Attitudes towards euthanasia among physicians, nurses and the general public in Finland

Abstract

The object of this study was to investigate the attitudes of physicians, nurses and the general public to physician-assisted suicide (PAS), active voluntary euthanasia (AVE) and passive euthanasia (PE) in Finland.

Respondents received a postal questionnaire to evaluate the acceptability of euthanasia in five scenarios, which were imaginary patient cases. Age, severity of pain and prognosis of the disease were presented as background factors in these scenarios.

This work was carried out in Finland in 1998.

The respondents include a random selection of 814 physicians (506 responded, 62%), 800 nurses (582 responded, 68%) and 1000 representatives of the general public (587 responded, 59%).

Thirty-four percent of the physicians, 46% of the nurses and 50% of the general public agreed that euthanasia would be acceptable in some situations. Of the scenarios, PE was most often considered acceptable in cases of severe dementia (physicians 88%, nurses 79% and general public 64%). In the same scenario, 8% of physicians, 23% of nurses and 48% of general public accepted AVE. In the scenario of an incurable cancer, 20% of the physicians, 34% of the nurses and 42% of the general public accepted PAS. All forms of euthanasia were generally more acceptable in older, than in younger, scenario patients.

This paper conclude that PE was largely accepted among Finnish medical professionals and the general public. Only a minority favored AVE and PAS.

Public Health (2002) 116, 322–331

Introduction

The debate over euthanasia has become increasingly active throughout western societies in recent years. Great technological advances in medicine during the last decades have made it possible to prolong life considerably. One of the nagging ironies of modern medicine is that suffering may actually be increased by extending the natural dying process with such technologies. At the same time, attitudes towards death have changed, too, although euthanasia remains an emotionally charged issue.

Euthanasia has been a neglected topic in Finland for many decades. During the last years, however, euthanasia and physician-assisted suicide (PAS) have become issues of public debate. The legalization of euthanasia has been supported by the general public, and also by some physicians. There are presently several associations and movements that are actively applying pressure on politicians to legalize euthanasia in Finland. Among the general public, there may be some fears concerning difficult and painful deaths, in addition to their insecurities regarding medical technology. Subsequently, people are increasingly prepared to take control of their own dying process.

The word ‘euthanasia’ literally means ‘a good death’, and is used to indicate a serene and peaceful departure; the kind of death we might all wish for ourselves and others.1, 2

In PAS, a physician provides a medical means for death, usually as a prescription for a lethal amount of medication that the patient takes on his or her own. Euthanasia occurs when the physician directly and intentionally administers a substance to cause death.³ In such a case, the euthanasia is considered to be ‘active’. When death is brought about by an inaction, such as non-resuscitation in a case of cardiac arrest, it is called ‘passive’ (passive euthanasia, PE). Some ethicists have criticized the subtle division between ‘active’ and ‘passive’ forms of euthanasia, because the ultimate goal and result are, in fact, the same.⁴ Indirect euthanasia is exemplified by the administration of narcotics to relieve pain, but in such large doses as to eventually cause respiratory depression and, subsequently, the patient's death.⁴

Euthanasia is called ‘voluntary’ (active voluntary euthanasia, or AVE) when it is administered to people who have requested it, or who have given their informed consent. Euthanasia is called ‘involuntary’ when it is administered to people who have indicated that they wanted to live, or that they wanted to live and no one had ever bothered to ask. In the case of non-voluntary euthanasia, the patient had not expressed wishes or desires, or it was impossible to obtain such information. Both involuntary and non-voluntary euthanasia have been considered as benevolent, and must be distinguished from murder.⁴

The discussion concerning both AVE and PAS is important to physicians, nurses and patient, as all groups favor an easing of the dying process by reducing the time of pain and suffering in terminal patients. But attitudes toward AVE vary considerably; some consider AVE as a euphemism for murder, while others view this as a caring act that assists the terminal patient towards inevitable death. Several declarations have condemned AVE and PAS as unethical (World Medical Association Declaration on Euthanasia, adopted by the 39th World Medical Assembly, Madrid, Spain, October 1987, World Medical Association Statement on Physician-Assisted Suicide, adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992, The Handbook of the World Medical Association Policy, http://www.wma.net/e/policy.html).

Typically, AVE is rejected on the basis of religious arguments; eg life is considered to be a gift from God, and a human being has no right to take it away, even when asked. Commonly mentioned is the ‘slippery slope’ hypothesis; legalizing AVE may lead to an extension from competent patients to incompetent ones, like children, and those who are mentally ‘incompetent’ or comatose. One strong argument against AVE is that its legalization under voluntary circumstances may permit an exception to become a standard; where chronically ill patients may be pressured, either verbally or by a common attitude, to choose AVE in order to avoid the high costs of their terminal care.⁴ One remote concern is that consistently rising health care costs could force a community to authorize AVE for economic reasons. It has also been argued that favoring AVE is the result of a paradoxical human hybris; eg a post-modern human being wants to manipulate death by taking the initiative, like Nazi-leader Goering, who avoided execution by committing suicide.

In the Hippocratic Oath the physician promises ‘not give a deadly medicine to anyone’, which has engendered a dominant attitude for centuries. Opponents of AVE often remind us about the horrific examples of euthanasia in Nazi Germany, similar to opponents of abortion, which is also contrary to the Oath. Seldom, however, do individuals carefully consider the opening sentence of the Hippocratic Oath, which states ‘according to ability and judgement’. In short, the physician is to be educated and experienced enough to make these case by case decisions.

The idea of AVE appears throughout history. Thomas Moore and Francis Bacon, for instance, recommended euthanasia for patients with incurable diseases. S.D. Williams in 1870, C.E. Goddard in the early 20th century and C.K. Millard in 1931 all proposed the legalization of AVE.⁴ Some countries, like Oregon State in the United States, Australia and Switzerland have at least partially legalized AVE, but in facto and not in jure. The Netherlands has legalized euthanasia also in jure.

Arguments supporting AVE are based on four major claims:⁴

• The autonomy of a human being justifies him or her to decide about the ending of one's own life.

• AVE is seen as a caring action for a suffering person.

• Active AVE is not considered as different from passive AVE. If withholding a hopeless treatment is not seen as unethical, then active AVE must be seen as having equal ethical value.

• Bad experiences from Nazi Germany, or the idea of a ‘slippery slope’, are too abstract and speculative to be used as meaningful examples of AVE for the future.

These conflicting opinions are still debated in countries that have taken steps to legalize AVE, as well as in countries that have strictly denied the practice of AVE. Finland is a country where AVE and PAS are completely illegal, and condemned by the majority of medical professionals. PE is accepted, in practice, where it can be disguised as medical decision making.

Several studies exist on attitudes concerning AVE. Table 1 presents a summary of such studies that have been published in recent years. In English-speaking countries, most studies show that a slight majority of physicians support AVE, with even larger support among the general public. Also, the majority of seriously ill patients supported AVE, at least in certain situations. In other countries, mostly those on the European continent, physicians are far more critical of AVE, which currently has about 15–30% support among this group. In several studies, religious beliefs strongly affect attitudes, and people with religious commitments are less commonly favoring AVE. The elderly, and those more experienced with death, are also supportive of AVE.

Some researchers have considered that a simple question about the willingness to perform or legalize AVE or PAS cannot tell the whole truth about individuals' true attitudes. Therefore, researchers have carried out studies to gauge attitudes towards AVE or PAS through imaginary scenarios. Fried et al⁵ performed a study where physicians were asked how they would respond in five hypothetical situations. Three scenarios concerned the omission of a hopeless treatment, while two scenarios were cases where AVE was requested by a terminally ill patient. In the first three cases, 59–98% of physicians agreed to withholding hopeless treatment, but in last two cases, only 1–9% accepted active AVE.

In a study by Shapiro et al,⁶ three scenarios were presented to the physicians. All of them included a case where a patient asked for AVE; first in a case of stroke, then a case involving serious burns and the last was a case of Alzheimer's disease. A minority of physicians (2–29%) accepted AVE in all cases. Typically, when attitudes have been asked in the form of scenarios, AVE gains less support than in more conventional questions.

Although the amount of debate on euthanasia in Finland among the general public and health care personnel is increasing, there is currently not enough information on attitudes towards euthanasia in general, and especially towards different kinds of euthanasia practices. This information is urgently needed before serious discussions on legalizing euthanasia can begin.

The aim of this study was to evaluate the attitudes of physicians, nurses and the general public towards AVE, PE and PAS by using five different imaginary patient scenarios.