding ethical considerations: even though not legal, physicians in the Netherlands have made an agreement with coroners regarding situations when an incompetent child is dying and the suffering is unbearable. In this case physicians might get the coroners acceptance to euthanise such a child (Groningen protocol).12

Even though there are differences between veterinary surgeons' and physicians' practices and patients, it is difficult to maintain that veterinary surgeons do not know what euthanasia and PAS is about. Accordingly, it might also be difficult to maintain that knowledge of PAS and euthanasia makes people have more restrictive attitude towards PAS and euthanasia and vice versa. Having experiences about euthanising animal patients does not necessarily imply that veterinary surgeons know everything about human patients' needs, reactions, ambivalence and how they behave at the end of life. But they might nevertheless have an idea of how it might be to provide euthanasia or PAS to even a human patient.

Similarities and differences between animal patients and human ones

A similarity between physicians and veterinary surgeons is that they experience similar reactions from the “family” of the patient. Today, it is rather common that companion animals are considered as family members.13 Sometimes before euthanising an animal, the family even have a farewell ceremony, as if the animal was a member of the extended family. Accordingly, both physicians and veterinary surgeons have to learn how to give bad news to both patients and families/animal owners.14 In addition, among veterinary surgeons there is a widely shared notion that they need to support some animal owners in the same manner as palliative healthcare providers act towards relatives of dying human patients.15

Both physicians and veterinary surgeons also seem to share similar experiences after ending the life of a patient, even if the species of the patient differs. The moral concerns and agonies after having euthanised a seriously ill human patient as described by Dutch physicians16 show many similarities to the reactions reported by veterinary surgeons, especially those involved in the care of companion animals.10 But although both professions may experience moral concerns, euthanasia may also be regarded the least bad thing to do in the particular situation.

Although physicians and veterinary surgeons have common goals in their professions, there are differences in how these goals are achieved. According to the Swedish legislation, it is mandatory for a veterinary surgeon to euthanise a suffering animal in the end of life and most veterinary surgeons have no moral concern in doing so. Veterinary surgeons might consider it morally problematic when they are asked to euthanise a healthy animal. Physicians in Sweden (as well as most other countries), on the other hand, are forbidden to intentionally hasten the death of their patients, even if the patients are terminally ill and suffering unbearably. Accordingly, physicians have to carefully titrate and justify the doses and use of for example morphine and barbiturates in order to prevent any accusation of euthanasia. Such considerations might influence whether or not symptoms are treated adequately. Although physicians might be accused of neglect if patients are treated inadequately, it cannot be ruled out that human patients sometimes receive suboptimal treatment in the end of life.

Validity aspects

The relatively low response rate among veterinary surgeons may be due to the fact that it was a web-based survey17 and the fact that PAS is not a central issue for them.

The respondents were, however, representative of the total group of members of the Swedish Veterinary Association with regard to age and male/female ratio. The risk of gender and age bias might therefore be considered as rather low, which is important since men are over-represented among older veterinary surgeons and women among younger ones. The survey among veterinary surgeons was conducted two and a half years after the studies concerning physicians and the general public. However, during that period no changes in legislation or other events occurred that might have influenced the veterinary surgeons.


Similar to the general public, most Swedish veterinary surgeons are in favour of PAS. Since veterinary surgeons have long experience of performing euthanasia in animals it seems difficult to assert that they do not understand what it means to provide PAS at the request of a terminally ill and competent patient. Accordingly, it is difficult to maintain that knowledge about PAS and euthanasia is unambiguously associated with a restrictive attitude towards these measures.


We thank Ph. D. Petter Tinghög, who has offered valuable comments on statistics as well as on methodology for the study of veterinary surgeons. He was also helpful in suggesting valuable statistical literature for this study.


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  • Funding HL and BA received a grant from KSLA (Stiftelsen Carl-Fredrik von Horns fond, H-526) for the study of attitudes among veterinary surgeons.

  • Competing interests None declared.

  • Ethics approval The study design for this study has been presented to one of the research ethical committees in Sweden, and the committee had no concerns (Dnr M155-09).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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