Spiritual Beliefs and Hastened Death: A Study on Medical Students

Abstract

This study focuses on the impact of common spiritual beliefs regarding metaphysical questions in agreeability with the practice of hastened death. A sample of 497 Portuguese medical students was collected. Differences between genders and religions, predictors for agreeability with hastened death and the association between spiritual beliefs and opinion towards hastened death cases were assessed. Respondents were mostly favourable to the practice of hastened death. Formal religious affiliation and higher levels of religiosity significantly associated with lesser agreeability with hastened death. Statistically significant association was found between every hastened death scenario and multiple of the spiritual beliefs used. A number of spiritual beliefs were predictors of agreeability. We discuss the implications of religion and spirituality in agreeability with hastened death. Further research is required to better understand the true weight of spirituality in one’s opinion towards this ethical dilemma.

Keywords

euthanasia suicide assisted spiritual beliefs spirituality students medical

Life and death pose ever-confusing questions to the human being. The immaterial, mysterious, and subjective nature of these topics poses many questions we ought yet to be able to answer. Although this explains why a wide variety of beliefs regarding these questions exists, democratic societies must find common-ground in legislating on topics that raise these questions.

When medicine was born, the reigning world views were those of traditional religions: Life is sacred and should be preserved in every circumstance (Chakraborty et al., 2017). Nowadays, we have reached a point where we live longer than ever before and can cure or treat most short-term deadly diseases. This inevitably translates into our population being increasingly older and living with chronic diseases (Hardwig, 2009). These are often gradually debilitating, breeding disabilities and suffering, both physical and psychological. Accordingly, medicine oftentimes itself is part of the reason why there is the possibility of maintaining a dependent life in the first place – a life all too dependent on external help, such as invasive ventilation or feeding (Donald Boudreau & Somerville, 2013; Rousseau, 2017). As medicine advances, it may appear that, in some cases, all this scientific innovation has not been extending life, but merely lengthening the process of dying (Rizzo, 1996). Moreover, health costs at the very end of life increase in a rather drastic fashion (Marsala, 2019). This brings about new challenges and controversial questions that populations of the past did not need to face. It is as if, in some cases, medical care could be regarded as a futility – a costly one.

At the same time, although religion is still important to most people in the West (Stempsey, 2010), societies are becoming increasingly secular (Elder & George, 2016), in terms of both religious affiliation and religiosity (Cohen et al., 2006; Danyliv & O’Neill, 2015; Marsala, 2019). Alongside that, individual rights such as freedom, autonomy, and self-determination are increasingly more dear to today’s societies than are older traditions and values – and even life itself (Cohen et al., 2006; Washington Death with Dignity Act, 2008; Fraser & Walters, 2002).

From this background arise new and important ethical questions about how people are treated and what the limits (if any) of medicine should be. One of the most emergent topics of debate in modern societies is that of hastened death (Bulmer et al., 2017; Siden, 2005). Important arguments have been raised on both ends of the discussion (Math & Chaturvedi, 2012; Ricou & Wainwright, 2019), but the determinants of one’s standpoint in this matter have not been given full attention. An individual’s position in such matters should essentially be a complex end-product of personality traits, personal beliefs and environment. As this matter raises existential questions to which there are no definite scientific answers, beliefs may play a unique role.

Beliefs provide a solid (but not necessarily factual) representation of the world and are fundamental to guiding us through our everyday life, explaining what is around us and what to expect from it, and guiding our behaviour (Bautista et al., 2018). Hence, belief systems provide us with meaning and answers to existential questions. These beliefs can be of different types, whether secular, political, spiritual, or religious, among others, and may have an important social component, especially religious and political ones, which renders them more resistant to change. Yet, being based on a probabilistic judgement of the world around us, they constitute a biased product of our own assessment (Seitz et al., 2018). It has been shown that public opinion on matters such as that of hastened death can quickly change with mediatic cases (Cohen et al., 2006). It is, then, a complex but not always self-conscious interplay between the individual and his environment.

When dealing with existential questions to which no proven scientific answer exists, spirituality is very often the human being’s first-aid. Amidst this existential confusion, religions sneak in with sets of predefined spiritual beliefs readily able to answer these potentially haunting questions about the nature of being. As it is typical of religions to be able to provide answers to the everlasting mystery of the after-death (Vail et al., 2010), we would perhaps infer that religious people would be more accepting of death and, therefore, more sympathetic towards hastened death than if they held not-as-pleasant beliefs about what happens next. As a matter of fact, the opposite is true. This is because religions teach that life is sacred and only supernatural entities can interfere with its limits; thus, most of them condemn killing, and, by extension, the act of hastened death as well (Baume et al., 1995). Catholics seem to be the least open of all common religions (Anderson & Caddell, 1993; Kitchener, 1998; Portenoy et al., 1997). However, some religious people may be sympathetic towards hastened death even if they are aware of the apparent contradiction between its practice and their beliefs (Gielen, van den Branden, & Broeckaert, 2009a).

The recent increasing interest in Eastern religions and philosophy in the West is also noteworthy (Mitchell, 2002), though the first of the 10 Buddhist precepts commands refraining from destroying life as well (Lecso, 1986). One particular Eastern concept that has become rather popular in Western culture, in people who identify as either religious or non-religious, is that of Karma (Lecso, 1986). Karma arises as yet another magical belief and, as such, serves the purpose of sense-making and psychological control (White & Norenzayan, 2019). It teaches that positive actions bring pleasant rewards to one’s life while negative actions bring suffering. Therefore, the suffering that may be experienced at end-of-life stages is repayment of a karmic debt, as Lecso (1986) puts it, and so it is to be considered fair – the patient must be held accountable for it. Thus, hastened death would externally disrupt karma’s action and so cannot be permitted.

Religion not only has been consistently associated with lesser approval (Hamil-Luker & Smith, 1998; Ward, 1980) but is one of the key predictors of attitudes towards hastened death (Bulmer et al., 2017; Danyliv & O’Neill, 2015; Marsala, 2019; Silva et al., 2019). Hence, as we have been witnessing a secularization of modern societies, it makes sense that agreeability with hastened death has been increasing over time (Danyliv & O’Neill, 2015). The most important contributor to this social change seems to be the effect of cohort replacement rather than individuals changing as they age, though approval of hastened death does decline as people get older (Marsala, 2019). Older people are more religious, as well (Bautista et al., 2018).

Non-religious people, however, oftentimes hold some type of spiritual beliefs too. For instance, studies have consistently shown that while being aware of the biological concept of death, people – even non-religious – still hold beliefs according to which some cognitive and emotional functions may continue to exist in the afterlife (Georgiadou & Pnevmatikos, 2019). This demonstrates the role of such constructs in buffering death anxiety. Results from previous studies have suggested that, for theists and atheists alike, the need for meaning in general and also threats to existence (such as natural disasters (Sibley & Bulbulia, 2012)) increase adherence to magical beliefs, such as mind-body dualism and superstitions (Nelson et al., 2019). In fact, it has been theorized that dualist thinking is intuitive in human beings, as we engage, from early on, in making inferences about others’ unobservable-mental world in order to predict and understand their observable behaviours (Forstmann & Burgmer, 2018). Therefore, it could be that all we do through scientific knowledge and cultural factors is overlay this implicit spirituality with other constructs. Hence, these magical beliefs can be religious (Norenzayan & Hansen, 2006) when associated with formal religions, though not all magical beliefs are religious. The mind-body dualism and the existence of some supernatural entities (such as ghosts) or forces (such as Karma), for instance, do not presuppose the existence of a god or the practice of religious activities. It is possible to have a deep sense of spirituality and no formal engagement in religious activities. Many sports players perform very specific sequences of actions before taking to the field; some of these actions are religious, but some of them are not (Maranise, 2013; Schippers & Van Lange, 2006). These repeated rituals serve as superstitions they believe could increase their odds of success, which might be through conditioning, for the illusion of control (Schippers & Van Lange, 2006), as an escape mechanism from anxiety (Maranise, 2013), or others. In fact, spiritual beliefs have been shown to account for meaningful effects in the development and maintenance of other, more tangible, belief systems, ultimately shaping one’s behaviour. In this study, the phrase “spiritual beliefs” will refer to all kinds of magical thinking held by people, from superstitions and non-religious spiritual beliefs to proper religious beliefs. What the role of particular spiritual beliefs may be in defining one’s standpoint towards hastened death, especially non-religious ones, has not been properly studied before.

In February 2020, the Portuguese Parliament voted and accepted five bills¹ aimed at decriminalizing hastened death in the country. Considering the role of religion and the trend of increasing secularization, it seems natural that, in the coming years, more legal challenges may arise in other developed countries as well. However, if anything is clear, it is that further research should not be ruled out before other bills are voted on. A study by Silva et al. (2019) presented a sample of Portuguese physicians with six very distinct hastened death situations. It was shown that their opinions differed greatly from case to case, depending on the patient’s condition, awareness and life-expectancy with presumedly good quality of life. These results were consistent with previous findings (Mullet et al., 2014).

To further understand what defines peoples’ standpoints towards such a complex topic, we sought to look into their spiritual beliefs regarding life and death and how these could be at the core of the various standpoints. Simply asking people what religion they most identify with could be limiting given that it may not fully represent the people’s core beliefs (especially in today’s increasingly secular societies). There are different levels of religiosity, and people – especially those in developed countries – are increasingly questioning their religions’ classic values (Gielen et al., 2009b; Halman & Draulans, 2004). Therefore, one person might identify with one religion, while not being engaged in its beliefs or practices at all. On the other hand, as previously mentioned, spiritual beliefs are common among the non-religious as well (Georgiadou & Pnevmatikos, 2019). Previous studies have noted that the operationalisation of religion should include questions about specific beliefs and measures of religiosity (Gielen et al., 2009b). Moreover, some suggest that some spiritual beliefs, such as afterlife beliefs, could be religious-independent constructs that feed deeper psychological needs (Georgiadou & Pnevmatikos, 2019). Therefore, we opted to ask participants not only about their religious affiliations but also about their religiosity practice and their agreement towards a set of independent sentences regarding common spiritual and metaphysical beliefs (Bautista et al., 2018; Georgiadou & Pnevmatikos, 2019). To do so, we adapted the beliefs used in this study from pre-existing scales (Delaney, 2005; Echebarría & Perez, 2017; Hills et al., 2005; Hodge, 2003; Riekki et al., 2013; Tobacyk, 2004). We chose to study medical students because they represent a new generation of doctors inevitably moulded by the new social determinants surrounding them and will most likely be the decision-makers once hastened death is fully legalized in Portugal. Nonetheless, it is very important to mention that the position of doctors has previously been found to be in contrast to that of the general public (Jaques, 2012; Suarez-Almazor et al., 1997; Wolfe et al., 1999). This could be partially explained by the fact that popular culture is still largely dominated by non-scientific and magical beliefs and that the general public knows and understands little about scientific advances (Bautista et al., 2018).

Previous studies conducted among nurses (Musgrave et al., 2001), medical students (Muller et al., 1996), and doctors (Anderson & Caddell, 1993; Baume et al., 1995; Silva et al., 2019) have all consistently shown a negative relationship between levels of religiosity and approval of hastened death (Gielen et al., 2009a). Accordingly, we expect less approval of hastened death from more religious participants. However, none of these explored particular non-religious spiritual beliefs. Like most Western European countries, Portugal has a vast majority of Catholic people, followed by people who do not identify with any religion, and then other Christians, such as Protestants and the Orthodox. In the 2011 Portuguese census, only 0.5% of respondents identified with non-Christian religions, while a crushing 81% identified asCatholic (Instituto Nacional de Estatística [Statistics Portugal], 2012). On the other hand, 6.9% identified as non-religious, a figure that grew 79% since the 1991 census. Therefore, we expect the same trend in this study. Religious diversity has also been increasing (Observatório das Migrações [Migration Observatory], n.d.). As medical schools require high levels of scientific preparation and study, and based on previous findings that more educated people – especially in scientific areas – tend to show lower levels of religiosity (Bautista et al., 2018; Pennycook et al., 2012), besides the aforementioned effects of cohort replacement and age in religiosity, we expect participants in this study to be less religious than the general population. This effect is to be expected in both religious affiliation and religiosity, and should have an impact on the outcome, as Silva et al. (2019) found in their study among Portuguese doctors. Younger doctors were more supportive of euthanasia in a statistically significant manner: 66.2% in the 25- to 45-year-old group versus 47.8% in the 46- to 65-year-old group. Other studies have found that education is independently linked to approval of hastened death (Bulmer et al., 2017). However, some studies have shown a stronger positive link between moral concern, social and emotional cognition and spiritual beliefs than the negative one seen with analytical thinking (Jack et al., 2016), which could be relevant among medical students, as medicine implies the care of the ill and a sense of social responsibility. The tendency of more intelligent and educated people to be less religious does not necessarily mean that their beliefs about existential and metaphysical questions are closer to the truth. It could simply be the case that they are armed with other constructs by which to explain these same questions – namely, constructs more rooted in scientific, rational, and empirical bases than supernatural or magical ones. Nonetheless, it is worth remembering that the ungraspable nature of these subjects still ultimately lies beyond all our scientific truths.

This study aims to understand the link between common religious and spiritual beliefs about life and death and agreeability towards hastened death in medical students.

Methods

Participants

Four hundred and ninety-seven medical students from all 10 Portuguese Universities with Medicine graduation (Universidade do Algarve [University of Algarve], Universidade do Minho [University of Minho], Universidade da Beira Interior [University of Beira Interior] Universidade da Madeira [University of Madeira], Universidade dos Açores [University of Azores], Universidade de Coimbra [University of Coimbra], Universidade do Porto [University of Porto], Universidade de Lisboa [University of Lisbon], Instituto de Ciências Biomédicas Abel Salazar [Abel Salazar Institute of Biomedical Sciences] and NOVA University) voluntarily participated in this study. Students from all six years of studies participated proportionately with a mild majority of sixth grade respondents (23.5%). Ages ranged from 18 to 54 years old (M = 22.3, SD = 4.2) and 71% of respondents were women. No particular inclusion or exclusion criteria were used to further select participants, so all 497 responses were included in the analysis.

Instruments

A questionnaire composed of four main sections was created for this purpose. First, informed consent was presented, including the pertinence and aim of the study. Explanations related to the protection, privacy, and confidentiality were provided, as stated by EU General Data Protection Regulation ( 2016). In the second section, demographic data of participants were collected, including religious affiliation and attendance to religious practices. In the third section, in order to analyse students’ positions about relevant spiritual beliefs, 11 sentences were created taking the literature in this field into account. These beliefs were derived from pre-existing scales (Delaney, 2005; Echebarría & Perez, 2017; Hills et al., 2005; Hodge, 2003; Riekki et al., 2013; Tobacyk, 2004) and explored matters such as the mind-body dualism, afterlife beliefs, belief in paranormal events, superstitious beliefs and the role of these beliefs in participants’ lives. One particular statement (number five) had a distinct intent to explore some degree of conflict between what one believes is real and what he/she wishes was real. This confusion within could be influential in one’s standpoint towards such life-and-death issues. These sentences were created and applied in Portuguese and posteriorly translated for publication purposes. In order to collect information and obtain agreement among a group of experts regarding the suitability of these sentences, the e-Delphi panel technique was used (Logue & Effken, 2013; Streiner et al., 2015). All sentences were analysed concerning their theoretical and practical adequacy. The 11 sentences were sent by email to the e-Delphi panel, composed of five experts, including researchers and health professionals. The analysis was performed through a dichotomous classification (agree or disagree), with space for comments or suggestions on each item. Changes to the questionnaire were made based on the suggestions and comments made by the panel. Multiple phases were conducted to reach a consensus among the panel of at least 80% (Logue & Effken, 2013; Streiner et al., 2015). Participants were asked to manifest their agreeability with these statements on a scale of one to six. Finally, in the fourth section, participants were presented with six hastened death situations that were previously used by Silva et al (2019). The aim was to explore their agreeability with hastened death according to each situation. These hastened death situations were applied in Portuguese and posteriorly translated for publication purposes.

Procedures

To reach a representative sample, students from all Portuguese Medicine Universities were included. To collect the data, we asked the Students’ Association of each medical school for collaboration. They introduced the study to the students of their respective universities and invited them to participate. The questionnaire was made available to participants via a link shared through direct e-mail. The questions were answered on-line through the Google Forms platform. This procedure was used to increase participation, since a national dissemination of the questionnaire was intended. Data collection took place from January to February 2020.

Ethical procedures were accomplished via analysis and approval of the study by an independent Ethical Committee (Comissão de Ética para a Saúde – Centro Hospitalar de São João [Ethics Committee of São João Hospital Center]). All students participated in the study anonymously. No reward was made available for participating in the study.

Data Analysis

Statistical analysis was performed using Statistical Package for the Social Sciences (IBM SPSS, version 26.0). Agreeability with hastened death scenarios and spiritual beliefs, initially collected on a six-point bipolar scale, were recoded into binary variables. Values from one to three represented disagreement and values from four to six represented agreement. In the generality of beliefs presented, agreement implies higher spirituality, while disagreement implies lesser spirituality. However, the rationale behind beliefs number four and five is the opposite. Higher agreeability with these particular statements suggests lesser spirituality, and not higher. For these beliefs, disagreement (values one to three) represented higher spirituality, while agreement (values four to six) corresponded to less. Categorical variables were presented in frequency and percentage. The Mann-Whitney test was performed to analyse differences in agreeability with hastened death between male and female participants and between Catholics and atheists/agnostics. The Pearson's Chi-Square Test was used to test the independence between categorical variables and compare proportions between categories of variables. A multiple regression analysis (stepwise forward method) was employed to evaluate the spiritual belief variables which represented independent and significant predictors of agreeability with hastened death scenarios. Statistical assumptions were verified through the Durbin-Watson test, collinearity diagnostics and standardized residual plots.

Statistical significance was set at p-value < 0.05.

Results

Religious Affiliation and Practice of Religiosity

Regarding religious affiliation, 53.5% of participants identified as Catholic while 41.9% identified as atheists or agnostics. The remaining 4.6% identified with other religious ideologies.

As far as religiosity practice is concerned, 31.8% identified themselves as religiously practicing, while 24.7% admitted to be non-practicing. In terms of how regularly they attend a place of religious or spiritual cult, 22.3% answered with “never”, 34.4% with “1–3 times a year”, 12.9% with “more than 3 times a year but less than 1 time per month”, 6.0% with “1–3 times per month” and 12.3% with “at least once a week”.

Agreeability With Spiritual Beliefs

A mente é uma forma de energia independente do corpo, estando-lhe apenas temporariamente confinada [The mind is a form of energy independent from the body, being only temporarily confined to it].

A total of 20.8% of participants agreed with this belief, while 79.2% disagreed with the statement.

2. A alma existe [The soul exists].

A total of 56.9% of participants agreed with this belief, while 43.1% disagreed with the statement.

3. Acredito que possam existir outras dimensões depois da morte, como a reencarnação ou outra [I believe there could be other dimensions after death, such as reincarnation or other].

A total of 44.7% of participants agreed with this belief, while 55.3% disagreed with the statement

4. Somos apenas carne e osso e toda a nossa vivência cessa com a morte [We are but flesh and bones and all of our life experience ends with death].

A total of 43.7% of participants agreed with this belief, while 56.3% disagreed with the statement.

5. Eu gostaria que houvesse um propósito para a minha existência, mas tudo me faz crer que ela termina definitivamente com a morte [I would like for my existence to have a purpose, but everything leads me to believe that it completely ends with death].

A total of 49.1% of participants agreed with this statement, while 50.9% disagreed.

6. Acredito que existe uma força universal transcendente que não posso ver diretamente, mas cuja energia posso sentir [I believe there is a transcendent universal force, which I cannot see directly, but the energy of which I can feel].

A total of 54.9% of participants agreed with this belief, while 45.1% disagreed with the statement.

7. Existem certas ações ou símbolos que acarretam Sorte ou Azar [There are certain actions or symbols that convey good or bad luck].

A total of 21.9% of participants agreed with this belief, while 78.1% disagreed with the statement.

8. As minhas crenças espirituais, religiosas ou metafísicas ajudam-me a lidar com os desafios e decisões importantes da vida] My spiritual, religious or metaphysical beliefs help me cope with the important challenges and decisions of my life].

A total of 53.1% of participants agreed with this statement, while 46.9% disagreed.

9. Acredito já ter testemunhado uma manifestação da presença de Deus ou outra entidade divina na minha vida [I believe to have witnessed a manifestation of the presence of God or other divine entity in my life before].

A total of 30.6% of participants agreed with this belief, while 69.4% disagreed with the statement.

10. Acredito na existência de fenómenos paranormais [I believe in the existence of paranormal phenomena].

A total of 28.2% of participants agreed with this belief, while 71.8% disagreed with the statement.

11. É possível comunicar com os mortos [It is possible to communicate with the dead].

A figure of 10.7% of participants agreed with this belief, while 89.3% disagreed with the statement.

Agreeability With Hastened Death Scenarios

Adulto com doença incurável e dor intensa (8-10, numa escala de 0 a 10, em que 10 é a dor máxima, insuportável) pede para terminar a sua vida [Adult with an incurable disease and intense pain (eight out of ten, with ten being unbearable extreme pain) asks for his life to be ended].

A figure of 71.0% of participants agreed with hastened death in this scenario, while 29.0% opposed.

b. Adulto com doença incurável, muito incapacitante (problema grave ou completo na Classificação Internacional de Funcionalidade, Incapacidade e Saúde, da Organização Mundial de Saúde), pede para terminar a sua vida. [Adult with a very incapacitant (serious or complete problem in the World Health Organization’s International Classification of Functioning, Disability and Health) and incurable disease asks for his life to be ended].

A figure of 74.6% of participants agreed with hastened death in this scenario, while 25.4% opposed.

c. Adulto com doença terminal referencia um sofrimento insuportável e pede para terminar sua vida [Adult with terminal disease who mentions that he is experiencing unbearable suffering asks for his life to be ended].

A figure of 77.9% of participants agreed with hastened death in this scenario, while 22.1% opposed.

d. Adulto com doença terminal, em evolução, ainda com boa qualidade de vida, pede para terminar sua vida [Adult with a terminal disease in evolution, though with a good quality of life currently, asks for his life to be ended].

A figure of 31.4% of participants agreed with hastened death in this scenario, while 68.6% opposed.

e. Adulto com doença incurável e incapacidade permanente de manifestar sua vontade. Os familiares pedem ao médico para terminar a sua vida, afirmando que essa seria a sua vontade [Adult with an incurable disease and permanent incapacity to express his will. His family members ask the physician for his life to be ended, stating that that would be his will.]

A figure of 35.8% of participants agreed with hastened death in this scenario, while 64.2% opposed.

f. Criança de três anos com doença incurável e dores crônicas difíceis de suportar. Os pais pedem ao médico para terminar sua vida [Three-year-old child with an incurable disease and hard-to-bear chronic pain. Their parents ask the physician to end the child’s life].

A figure of 40.4% of participants agreed with hastened death in this scenario, while 59.6% opposed.

Differences in Agreeability With Hastened Death Practices Between Groups

The Mann-Whitney test was performed to determine whether agreeability with hastened death was different between genders, among different religious affiliations and between those who identify as religiously practicing and those who do not. Statistically significant differences were found in all of these comparisons (Table 1). Women showed higher levels of agreeability with hastened death (U = 20167.0, p < 0.05), irreligious (atheists and agnostic) participants showed higher levels of agreeability than Catholic respondents (U = 19082.0, p < 0.05), and participants who identified as religiously practicing showed lesser levels of agreeability (U = 6336.5, p < 0.05) than those who did not.

Table 1.

Differences in Agreeability With Hastened Death Practices Between Groups: Mann–Whitney Test.

Groups	N	Mean rank	Mann–Whitney
Male	144	211.55	20167.0
Female	353	263.87	20167.0
Catholic	266	205.24	19082.0
Atheists and agnostic	208	278.76	19082.0
Religiously active	158	119.60	6336.5
No religiously active	123	168.48	6336.5

Differences in Agreeability With Spiritual Beliefs Between Genders

To determine whether agreeability with spiritual beliefs was different between genders, the Mann-Whitney test was performed. Statistically significant differences between male and female respondents were found in spiritual beliefs one (U = 22352.0, p < 0.05), two (U = 20944.0, p < 0.05), four (U = 22899.5, p < 0.05) and six (U = 22161.0, p < 0.05) (Table 2).

Table 2.

Differences in Agreeability With Spiritual Beliefs Between Genders: Mann–Whitney Test.

Spiritual beliefs	Group	N	Mean rank	Mann–Whitney	p
Spiritual belief 1	Male	144	227.72	22352.0	0.00
Spiritual belief 1	Female	353	257.67	22352.0	0.00
Spiritual belief 2	Male	144	217.94	20944.0	0.00
Spiritual belief 2	Female	353	261.67	20944.0	0.00
Spiritual belief 3	Male	144	238.09	6336.5	0.20
Spiritual belief 3	Female	353	253.45	6336.5	0.20
Spiritual belief 4	Male	144	266.48	22899.5	0.04
Spiritual belief 4	Female	353	241.87	22899.5	0.04
Spiritual belief 5	Male	144	259.88	23849.5	0.21
Spiritual belief 5	Female	353	244.56	23849.5	0.21
Spiritual belief 6	Male	144	226.40	22161.0	0.00
Spiritual belief 6	Female	353	258.22	22161.0	0.00
Spiritual belief 7	Male	144	235.92	23532.0	0.07
Spiritual belief 7	Female	353	254.34	23532.0	0.07
Spiritual belief 8	Male	144	244.70	24797.0	0.62
Spiritual belief 8	Female	353	250.75	24797.0	0.62
Spiritual belief 9	Male	144	242.03	24412.0	0.38
Spiritual belief 9	Female	353	251.84	24412.0	0.38
Spiritual belief 10	Male	144	237.67	23785.0	0.14
Spiritual belief 10	Female	353	253.62	23785.0	0.14
Spiritual belief 11	Male	144	241.48	24333.5	0.16
Spiritual belief 11	Female	353	252.07	24333.5	0.16

Association Between Spiritual Beliefs and Hastened Death Scenarios

The Chi-Square Test of Independence was performed to evaluate the association between each spiritual belief and agreeability with each hastened death case. The Phi coefficient (−1 to 1) was applied to analyse the strength of relation. Statistically significant association was found between every hastened death scenario and multiple of the spiritual beliefs.

Hastened death scenario a)

Spiritual beliefs number two (X²₍₁₎ = 19.31, p = 0.00, p < 0.05), three (X²₍₁₎ = 9.72, p = 0.00, p < 0.05), four (X²₍₁₎ = 14.16, p = 0.00, p < 0.05), five (X²₍₁₎ = 20.15, p = 0.00, p < 0.05), six (X²₍₁₎ = 8.77, p = 0.00, p < 0.05), eight (X²₍₁₎ = 27.59, p = 0.00, p < 0.05) and nine (X²₍₁₎ = 38.62, p = 0.00, p < 0.05) were associated, in a statistically significant matter, with increased agreeability with the practice of hastened death in this scenario.

Hastened death scenario b)

Spiritual beliefs number two (X²₍₁₎ = 23.45, p = 0.00, p < 0.05), three (X²₍₁₎ = 13.51, p = 0.00, p < 0.05), four (X²₍₁₎ = 22.89, p = 0.00, p < 0.05), five (X²₍₁₎ = 20.33, p = 0.00, p < 0.05), six (X²₍₁₎ = 12.11, p = 0.00, p < 0.05), eight (X²₍₁₎ = 24.74, p = 0.00, p < 0.05), nine (X²₍₁₎ = 52.78, p = 0.00, p < 0.05), ten (X²₍₁₎ = 16.11, p = 0.00, p < 0.05) and eleven (X²₍₁₎ = 8.18, p = 0.00, p < 0.05) were associated, in a statistically significant matter, with increased agreeability with the practice of hastened death in this scenario.

Hastened death scenario c)

Spiritual beliefs number two (X²₍₁₎ = 25.99, p = 0.00, p < 0.05), three (X²₍₁₎ = 22.58, p = 0.00, p < 0.05), four (X²₍₁₎ = 27.40, p = 0.00, p < 0.05), five (X²₍₁₎ = 36.64, p = 0.00, p < 0.05), six (X²₍₁₎ = 16.28, p = 0.00, p < 0.05), eight (X²₍₁₎ = 30.65, p = 0.00, p < 0.05), nine (X²₍₁₎ = 61.19, p = 0.00, p < 0.05), ten (X²₍₁₎ = 9.77, p = 0.00, p < 0.05) and eleven (X²₍₁₎ = 4.82, p = 0.03, p < 0.05) were associated, in a statistically significant matter, with increased agreeability with the practice of hastened death in this scenario.

Hastened death scenario d)

Spiritual beliefs number two (X²₍₁₎ = 12.11, p = 0.00, p < 0.05), three (X²₍₁₎ = 6.08, p = 0.01, p < 0.05), four (X²₍₁₎ = 12.15, p = 0.00, p < 0.05), five (X²₍₁₎ = 22.28, p = 0.00, p < 0.05), six (X²₍₁₎ = 8.14, p = 0.00, p < 0.05), eight (X²₍₁₎ = 29.13, p = 0.00, p < 0.05) and nine (X²₍₁₎ = 20.74, p = 0.00, p < 0.05 were associated, in a statistically significant matter, with increased agreeability with the practice of hastened death in this scenario.

Hastened death scenario e)

Spiritual beliefs number five (X²₍₁₎ = 9.66, p = 0.00, p < 0.05), seven (X²₍₁₎ = 5.07, p = 0.02, p < 0.05), eight (X²₍₁₎ = 8.50, p = 0.00, p < 0.05), nine (X²₍₁₎ = 11.14, p = 0.00, p < 0.05) and eleven (X²₍₁₎ = 4.53, p = 0.03, p < 0.05) were associated, in a statistically significant matter, with increased agreeability with the practice of hastened death in this scenario.

Hastened death scenario f)

Spiritual beliefs number five (X²₍₁₎ = 6.85, p = 0.01, p < 0.05), eight (X²₍₁₎ = 11.82, p = 0.00, p < 0.05) and nine (X²₍₁₎ = 10.68, p = 0.00, p < 0.05) were associated, in a statistically significant matter, with increased agreeability with the practice of hastened death in this scenario.

Spiritual beliefs number five, eight and nine were found to be the most associated with increased agreeability with hastened death, as measured through the scenarios presented. Increased agreeability with these beliefs was associated with increased agreeability with the practice of hastened death in every scenario presented in a statistically significant manner. Spiritual belief number six followed, showing significant association with four of the six hastened death scenarios presented. Spiritual beliefs number two, three and four showed significant association with four of the six hastened death scenarios. Spiritual belief number 11 showed significant association with three of the six hastened death scenarios. Spiritual belief number ten showed significant association with two of the six hastened death scenarios. Spiritual belief number seven showed significant association with one of the six hastened death scenarios. Only spiritual belief number one did not show significant association with any of the hastened death scenarios presented.

Predictors of Agreeability With the Hastened Death Scenarios

The multiple regression analysis found that the variability of the dependent variable was explained by a set of independent variables, as shown in Table 3. We found five variables statistically significant to the model [F(5.491) = 19.49, p < 0.001; R² = 0.166]. Spiritual beliefs number one (B = −0.123; t = 2.84, p < 0.05), number five (B = −0.141; t = 2.85, p < 0.05), number seven (B = −0.100; t = 2.38, p < 0.05), number eight (B = −0.137; t = −2.76, p < 0.05) and number nine (B = −2.40; t = −4.88, p < 0.05) constituted predictors of agreeability with hastened death in the situations presented.

Table 3.

Spiritual Beliefs Which Were Predictors of Agreeability With the Euthanasia Situations.

	Total agreeability with euthanasia
Variable	Model B	B	p
Constant	9.38		0.000
Belief_9	−102	−0.24	0.000
Belief_8	−0.53	−0.13	0.006
Belief_1	0.52	0.12	0.005
Belief_5	0.55	0.14	0.005
Belief_7	0.47	0.10	0.01

R²	.166
F	19.49		0.000

Discussion

This sample of Portuguese medical students followed the trend of religious affiliation seen in the Portuguese general population, with Catholicism being the dominant ideology, followed by irreligiosity. A total of 53.5% identified as Catholic, while 41.9% identified as atheists or agnostics. The figures of atheists and agnostics were combined as both refer to irreligious people, who, therefore, have no religious faith and do not hold concrete religious beliefs. While in alignment with the trend seen in the general population, these figures are drastically more inclined towards irreligiosity than those of the latter. In the 2011 Portuguese Census, 81% of the population identified as Catholic and 6.9% as irreligious (INE, 2012). Although we could expect the irreligious figure to have grown since 2011, following the 79% increase it saw from 2001 to 2011 (Observatório das Migrações [Migration Observatory], n.d.), it should still lie rather far from the 41.9% seen in these medical students. Therefore, this sample is considerably more irreligious than the general population, as expected. Participants in this study largely belonged to a young generation, and, as medical students, were more scientifically educated than the general population (Bautista et al., 2018). These factors can account for the lower religious affiliation seen in this sample (Bautista et al., 2018; Marsala, 2019).

Respondents mostly disagreed with the spiritual beliefs presented – only three of them gathered over 50% of agreeability. Yet, it should be noted that the rationale behind statement numbers four and five is the opposite, as agreeability presupposes a lesser sense of purpose in life. Therefore, the disagreeing figures are the more spiritual ones. Thus, participants showed higher spirituality in five out of the 11 spiritual beliefs presented. This result further suggests that these university students manifest a tendentially secularized and scientific world view, contrasting with the country’s traditionally highly religious background (INE, 2012).

As expected, and as consistently reported in previous studies (e.g., Hamil-Luker & Smith, 1998; Muller et al., 1996), agreeability with hastened death was different among students who had a formal religious affiliation as compared to atheist or agnostic students, with lesser agreeability in the Catholic group. Favourability towards hastened death also seemed to vary with self-identified engagement in religion. Students who identified as religiously practicing showed lesser levels of agreeability with hastened death than their counterparts. These results are consistent with the principles of most formal religions, which stand against the practice of hastened death (Chakraborty et al., 2017). However, only Catholicism reached a sizeable number in this sample. Each of the other religions gathered no more than four answers. Thus, it was not possible to test how agreeability with hastened death, as measured through the presented cases, would vary with other particular religions or how these would compare to that seen with Catholicism. Once again, in this study religion stands as a factor of the utmost importance in defining one’s position towards hastened death.

Identical to the general population and the trend seen in the societies of other developed countries (Cohen et al., 2006), this sample of medical students proved to be mostly favourable towards hastened death practices. However, this agreeability was largely modified by the particularities of each situation. Three of the presented scenarios (a, b and c) gathered over 70% favourable answers, while the remaining three (d, e and f) did not amount to over 40% of agreeability. These three less consensual scenarios (d, e and f) represented situations in which the patient either still had a good quality of life (d) or was not the one asking for his death to be hastened (e and f). In one of the latter (f), the patient was a child, unlike in every other situation, which may additionally have an impact in agreeability with this situation. These findings suggest that, when patients suffer from terminal conditions that do not yet greatly impair their quality of life or are not autonomous enough to express their own wish to die, hastened death is not easily accepted by these medical students. This variability has been seen before (Silva et al., 2019) and reinforces the need for hastened death laws to be carefully tuned so that they protect not only patients’ rights but also society’s values.

There were some notable differences between genders in this study. Women showed higher levels of spirituality in the majority of the spiritual beliefs presented, with a statistically significant difference in beliefs number one, two, and six. This result is consistent with the findings of other studies that have reported higher spirituality levels among women (Brown et al., 2013). It has been hypothesized that this difference stems from not only biological sex differences but also sociocultural factors in gender roles and socialization patterns, being more marked in less gender-egalitarian backgrounds (Robinson et al., 2019). Additionally, women showed higher agreeability with hastened death. Previous literature has been inconsistent regarding the existence of gender differences in the acceptance of hastened death. Some studies have reported higher agreeability among women (Muller et al., 1996) and some among men (Ramírez-Rivera et al., 2006), while others have reported no gender differences (Rodríguez-Calvo et al., 2019).

One of the most remarkable results of this study was how the used spiritual beliefs were significantly associated with the level of agreeability with hastened death as measured through the scenarios presented. This finding reinforces the need to measure spirituality through multi-item tools rather than single closed questions about religious affiliation. Spirituality represents a core dimension in defining one’s motives and behaviour towards life’s challenges (Forstmann & Burgmer, 2018). It can provide meaning and answers, especially when questions are of a nature that stands beyond our analytical understanding, such as those regarding the afterlife. Therefore, it seems natural that our intrinsic spiritual constructs are deeply connected to our explicit answers to questions regarding bioethical dilemmas such as that of hastened death. Out of all the 11 spiritual beliefs presented, only one did not have a significant correlation with any of the hastened death situations presented, while three of them were significantly associated with all six situations.

The surprising twist is that higher spirituality as measured through some particular beliefs was, in fact, associated with higher agreeability with hastened death and not the opposite, as seen with religion. Specifically, spiritual beliefs number one, five, seven, eight, and nine were found to be predictors of agreeability with hastened death in these scenarios. It could, then, be hypothesized that although religion promotes disagreeability with hastened death, independent spiritual beliefs concerning concrete metaphysical questions favour agreeability – specifically, beliefs regarding mind-body dualism, in which the mind is viewed as a form of energy (belief number one), and superstitions (belief number seven). These two beliefs do not presuppose religious intervention nor do they refer to traditional religious concepts, so they are not necessarily religious. In fact, they relate to pagan concepts, namely the existence of energy as a transcendent force and the existence of luck and mischance. Nonetheless, belief number eight, which does not represent a belief in itself, but, rather, states that spiritual, metaphysical, and religious beliefs help with life’s challenges, also seems to favour agreeability. All main world religions are typically monotheist and doctrinal. Along that line, very religious people may show a tendency towards being defensive of the exclusivity of their beliefs. Hence, they may be reluctant to identify with a statement – such as belief number eight – that explicitly assumes the existence of other types of beliefs. Based on previous literature, and as we have stated before, belief in the afterlife or other solutions to the death problem could theoretically increase acceptance towards hastened death, as if it were just some transition to an assured existence elsewhere. This could explain how non-religious yet spiritual individuals may be favourable towards hastened death. However, among non-religious, non-spiritual, more sceptical individuals, it might be both the devaluation of life (as a non-sacred value or through disbelief in a higher purpose) and the contrasting importance of individual autonomy that makes them more tolerant towards the practice of hastened death (Bulmer et al., 2017). Once again, although more secular, these, too, consist of beliefs regarding metaphysical questions. As a matter of fact, belief number five, which not only reflects this scepticism towards the value of life but also reflects introspection towards this dilemma with resulting confusion between what one believes is true and what he/she wishes were true, was a predictor of agreeability with hastened death in this study. A considerable figure of roughly 50% of these medical students identified with this statement. This indicates that, although largely formally irreligious (41.9%), many participants in this study manifest an internal conflict that seems to make them more prone to agree with hastened death. Finally, believing to have witnessed the presence of God or another divine entity was represented in belief number nine, the last of these five beliefs that predicted agreeability with hastened death practices in this study. In line with what was previously stated, believing to have witnessed the presence of the divine can be a life-changing experience. Therefore, there are multiple ways one could be affected. As with belief number eight, however, here, too, very religious participants may be reluctant to identify themselves with a statement that refers to “other spiritual entities” beyond their monotheistic god. Nonetheless, as noted before, some religious people may be sympathetic to hastened death even if they are aware that it stands against their religion’s formal beliefs (Gielen et al., 2009a). No previous literature on the relationship between particular spiritual beliefs and agreeability towards hastened death practices was found to properly justify these findings.

The contribution of this study was twofold. It further consolidated the well-established association between formal religiosity and disagreeability with hastened death and it raised important questions about how particular spiritual – but not necessarily religious – beliefs could be at the basis of individuals’ answers about hastened death, particularly in an opposite direction to that seen with religiosity. Still, some limitations of this study must be pointed out: only hastened death was studied, and not other medical ethical dilemmas of interest, such as that of abortion; and only one generational cohort was significantly used, though positions towards such dilemmas are known to differ between generations (Marsala, 2019). The effect of these spiritual beliefs in other generations is not assured. Furthermore, spirituality stands on beliefs and perceptions that are often implicit and which may not be easily accessible through self-reporting.

Spirituality comes out of this study as a factor potentially determining one’s view towards hastened death. Although religion was associated with lesser agreeability towards hastened death, several other spiritual beliefs were found to predict favourability. Other factors may be playing a role along with spirituality here. Several ideologies and traits have been found previously to independently predict agreeability towards hastened death, such as higher levels of education, higher levels of political liberalism and higher levels of extraversion (Bulmer et al., 2017). These authors also found a significant correlation between lower levels of authoritarianism and agreeability towards hastened death. The degree to which these other factors may be associated with non-religious spirituality is not well-established, but is a target of interest for future research. This could help account for the effect of spirituality on younger generation cohorts. In whichever case, future studies are needed to more thoroughly assess the role of particular spiritual beliefs regarding metaphysical questions in one’s point of view towards bioethical dilemmas such as that of hastened death. The focus should be put on further dissecting different dimensions of spirituality, ideally comparing non-religious but spiritual individuals not only with religious and spiritual individuals but especially with non-religious and non-spiritual individuals, to better discern the full scope of the influence of spirituality on this matter.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Sílvia Marina

Miguel Ricou

Note

Author Biographies

Alexandre Sousa graduated in medicine from Faculty of medicine of University of Porto.

Sílvia Marina, psychologist, master in Clinical and Health Psychology. Researcher at CINTESIS – Center for Health Technology and Services Research. She works in private practice at the Medical Innovation Center in Porto. She is a PhD student in Palliative Care at Faculty of Medicine of Oporto University. Her main research work is in the areas of psychological intervention, end-of-life decision making and the role of psychologists in euthanasia/assisted suicide. Member of the European Platform ‘Wish to Die'.

Miguel Ricou, psychologist, master in Bioethic and PhD in Clinical Psychology. president of the Ethics Committee of the Portuguese Psychologists Association. Member of the Board of Ethics of EFPA – Portuguese Representative. Assistant professor of Bioethics and Palliative Care, Faculty of Medicine of Oporto University, Portugal. Assistant professor of Psychopathology, Portucalense University, Portugal. Associated member of CINTESIS – Center for Health Technology and Services Research. Coordinator of the European Platform ‘Wish to Die'.

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