Questionnaire-based survey suggests that the majority of Danish geriatricians are against euthanasia
Introduction: Euthanasia (EU) and/or physician-assisted suicide (PAS) is legal in some countries and being considered in others. Attitudes to EU/PAS among Danish geriatricians were studied.
Methods: An online questionnaire with 12 questions was e-mailed to all members of the Danish Geriatric Society.
Results: The response rate was 46% (120/261). A total of 55.8% (67/120) disagreed that EU is ethically justifiable, whereas 22.5% (27/120) found that EU is justifiable. Furthermore, 13.3% (16/120) agreed that EU should be offered as an alternative to palliative treatment, 73.4% (88/120) disagreed. A total of 64.2% (67/120) disagreed that PAS is ethically justifiable, whereas 19.2% (23/120) found that PAS is justifiable. In all, 15% (18/120) agreed that PAS should be offered as an alternative to palliative treatment, whereas 76.6% (92/120) disagreed. The impact of legalisation of EU/PAS on the relationship between physician and patient was believed to be negative by 62.2% (74/119), positive by 12.6% (15/119) and without implications by 25.2% (30/119). Younger physicians tended to be more positive towards
Conclusion: The majority of Danish geriatricians are opposed to EU and PAS.
Trial registration: none.
Over the past decades, a small number of Western European countries and states within the US have legalised euthanasia (EU), which is a life-ending act where a physician administers a lethal drug to immediately end an
incurable patient’s suffering, and/or physician-assisted suicide (PAS), which is a life-ending act where a patient takes a lethal drug prescribed by a physician [1, 2]. Simultaneously, a rise in public acceptance towards EU and PAS has been observed across Western Europe .
Regardless of the legal framework, the topic is controversial with arguments focusing on ethical dilemmas, personal freedom and concerns about what impact legalisation may have on society . In Denmark, it is illegal to perform EU and PAS, and neither the Danish Council of Ethics nor the Danish Medical Association supports EU or PAS. In contrast, the opinions of the Danish public are more positive towards a legalisation and on par with Belgium and the Netherlands .
Geriatricians treat many patients with advanced age, multimorbidity, functional limitations and reduced life expectancy. In Norway, younger physicians seem more prone to foregoing life-prolonging treatment . The attitudes and experiences of Danish geriatricians regarding EU and PAS were studied in relation to sex and age.
An online questionnaire was sent to all 261 members of the Danish Geriatric Society. In the introduction, the sections concerning palliative care in the Danish Health Act (Section 25.2, Section 25.3) were presented. The questionnaire consisted of 12 items (Figure 1), five multiple choice questions and seven statements to which agreement was measured on a five-point Likert scale.
The questionnaire was validated by three independent consultants in geriatric medicine. The Cognitoforms.com platform was used, and data were collected and stored anonymously in an encrypted database, with no emails, IP addresses or other IDs attached. Respondents were contacted twice by email at a one-week interval between 13th April and 27 April 2015. Data were analysed with SPSS version 22, chi-squared was used. The significance level was set at 0.05.
Trial registration: none.
The response rate was 46% (120/261), 52.1% (62/120) were consultants in geriatric medicine (Table 1). To ensure anonymity, data from non-responders were not available, and data on employment region were not used.
In total, 40% (48/120) had experienced situations in which it was difficult to ensure good patient treatment while complying with Danish law. A total of 60% (72/120) had never experienced such situations.
Almost every geriatrician, 97.5% (115/118), had experienced patients who repeatedly expressed that they did not wish to continue living; only 2.5% (3/118) had never experienced this. A total of 35 physicians reported that they had encountered a wish to not continue living more than eight times per year.
Of the geriatricians who participated in the study, 68.3% (82/120) had experienced patients who asked for help to hasten the onset of death, while 31.7% (38/120) had never experienced this. Out of the 82 physicians who received these requests, 29.3% (24/82) had complied with the patient’s request; of this group, seven concluded that they had broken Danish law and five were unsure. The remaining 70.7% (58/82) had not broken Danish law.
A total of 32.8% (39/119) agreed that every person has the right to decide him or herself when to die, but only 13.3% (16/120) and 15% (18/120), respectively, agreed that EU and PAS should be offered as an alternative to palliative treatment (Table 2).
A total of 55.8% (67/120) agreed/strongly agreed that EU was not ethically justifiable, and 73.4% (88/120) thought that EU should not be offered as an alternative to palliative treatment (Table 2). There were no gender differences, but a more positive attitude was found among younger physicians. A total of 29.6% (21/71) of those who were younger than 50 years agreed/strongly agreed that EU was ethically justifiable in some cases. This was seen only among 12.2% (6/49) of physicians above 50 years (p = 0.03).
A total of 64.2% (77/120) agreed/strongly agreed that PAS was not ethically justifiable, and 76.6% (92/120) thought that it should not be offered as an alternative to palliative treatment (Table 2). Again, there were no gender differences, but a more positive attitude among younger physicians; 26.8% (19/71) in the younger group agreed/strongly agreed as compared with 8.2% (4/49) in the older group that PAS in some cases was ethically defensible (p = 0.02).
A total of 62.2% (74/119) physicians reported that legalizing EU would have a negative impact on the relationship of trust between doctor and patient whereas only 12.6% (15/119) thought that the impact would be positive (Table 3). There were no gender differences, but 50.7% (36/71) of the younger as compared with 79.2% (38/48) of the older physicians thought that legalisation on this issue would have a negative impact
(p = 0.018).
A total of 65.3% (77/118) of physicians reported that legalising PAS would have a negative impact on the relationship of trust between doctor and patient and only 11% (13/118) thought that the impact would be positive. There were no gender differences, but although non-significant, 55.7% (39/70) of the younger as compared with 79.2% (38/48) of the older physicians thought that legalisation would have a negative impact.
Due to the low response rate (46%), the results must be interpreted with caution. The main findings were that almost every Danish geriatrician has encountered patients who repeatedly expressed that they did not wish to continue living, and 68.3% have encountered patients who asked for help to hasten the onset of death. Although many Danish geriatricians have been in situations where they found it hard to reconcile sufficient symptom treatment with legal requirements, the main findings of this survey are that the majority of Danish geriatricians are against EU and PAS. The fact that a limited number believe that they may have broken the law probably illustrates the gradual transition between palliative care and EU, and the problematic nature of the decisions physicians are facing when treating patients who are at the end of their lives. On one hand, they are obliged to follow the law and the Hippocratic Oath to do no harm. On the other hand, they should acknowledge the patient’s request and treat them in accordance with their wish. Also, in Norway, a few physicians admitted to having performed EU or PAS .
A majority of Danish geriatricians are against legalising EU and PAS. Nearly one third agrees that every person has the right to decide for themselves when to die. Still, only one in five thinks that it is ethically justifiable to provide EU and/or PAS to a suffering patient when he/she repeatedly and explicitly expresses a wish to die. A majority believe that legalisation would have a negative impact on the relationship of trust between the physician and patient. These views are in line with the arguments of the Danish Council of Ethics.
Depending on the country of origin, physicians around Europe tend to have different views that either correlate or differ from the views of the public they serve [7-9]. Since the legalization of EU in Belgium, physician acceptance towards EU has increased. This suggests that a shift in political paradigm may have an impact . The European Values Survey [3, 5] found that the opinion of EU in the Danish public was at the same level of acceptance as in the Netherlands. The discrepancies between the physicians’ and the public’s attitudes may be due to differences in several factors such as knowledge of palliative care, experience working with dying patients and the questions addressing the topic. The public acceptance of EU decreases with age and
varies with religious belief .
Our data indicate that physicians under the age of 50 are more inclined to find EU ethically acceptable than their older colleagues. They are also more positive towards legalisation and are less likely to feel that it would damage the physician/patient relationship. Although non-significant, the same trend was found for PAS. It is therefore possible that the acceptance of EU and PAS decreases with clinical experience and that the concept of dying becomes more real on a personal level for older physicians, leading to a change in opinion. The same differences between age groups have also been found in Norway and Belgium [6, 8].
As part of the international debate, some fear that a legalisation of EU and PAS could be detrimental to the development of palliative care. However, studies from the Benelux countries show that the number of structural resources allocated for palliative treatment is on par with or higher than in countries where EU and/or PAS are illegal . Ethical issues notwithstanding, there are few data to support that improving palliative care and legalising EU/PAS are mutually exclusive. Others believe that by improving palliative care, EU and PAS become redundant. Belgium is considered to have a high standard of palliative care. The past years have seen a small increase in the number of requests for EU [11, 12]. Just like the Netherlands and Switzerland, most of the requests originate from cancer patients, followed by patients with diseases in the nervous system [1, 12, 13]. Many patients who request EU or PAS express that their main reason is to regain control over their fate or autonomy, to reclaim their dignity, not to be a burden to
others, and some are afraid of what the future might bring [14, 15]. In general, socioeconomic status, culture and religious beliefs have an impact on whether or not a request is made. Highly educated people, younger people, men and people living alone are more likely candidates .
Before being legally controlled, EU was estimated to account for 1.1% of all deaths in Belgium in 1998 and 2.6% of all deaths in the Netherlands in 2001 . According to both Belgian and Dutch law, all cases of EU have to be reported for review by a special committee . Estimates show that 80% of all EU cases are reported in the Netherlands and 53% in the Flemish part of Belgium [1, 2]. Incorrect labelling is the main reason for non-reporting, and in many cases such incorrect labelling is due to a lack of knowledge or to cultural beliefs [2, 17]. The impact of sedatives in terminal treatment can be difficult to assess [1, 18]. When neuromuscular relaxants are being used and the patient dies directly
after infusion, the report rate is estimated to be 99%
in the Netherlands . The impact of cultural beliefs
can be seen in Wallonia, the French speaking part of Belgium, where many physicians view EU as a personal matter between them and their patient – leading to a large share of missing reports . Authorities in both Belgium and the Netherlands may legally investigate questionable cases. If a reported case is viewed as unsatisfying by the committees, they shall turn it over to the justice system. Between 1999 and 2012, 70 cases, representing 0.21% of reported cases were turned over to the justice system in the Netherlands [2, 19]. No case in Belgium has been turned over, and no legal consequence has followed for physicians who fail to report EU [2, 4]. In all countries where EU or PAS is legal, physicians have a right to abstain from performing these acts .
The general population in the Netherlands has become more positive towards granting EU requests from patients suffering from dementia and psychiatric diseases and from elderly who are tired of living. However, physicians are still reluctant to accommodate these types of requests .
Cultural differences, the wording of the law and the physician’s beliefs and knowledge seem to be factors determining how the law is enforced in countries where EU and PAS are legal as well as in countries where these practices are illegal [2, 17, 19]. The controversial nature of the topic may have excluded some respondents and introduced a self-selection bias. Other studies with the same topic have had similar response rates [6, 7, 9].
A majority of Danish geriatricians are against legalisation of EU and PAS and find that these should not be an alternative to palliative treatment. Physicians fear a breach of trust between physician and patient if EU and/or PAS are legalised.
Correspondence: Lars-Erik Matzen. E-mail: firstname.lastname@example.org
Accepted: 9 November 2015
Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk
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