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Background Despite considerable public interest in legalizing physician-assisted suicide and euthanasia, little is known about physicians' attitudes toward these practices.
Methods We sent questionnaires to 1355 randomly selected physicians in the state of Washington, including all hematologists and oncologists and a disproportionately high number of internists, family practitioners, psychiatrists, and general surgeons. To avoid ambiguity in our survey, instead of "physician-assisted suicide," we used the phrase "prescription of medication [e.g., narcotics or barbiturates] or the counseling of an ill patient so he or she may use an overdose to end his or her own life." Instead of "euthanasia," we used the phrase "deliberate administration of an overdose of medication to an ill patient at his or her request with the primary intent to end his or her life."
Results Of the 1355 eligible physicians who received our questionnaire, 938 (69 percent) responded. Forty-eight percent of the respondents agreed with the statement that euthanasia is never ethically justified, and 42 percent disagreed. Fifty-four percent thought euthanasia should be legal in some situations, but only 33 percent stated that they would be willing to perform euthanasia. Thirty-nine percent of respondents agreed with the statement that physician-assisted suicide is never ethically justified, and 50 percent disagreed. Fifty-three percent thought assisted suicide should be legal in some situations, but only 40 percent stated that they would be willing to assist a patient in committing suicide. Of the groups surveyed, hematologists and oncologists were most likely to oppose euthanasia and assisted suicide, and psychiatrists were most likely to support these practices.
Conclusions The attitudes toward physician-assisted suicide and euthanasia of physicians in Washington State are polarized. A slight majority favors legalizing physician-assisted suicide and euthanasia in at least some situations, but most would be unwilling to participate in these practices themselves.
The debate on these issues among professionals and academic physicians has been contentious,3,4,5,6,7,8,9,10,11,12 and specific proposals for permitting assisted suicide or euthanasia have provoked controversy13,14,15. Despite extensive discussion, relatively little is known about the opinions of physicians on this subject. The available surveys of physicians concerning assisted suicide and euthanasia have been hampered by small samples,16,17,18,19 low response rates,16,19,20,21,22 limited generalizability,16,17,19,21,22 ambiguous terminology,17,19,20,21,22 and insufficiently detailed questions16,19,20,22. Most surveys have dealt with several ethical issues related to terminal care instead of focusing on assisted suicide and euthanasia. Few surveys have examined the beliefs underlying stated opinions or explored preferences for specific restrictions and safeguards.
We conducted a population-based survey of attitudes toward assisted suicide and euthanasia among randomly selected physicians practicing in Washington State. The study was designed to determine whether physicians believe assisted suicide and euthanasia are ethical, whether they believe either or both should be legalized, and whether physicians are willing to participate in these practices personally. We also investigated the reasons for physicians' positions and their views about the safeguards necessary in possible legislation permitting these practices.
Methods
Respondents
We selected potential respondents from a Washington State Medical Association data base that includes both members of the organization (62 percent) and nonmembers (38 percent) and that incorporates data supplied by the Washington State Division of Licensing, the American Medical Association, county medical societies, insurance companies, hospitals, and clinics. We excluded retired physicians, trainees, and physicians practicing outside the state. We randomly selected 250 physicians from each of the following fields: general internal medicine, family practice, general surgery, psychiatry, and a combination of all the other specialties except hematology and oncology, for a total of 1250 physicians. We also included 166 hematologists and oncologists: 98 from the medical-society data base and 68 from address lists of the American Society of Hematology, the American Society of Clinical Oncology, and the University of Washington faculty. The final sample thus totaled 1416 physicians.
Questionnaire
Our questionnaire was based on earlier surveys,19,20,21,22 discussions of issues in the literature,3,4,5,6,7,8,9 interviews with leading proponents and opponents of legalized assisted suicide and euthanasia in Washington, and extensive pilot testing. The survey consisted of 48 questions about the characteristics of the respondents, their attitudes toward assisted suicide and euthanasia, their opinions of possible legalization related to these practices, their willingness to participate in assisted suicide or euthanasia, the reasons for their positions, and their views about safeguards or restrictions that might be part of any legislation governing assisted suicide or euthanasia. Membership in the Washington State Medical Association was not ascertained. Responses were given in the form of ratings, on a five-point scale, of the degree of agreement with a variety of statements, ranging from "strongly agree" to "strongly disagree." For clarity, we collapsed the responses into three categories: strongly agree or agree, neutral, and disagree or strongly disagree.
To avoid ambiguity, we did not use the terms "assisted suicide" and "euthanasia" in the survey. Instead of "physician-assisted suicide," we used the following phrase: "prescription of medication [e.g., narcotics or barbiturates] or the counseling of an ill patient so he or she may use an overdose to end his or her own life." Instead of "euthanasia," we used the phrase "deliberate administration of an overdose of medication to an ill patient at his or her request with the primary intent to end his or her life." Although other actions may arguably be considered assisted suicide or euthanasia, these descriptions provide a clear indication of intent and action, reflect the consensus of experts in the field, and are consistent with the definitions proposed by the American Medical Association23 and the American College of Physicians24. For simplicity, we have used the terms "assisted suicide" and "euthanasia" in reporting our findings.
We mailed questionnaires to the physicians in the sample in December 1992. Although the survey was anonymous, return envelopes were coded to permit the identification of nonrespondents, to whom we sent additional surveys in February 1993 and again in March 1993. (Copies of the questionnaires are available from the authors.) To measure potential response bias, we randomly selected a 10 percent subsample of the physicians who had not responded by March 1993, mailed them an anonymous questionnaire containing 12 items from the initial survey, and telephoned them to encourage them to respond. Because the responses in the survey were anonymous, the study was exempt from review by the University of Washington Human Subjects Committee.
Statistical Analysis
For each item, we computed the frequency or mean response, with 95 percent confidence intervals,25 and compared means between subgroups using the unpaired-samples t-test25. To adjust for the oversampling of some specialties, we performed a weighted analysis to reflect the actual distribution of specialists among physicians in Washington State. The results of the weighted analysis were nearly identical to those obtained with unadjusted data. Only the unadjusted results are therefore presented.
We used logistic regression to assess the independent effects of specialty, age, sex, and practice characteristics (the independent variables) on attitudes toward assisted suicide and euthanasia (the dependent variables)26 and estimated odds ratios for each independent variable. For comparisons between specialties, general internal medicine was used as the reference category. All P values are two-tailed.
To determine which medical conditions were considered by physicians to create a situation in which euthanasia or assisted suicide might be appropriate, we analyzed separately the replies of physicians who believed that both euthanasia and assisted suicide are sometimes ethical. To investigate which specific safeguards and restrictions physicians considered important, we analyzed separately the responses of physicians who supported legalizing both euthanasia and assisted suicide.
Results
Of the 1416 physicians surveyed, 61 were found to be ineligible because of address changes or retirement. Of the remaining 1355 physicians, 938 (69 percent) completed surveys. The characteristics of the respondents are shown in Table 1. The differing proportions of respondents in the various specialties reflect the composition of our sample and the varying response rates. Women represented a higher proportion of the responding internists (30 percent) and family practitioners (25 percent) than of the hematologists or oncologists (16 percent) or surgeons (5 percent). The mean number of terminally ill patients seen in the previous month was 7; this figure ranged from 2 for psychiatrists to 28 for hematologists and oncologists. Forty-two percent of the respondents were affiliated with a student, residency, or fellowship training program (range, 33 percent for family practitioners to 64 percent for hematologists and oncologists).
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Forty-eight percent of respondents said they agreed with the statement that euthanasia is never ethically justified, and 42 percent disagreed (Figure 1). Fifty-four percent thought euthanasia should be legal in some situations, but only 33 percent stated that they would be willing to perform euthanasia themselves. There was slightly more support for physician-assisted suicide. Thirty-nine percent of respondents agreed with the statement that assisted suicide is never ethically justified, and 50 percent disagreed. Fifty-three percent thought assisted suicide should be legal in some situations, but only 40 percent stated that they would be willing to assist a patient in committing suicide.
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Attitudes toward assisted suicide and euthanasia varied significantly among the specialties (Figure 2). Of the groups surveyed, psychiatrists were most supportive of these two practices, and hematologists and oncologists were least supportive. These differences in attitudes persisted after logistic-regression models were used to adjust for potential confounding by sex and affiliation with a training program.
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Reasons for Attitudes toward Assisted Suicide and Euthanasia
We analyzed the reasons physicians gave for their attitudes by grouping respondents with similar positions on euthanasia and assisted suicide and excluding those who either felt differently about the two forms of physician-assisted dying or were neutral toward either. Fifty-six percent of the 318 respondents who agreed that euthanasia and assisted suicide are never ethically justified stated that they were influenced by religious beliefs, as compared with 15 percent of the 343 respondents who disagreed with those statements. Seventy-four percent of those who opposed euthanasia and assisted suicide considered these practices inconsistent with the physician's role in relieving pain and suffering. In contrast, 91 percent of those who believed the practices to be ethical considered them consistent with the physician's role. Eighty percent of those who opposed euthanasia and assisted suicide cited the potential for abuse. Thirty-two percent of those who considered the practices unethical believed that currently available treatments may be inadequate to eliminate pain and suffering, as compared with 80 percent of those who believed that these practices are ethical. Ninety-seven percent of those who supported assisted suicide and euthanasia said that patients' right to self-determination should be respected, and 91 percent said that the availability of assisted suicide and euthanasia might reduce patients' fears of losing control or of a painful death.
Situations in Which Euthanasia or Assisted Suicide May Be Appropriate
Among the 343 physicians who believed that both euthanasia and assisted suicide are sometimes ethical, 88 percent thought that a poor quality of life, despite adequate pain control, might be sufficient justification for these practices; paradoxically, 51 percent thought that a patient's pain should be beyond control in order to justify euthanasia or assisted suicide, and 64 percent believed that a patient's life expectancy should be less than six months. Thirty-one percent agreed with the statement that if a "patient has a good quality of life at present, but has an illness which will cause severe mental and/or physical deterioration in the future, fatal overdose may still be appropriate." Twenty-one percent agreed that euthanasia or assisted suicide may be appropriate if external factors (such as not wanting to burden the family or not wanting to deplete savings) led to the patient's request, despite adequate pain control and quality of life.
Restrictions and Safeguards
Among the 432 physicians who favored the legalization of both assisted suicide and euthanasia, the safeguard supported most strongly was the requirement that the patient's request be witnessed by an independent person who would not benefit from the patient's death (Table 2). Other favored safeguards included confirming the patient's mental competence, requiring that two physicians agree with the decision, and requiring that the physician administering or prescribing a fatal overdose have an established relationship with the patient.
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Of 40 physicians who did not respond to the initial questionnaire whom we surveyed after March 1993, 29 responded; 2 others had moved out of state, and 1 had retired. The attitudes of the nonrespondents, as measured by the briefer questionnaire, did not differ significantly from those obtained in the initial survey.
Discussion
Physicians in Washington have sharply polarized attitudes toward assisted suicide and euthanasia, which mirror the sharp divisions among voters in Washington and California. Only about 10 percent of physicians stated that they were neutral on the questions of euthanasia and assisted suicide. Only a minority of physicians expressed a willingness to participate in assisted suicide or euthanasia or believed these practices to be ethical. A slight majority, however, favored their legalization. In general, attitudes toward physician-assisted suicide were more favorable than those toward euthanasia, although the percentages of physicians favoring legalization of the two practices were similar.
There were wide variations in the responses according to specialty, sex, and affiliation with a training program. These variations could not be attributed to age, contact with terminally ill patients, or other practice characteristics. Hematologists and oncologists had the most exposure to terminally ill patients and were also the strongest opponents of euthanasia and assisted suicide. Psychiatrists, who had the least contact with terminally ill patients, were the strongest proponents of the two practices. One explanation for these findings may be that many hematologists and oncologists believe that more effective use of available treatments to relieve pain and suffering would obviate the need for euthanasia and assisted suicide. Further study of these issues is needed to clarify these divergent views.
Our study has several strengths. To enhance its validity, we used terminology in the questionnaire that was unlikely to be ambiguous, and we focused exclusively on assisted suicide and euthanasia. To enhance the generalizability of our findings, we randomly sampled a wide cross section of physicians in a variety of medical specialties, practice settings, and geographic locations. In addition, public debate about the ballot initiative in Washington that would legalize euthanasia and assisted suicide has presumably made physicians in the state better informed than average about the issues, perhaps with the results that their responses are more thoughtful than might be the case elsewhere27. The rate of response to our survey (69 percent) was relatively high. Moreover, in a small survey of physicians who did not complete the initial questionnaire we did not find evidence of a response bias.
Our study also has several limitations. First, the results of a survey of physicians in Washington may not be applicable to other regions of the country. Second, the Washington State Medical Association opposed Initiative 119, which would have legalized euthanasia and assisted suicide, and sent a newsletter outlining these views to its members, who make up 75 percent of the licensed physicians in the state. The views of the medical association may have influenced the attitudes of respondents. We did not ask respondents whether they were members of the association or whether the association's position had influenced their views. Finally, the fixed-response format of the questionnaire may have limited the amount of information obtained and the level of detail in the responses.
The results of this study have important implications for patients, physicians, and policy makers. The polarized attitudes of physicians will make it difficult to formulate and implement laws and policies concerning assisted suicide and euthanasia. Despite the lack of consensus on these issues, a substantial number of physicians believe that currently available treatments may be inadequate to eliminate pain and suffering for terminally ill patients and were dissatisfied with their legal options. To receive support from a large number of physicians, legislation permitting assisted suicide or euthanasia would have to contain ample safeguards. There was strong support among our respondents for previously proposed safeguards for physician-assisted suicide,14 which include the restriction of such suicides to mentally competent, terminally ill patients with a poor quality of life; the required exhaustion of all other reasonable treatment options; and the requirement that there be an established relationship between physician and patient.
The wide public interest in assisted suicide and euthanasia indicates clearly that physicians should work to improve the care of terminally ill patients. These efforts should include better communication with patients, maximal use of advance directives, effective control of pain and other symptoms, and development of hospices and similar programs for terminally ill patients28. Whether assisted suicide and euthanasia have a role in the care of such patients remains an issue for further debate.
Supported by the Northwest Health Services Research and Development Field Program, Department of Veterans Affairs Medical Center, Seattle.
Source Information
From the Section of General Internal Medicine, Minneapolis Veterans Affairs Medical Center and University of Minnesota, Minneapolis (J.S.C.); the Division of General Medicine, Seattle Veterans Affairs Medical Center and University of Washington, Seattle (S.D.F., E.J.B.); and the Departments of Medical History and Ethics (A.R.J.) and Medicine (R.W.W.), University of Washington, Seattle.
Address reprint requests to Dr. Cohen at the Minneapolis Veterans Affairs Medical Center, 1 Veterans Dr., Minneapolis, MN 55417.
References
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Related Letters:
Regulating Physician-Assisted Death
Callahan D., Feucht K. A., King D. R., Wright R. C., Lynn J., Billings J. A., Block S. D., Finlay I. G., Gilbert J., Randall F., Miller F. G., Quill T. E.
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Full Text
N Engl J Med 1994;
331:1656-1658, Dec 15, 1994.
Correspondence
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