Elsevier

Resuscitation

Volume 55, Issue 3, December 2002, Pages 235-240
Resuscitation

Medical end-of-life decisions in Norway

https://doi.org/10.1016/S0300-9572(02)00270-8Get rights and content

Abstract

Aim: Previous studies indicate that Norwegian physicians hold conservative attitudes towards ethically controversial end-of-life decisions. The present study was undertaken to explore whether in Norway euthanasia may be hidden under labels such as death after analgesic injections and withholding or withdrawing treatment. Methods: A postal questionnaire containing 76 questions on ethical, collegial and professional autonomy issues was sent to a representative sample of 1616 active physicians in Norway in 2000. Results: 83% responded. A total of 8.1% had terminated life-prolonging treatment based on the resource situation, while 53.5 and 40.1% respectively had stopped life prolonging treatment due to the wish of the patient and the wish of the patient's relatives. Although not significantly, anaesthesiologists more often reported to have stopped treatment due to resource considerations. One percent of the physicians reported to have shortened a patient's life intentionally (other than stopping futile treatment). All of these were men. Logistic regression showed no effect when gender, age and specialty were analysed simultaneously. 10.6%, and male more often than female physicians, had had experience of unintentional patient death in relation to pain treatment. Anaesthesiologists had had experiences of death following an analgesic injection no more than other specialists. Conclusions: Only a small minority of Norwegian physicians has committed euthanasia. However, patient death has occurred following ethically questionable decisions such as withdrawal of treatment based on resource considerations and requests from the family.

Sumàrio

Objectivo: Estudos prévios indicam que os médicos noruegueses têm atitudes conservadores em relação a decisões eticamente controversas sobre o fim de vida. O presente estudo foi realizado para explorar a hipótese de a eutanásia na Noruega ser escondida sob termos como morte após administração de analgésicos e suspensão ou retirada de analgésicos. Métodos: Um inquérito postal contendo 76 questões sobre assuntos de autonomia profissional, colegial e ética, enviado a uma amostra representativa de 1616 médicos activos na Noruega, em 2000. Resultados: Responderam 83%. Um total de 8.1% tinham terminado tratamentos para prolongar a vida baseados nos recursos disponı́veis, enquanto que 53.5 e 40.1%, respectivamente, tinham suspenso tratamentos para prolongar a vida por vontade expressa do doente e familiares. Embora sem significado estatı́stico, os anestesistas comunicaram com maior frequência terem suspenso tratamentos com fundamento nos recursos. Um por cento dos médicos afirmou ter encurtado intencionalmente a vida de um doente (para além da interrupção de tratamentos fúteis). Todos estes eram do sexo masculino. A análise de regressão logı́stica não revelou nenhum efeito quando foram analisadas simultaneamente a especialidade, idade e sexo. 10.6%, e os médicos mais do que as médicas, tinham tido experiência da morte não intencional de um doente em relação com o tratamento da dor. Os anestesistas não tinham tido experiências de morte após injecção de analgésico mais frequentemente do que os outros especialistas. Conclusões: Apenas uma pequena minoria dos médicos noruegueses cometeu eutanásia. No entanto, ocorreram mortes de doentes na sequência de decisões eticamente questionáveis tais como a retirada de tratamentos baseada em consideração de recursos e a pedido dos familiares.

Resumen

Objetivo: Estudios previos indican que los médicos noruegos mantienen actitudes conservadoras hacia decisiones éticas controversiales respecto a final de la vida. Este estudio se realizó para explorar si en Noruega la eutanasia se encuentre escondida bajo etiquetas tales como una muerte después de inyecciones analgésicas y mantención o retiro de tratamientos. Métodos: En el año 2000 se envió por correo una encuesta de 76 preguntas sobre temas éticos, de colegiatura y de autonomı́a profesional a una muestra representativa de 1616 médicos activos en Noruega. Resultados: El 83% respondió. Un total de 8.1% ha terminado tratamientos que prolongan la vida basados en la situación de recursos, mientras que 53.5 y 40.1% respectivamente ha detenido tratamientos que prolongan la vida a solicitud del paciente y de los familiares del paciente. Anestesistas han detenido tratamientos por consideraciones de recursos con mayor frecuencia, aunque la diferencia no es significativa. Un 1% de los médicos reportaron haber acortado la vida de un paciente intencionalmente (mas allá de detener tratamiento futil). Todos ellos eran varones. La regresión logı́stica no mostró efecto cuando se analizó simultáneamente sexo, edad y especialidad.10.6% han tenido experiencia de muerte no intencional de pacientes en relación con tratamiento de dolor, y médicos varones con más frecuencia que mujeres. Los anestesiólogos no tuvieron más experiencias de muerte después de inyecciones analgésicas que otros especialistas. Conclusiones: solo una pequeña minorı́a de los médicos Noruegos ha cometido eutanasia. Sin embargo, la muerte de pacientes ha ocurrido después de decisiones éticamente cuestionables tales como retiro de tratamiento basado en consideraciones de recursos y requerimientos de la familia.

Introduction

As medicine becomes more potent and technical, an increasing number of people die as a result of a medical decision, most frequently because medical treatment is withheld or discontinued. A decision to forego medical treatment may be ethically acceptable when the treatment is judged to be of no benefit to the patient [1], [2]. Life-prolonging treatment may require additional resources, and the gap between what is technically possible on the one side, and economically feasible on the other, is probably wider than ever. Withholding and withdrawing medical treatment that can be beneficial to the individual patient, in order to save resources may be ethically problematic. The guidelines 2000 for cardiopulmonary resuscitation and emergency cardiac care [2] state that while resuscitation might not be the best use of limited medical resources, concern about cost associated with prolonged intensive care should not preclude emergency resuscitative attempts in individual patients.

The failure of medicine to relieve suffering at the end of life is an important argument for legalisation of euthanasia and physician assisted suicide (PAS). Insufficient pain control may be explained by a physician's reluctance to give adequate doses of opioids for fear of the treatment being lethal. Van der Maas shows that in the Netherlands a substantial number of patients die more or less intentionally as a consequence of the administration of opioids, without these deaths being classified as euthanasia [3]. A Swedish study found that one third of physicians working with pain relief and palliative care had given analgesics or other drugs in doses that hastened the death of some of their patients [4].

When medical treatment shortens a patient's life it may be morally justifiable through ‘the doctrine of the double effect’ [5]. A presupposition for this moral justification is the physician's intention to relieve pain but not to shorten life [6]. It may, on the other hand, be argued that adequate pain relief often saves life. The fear of killing a patient with adequate doses of pain relieving opioids may therefore be exaggerated.

Previous studies indicate that Norwegian physicians have more conservative attitudes towards such ethically controversial end-of-life decisions than physicians in other countries [7], [8], [9]. It may be postulated that this conservatism is hypocrisy, and that euthanasia is hidden under labels such as death after analgesic injections and withholding or withdrawing treatment. In a questionnaire study of 1476 Norwegian physicians (around 10% of the physician population) six percent stated that they had performed an act that hastened a patient's death [7]. The study has been criticised for the questions being too vague [10].

In the present study we have tried to use less ambiguous questions in our attempt to assess the extent that Norwegian physicians perform euthanasia, how often they experience a death following an analgesic injection, and to what extent and for what reasons medical treatment is forgone.

Section snippets

Material and method

In 1993, the Research Institute of The Norwegian Medical Association recruited a Reference Panel by inviting a random sample of 2 000 active physicians to participate. A total of 1272 agreed, and have during subsequent years received questionnaires more or less annually. 21 subjects have since dropped out, due to death or voluntary withdrawal. In January 2000 another 795 randomly selected physicians who had received their license after 1993 were invited to join the panel, of which 365 agreed.

Response rate and representativity

A total of 1318 completed and 27 blank forms were returned, a response rate of 83% (1318/1589). Table 1 compares the respondents with the population of active Norwegian physicians in April 2000. General practitioners and older physicians are slightly overrepresented, while the age group 35–44 is somewhat underrepresented.

Foregoing treatment

For 31% of the physicians the question about termination of life-prolonging treatment based on the resource situation leading to the death of a patient was ‘not applicable’. Of

Discussion

Overtreatment is a major ethical dilemma in modern medicine [7], [11]. Physicians are often accused of making death unnecessarily technical and undignified. Treatment may be continued contrary to the patient's presumed wish, against the relatives’ wish, and even contrary to the individual clinician's wish. Thus, a Norwegian study from 1993 showed that one out of three Norwegian physicians claimed that they sometimes or often had continued treatment beyond meaningfulness [7].

In the present study

References (20)

  • R. Førde et al.

    The ethics of euthanasia-attitudes and practice among Norwegian physicians

    Soc. Sci. Med.

    (1997)
  • British Medical Association. Withholding and withdrawing life-prolonging medical treatment. London,...
  • European Recuscitation Council. Part 2: ethical aspects of CPR and ECC. European Resuscitation Council. Resuscitation...
  • P.J. van der Maas et al.

    Euthanasia, physician assisted suicide, and other medical practice involving the end of life in the Netherlands, 1990–1995

    N. Engl. J. Med.

    (1996)
  • E. Valverius et al.

    Palliative care, assisted suicide and euthanasia: a nationwide uestionnaire to Swedish physicians

    Palliative Med.

    (2000)
  • P. Foot

    The problem of abortion and the doctrine of double effect

    Oxford Rev.

    (1967)
  • R. Gillon

    When doctors might kill their patients: foreseeing is not necessarily the same as intending

    Br. Med. J.

    (1999)
  • B.J. Ward et al.

    Attitudes among NHS doctors to requests for euthanasia

    Br. Med. J.

    (1994)
  • A.P. Folker et al.

    Experiences and attitudes towards end-of-life decisions amongst Danish physicians

    Bioethics

    (1996)
  • Materstvedt LJ, Kaasa S. Euthanasia and physician-assisted suicide in Scandinavia – with a conceptual suggestion...
There are more references available in the full text version of this article.

Cited by (23)

  • Law, ethics and clinical judgment in end-of-life decisions-How do Norwegian doctors think?

    2012, Resuscitation
    Citation Excerpt :

    The reasons for this are unknown, but non-medical considerations are probably involved, such as doctors’ attitudes regarding utility and perceived responsibility for health care resources.12 Although the expenses are covered through taxation in Norway, life-saving treatment may be withheld because of resource constraints.13 The relationship between an ALS patient with decision-making capacity and the responsible doctor is demanding, since a patient's ability to exercise autonomy depends to a large extent on continuous conversations about the patient's preferences with respect to future life-prolonging treatment.

  • European Resuscitation Council Guidelines for Resuscitation 2010 Section 10. The ethics of resuscitation and end-of-life decisions

    2010, Resuscitation
    Citation Excerpt :

    A doctor is required only to provide treatment that is likely to benefit the patient, and is not required to provide treatment that would be futile. However, it would be wise to seek a second opinion in making this decision, for fear that the doctor's own personal values, or the question of available resources, might influence his or her opinion.66 In adult cardiac arrest various studies have addressed the impact of advance directives and DNAR orders in directing appropriate resuscitation efforts.

  • Culture and end of life care: A scoping exercise in seven European countries

    2020, The Ethical Challenges of Emerging Medical Technologies
View all citing articles on Scopus
View full text