Discussion

As expected, two different positions on the acceptability of PAS were found. Among lay people in Togo, the majority position was ‘acceptability depends on circumstances’. This finding was consistent with similar studies in India18 and France,20 and in contrast with a similar study in Kuwait.17 Among health professionals, the majority position was ‘never acceptable,’ consistent with a similar study conducted among French health professionals.19 Health professionals, in Togo as elsewhere, are trained to save lives not to end them and would be at risk of personal involvement in the performance of PAS. They would, therefore, be more likely than lay people to experience legal, ethical and emotional reservations about PAS.

Among the participants holding the ‘acceptability depends on circumstances’ position, all factors considered in the study—patient's age, curability of the illness, type of suffering and extent of patient requests to end her life—impacted significantly on acceptability judgments but patient's age and curability had the most impact. The great importance given to patient's age can be explained not, as in the study in India18 by a belief in reincarnation, but by the distinction in the Togolese culture between ‘good death’ and ‘bad death’. Death of a young person is considered premature and ‘unnatural’, leads to a partial destruction of social cohesion and is seriously mourned; no formal rituals are associated with burial.23 In contrast, death of an old person is considered a great blessing for the whole society since it is considered a ritual of passage into becoming an ancestor: ancestor status is the highest stage of the developmental trajectory of personhood.24

The great importance given to curability of the illness was, however, a new finding. In studies in India18 and France,20 the curability factor was significant but its effect was always limited in size. The scarcity of medical resources in Togo may incline lay people to consider the label of ‘difficult to treat’ not, as in France, as a property of the illness, that is, as a sign of illness severity (in which case PAS might be almost as acceptable for difficult to treat as for incurable) but as an indication of the difficulty of obtaining the treatment or of its high cost to the family.

The limited importance given to patient's request was consistent with findings in India18 and Kuwait17 but in sharp contrast to the studies among Westerners20 ,21 that have repeatedly shown that, in decisions about ending life, the principle of patient autonomy tends to dominate the other principles of medical ethics. As, however, explained by Blank (ref. 25, p. 204): “Three-quarters of the world's population is not linked to concepts such as individual autonomy and truth telling that are assumed by the conventional western bioethics community as critical in medicine.” One might worry, therefore, that, without an emphasis on patient autonomy, legalised PAS might lead to abuse.

Finally, the importance given to the type of suffering was also a new finding. In other studies,17 ,18 participants did not consider that completely dependent people should be treated differently from people suffering from physical pain. Among Togolese, however, PAS was more acceptable in the case of complete dependence. Keeping persons alive who are completely dependent and who wish to end their lives might appear nonsensical in a context in which other patients who could be successfully treated are unable to obtain treatment owing to lack of resources.

The study has, of course, limitations. First, the group of participants was a convenience sample and of only moderate size. Second, the judgments of people living in the capital city may differ from those of people living in other parts of the country. Third, the participants responded to vignettes, not to real patients. The use of vignettes, however, is useful—it permits statistical analyses to reveal how people weight and combine separate factors. Fourth, the experimenter did not ask further questions to elucidate the reasons, no doubt personal and cultural, for the participants’ responses. Fifth, the health professionals were contacted at their place of work whereas the lay people were contacted in the streets. It is possible that responding to the scenarios while in the hospital influenced the health professionals’ judgments. In summary, (a) a majority of people living in Lomé, Togo, do not appear to be systematically opposed to PAS, whereas a majority of health professionals are opposed to it; (b) the most important factors in increasing acceptability among people who were not systematically opposed to PAS were patients’ advanced age and curability of the illness; (c) additional acceptability was provided by the patients’ request to have their life ended, although much so less than in studies in Western countries, and by suffering characterised by complete dependence rather than by extreme physical pain.