Abstract
Two questionnaires directed to Swedish physicians and a sample of the Swedish population investigated attitudes towards physician-assisted suicide (PAS). The aim of the present work was to analyse qualitative data from these questionnaires in order to explore how respondents reason about PAS. Data were analysed in two steps. First, we categorized different kinds of responses and identified pro and con arguments. Second, we identified general conclusions from the responses. The data reflect the differences in attitudes towards PAS among the public and physicians, with the former mainly in favour of PAS and the latter mainly against. There was, however, considerable agreement about what requirements must be met before PAS could be considered ethical. Many arguments against PAS concerned the professional role of physicians, which indicates that it may not be assisted suicide as such that many PAS opponents disagree with, but rather that it is handled by physicians in the regular health-care system.
Introduction
Physician-assisted suicide (PAS) is perceived as controversial in many countries. 1–7 A number of ethical issues can be raised in relation to PAS, pivotal among them being the normative status of suicide and physicians' responsibilities for suicidal patients. Other important issues are the potential alternatives for patients who may consider PAS and the consequences of introducing PAS as an option in the health-care system.
Neither suicide nor assisting someone to commit suicide is a criminal act in Sweden, but physicians are expected to protect their patients and risk losing their licence if they prescribe lethal doses of drugs for self-administration or provide advice and information on how to commit suicide. 8 There are, nevertheless, physicians in Sweden who have testified that they or their colleagues prescribe lethal drugs to special categories of patients who express a wish to end their suffering by committing suicide.
In order to explore the attitudes towards PAS among physicians and a Swedish population sample, two questionnaires were constructed and distributed. In addition to quantitative data, qualitative data in the form of the respondents' own arguments as well as free-text responses to specific statements were generated from the questionnaires. The objective of the present work was to analyse these data in order to explore how the respondents reason about PAS.
Methods
During the spring of 2007 we included 1200 randomly selected physicians, 200 from each of six different specialities – psychiatry, surgery, general practice, geriatrics, internal medicine and oncology – in a questionnaire-based survey. A similar postal questionnaire was distributed to 1200 randomly selected individuals in the general population from the County of Stockholm. 9,10
The respondents were asked for their attitude to PAS, with response options ‘Yes’, ‘No’ or ‘Doubtful’ to the question whether they would find PAS acceptable under certain specified conditions (Box 1). The respondents were also asked to state to what degree they agreed with a number of well-known arguments presented for and against PAS. In addition, they were asked to prioritize between these arguments. Finally the respondents were asked whether or not PAS, if allowed, might influence their own trust or patients' trust in the health-care system. They were, furthermore, on several occasions given the opportunity to add their own arguments and comments (Box 1). In this way, they could both express their attitude towards PAS (in favour, against or unsure) and reason about PAS by stating their arguments.
Content and structure of the questionnaire to physicians
When in the following questionnaire you take a stand on the acceptable or unacceptable in prescribing drugs that a patient can take for the purpose of committing suicide, we assume that the measure has been legally accepted by the authorities.
In addition the following criteria are presumed to have been met:
The patient is at the end of life and his/her suffering is unbearable; The patient must be decision-competent and well informed about alternative palliative measures; The patient must be asking for PAS of his/her own accord, without being influenced by others; The patient must be capable of administering the drug by him/herself; The patient must not be suffering from any treatable psychiatric disorder; The treating physician must have known the patient for a considerable length of time; A second physician must verify that the listed criteria are fulfilled.
1) If these criteria were met, would you accept physicians prescribing drugs that a patient could take for the purpose of committing suicide painlessly?
□ Yes □ No □ In doubt
A row of arguments/reasons for/against accepting physician-assisted suicide will now follow. We ask you to decide which of these you find important/unimportant, and finally which argument you find the most important.
2)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
3)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
4)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
5)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
6)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
7)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
8)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
9)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
10)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
11)
□ Very important □ Fairly important □ Fairly unimportant □ Completely unimportant
12) Other reasons:
13) Which one of the arguments set out above (2–12) do you consider the most important: ___
Comments:
Do you think that patients' trust in the health-care system would be affected if physician-assisted suicide was allowed under the criteria set forth above?
□ would decrease a lot
□ would decrease rather a lot
□ would decrease slightly
□ would increase slightly
□ would increase rather a lot
□ would increase a lot
□ would not be affected at all
Comment:
Do you think that your own trust in the health-care system would be affected if physician-assisted suicide was allowed under the criteria set out above?
□ would decrease a lot
□ would decrease rather a lot
□ would decrease slightly
□ would increase slightly
□ would increase rather a lot
□ would increase a lot
□ would not be affected at all
Comment:
Finally a few questions about you:
Age:____ □ Male □ Female
In what speciality do you work? _______________
What year did you get your licence to practise: ____
Other comments:
Thank you for your participation!
Two reminders were sent out. A short version of the questionnaire, including only the main question of whether or not they accepted PAS plus background factors such as age and sex, was finally mailed a few weeks later. Data were registered using Epi Info 6 (CDC).
In the present work, qualitative data from the questionnaires' free-text responses have been analysed in two steps. The first step involved categorization into different kinds of responses by an iterated process of reading through a condensed version of all comments from both questionnaires. 11–13 Different pro and con arguments were also distinguished. In the second step, general conclusions from the responses were identified and discussed.
Results
Total questionnaire response rates were 58% (695/1200) in the population and 74% (890/1200) among physicians. The short version yielded 151 physician and 86 population responses. Almost 30% of the general public and physicians gave free-text responses running to more than 6500 words (in the short version only two persons from each group added comments). Among the physicians, older physicians (>51 years) gave more comments than younger ones (<50 years), and oncologists and psychiatrists wrote more comments than general practitioners. We found no other significant differences between specialties or between the sexes. In the population sample, no significant differences appeared regarding number of written comments in relation to age or sex.
The results of the qualitative analysis are categorized into five emerging themes: (1) argumentation about PAS; (2) emotional responses; (3) differences in attitudes; (4) disagreement not primarily about assisted suicide; and (5) agreement concerning PAS requirements.
Argumentation about PAS
The comments reflect willingness to reason about PAS – and about whether or not it is acceptable and should be openly introduced in Swedish health care. As is shown in the overview of pro and con arguments stated in the free-text responses (Table 1), most arguments in favour of PAS concern patients' right to autonomous decision-making regarding their own lives and their right to avoid unbearable pain and suffering. The autonomy argument allows PAS regardless of the state of the art in palliative care, while the avoidance-of-pain argument does not. Some proponents of PAS explicitly state that present palliative care cannot, or does not, help everyone.
Pros and cons concerning physician-assisted suicide (PAS)
Opponents of PAS use a wider variety of arguments. The main categories are: PAS is wrong as such; it is wrong for physicians to handle assisted suicides; PAS is wrong due to the risks involved; and there is no need for PAS. Very few opponents of PAS state that they are against it for religious reasons. Arguments that suicide is wrong as such are slightly more common, but still rare. Arguments that physicians should not be involved in assisting suicides and that there are unacceptable risks tied to introducing PAS in the health-care system dominate.
Arguments concerning physicians' professional role state that intentionally contributing to a patient's death is not part of the legitimate goals of the profession and that it may be detrimental to a physician's character. Risk arguments concern possible mistakes in diagnoses, that PAS might not be genuinely wanted and slippery slope arguments saying that what starts out from patient interest might eventually be used as a form of involuntary euthanasia.
Several arguments relate to palliative care. While some physicians claim that palliative care makes PAS superfluous, others are afraid that introducing PAS would have a negative impact on the further development of palliative strategies. The fear that trust in physicians and the health-care system will be undermined if PAS is introduced is expressed in relation to all three kinds of arguments (i.e. concerning professional role, risks and palliative care).
Emotional responses
The colourful language in some comments shows that there is also considerable emotional input and commitment regarding this issue. For instance, in the responses from the public there is a comment to the effect that it cannot be right that ‘animals can be relieved from their sufferings but not human beings…’. Others talk about the right to avoid ending up as a ‘package’ or ‘vegetable’. One respondent claims that PAS would be ‘a more dignified way to finish one's life than to be smashed to pieces by a train’. On the other hand, an opponent to PAS expresses fear that ‘PAS might open the door to an abyss’.
In the responses from physicians allusions are made to ‘Gestapo’ and ‘Hitler's death machinery’, and there are protests that PAS would introduce ‘Death doctors’ and that physicians would be considered ‘state executioners’. One respondent writes: ‘Let veterinaries [and not physicians] kill people if society accepts it’. Another respondent (actually in favour of PAS) uses the expression ‘executioner institutes’.
The rhetorical power of claiming that something is ‘humane’ or ‘inhumane’ is used on both sides. Proponents among the public and physicians find it humane to allow PAS and inhumane not to let people die when their pain and suffering is overwhelming, while some physicians opposing PAS refer to a ‘humane spirit’ when they say a definite ‘no’ and instead point to good palliative care.
The material also includes a few remarks on the rhetoric of labelling. These commentators would like to see ‘physician-assisted suicide’ replaced by some term that avoids the word ‘suicide’. They argue that the very term ‘suicide’ implies that there is something wrong about it, and that is a connotation they want to avoid.
Differences in attitudes
The responses to the questionnaires show a considerable difference between physicians and the public in their attitudes to PAS. While 72% of the general population respondents are in favour of PAS, 34% of the physicians share that conviction. 10,11 The free-text comments made in the questionnaires reflect this difference. Thus, there are many arguments in the responses from the public concerning the importance of respecting patient autonomy and letting people avoid unbearable pain, while responses from physicians often concern the importance of protecting the professional role and the potential risks of introducing PAS.
Comments also show that many of those who do not take sides are not undecided due to lack of interest in the PAS issue. Rather their comments show that they appreciate both pro and con arguments and find it difficult to settle for a ‘yes’ or ‘no’. For instance, one undecided respondent states that ‘all arguments in the questionnaire carry equal weight’. A physician writes that ‘to give the patient this opportunity is to show respect’, but adds that she fears that patients will be pressurized to use PAS. Some indecisive physicians stress the difficulty to distinguish depression from a genuine wish to die.
Disagreement not primarily about assisted suicide?
Although a majority of physicians state that they are opposed to PAS, the opposition manifest in the free-text comments is dominated by protests against the idea of physicians in regular health care assisting patient suicides. There are many arguments to this effect, including that it would be an unacceptable expansion of professional responsibility. For instance, one physician writes: ‘It is not the physician's task to assist suicide’. Another physician states that introducing PAS would be to ‘transgress an important boundary line for the action and responsibility of doctors’. Others argue that it might threaten the positive public perception of physicians and diminish trust in the health-care system. One physician states: ‘People must always be able to trust health care and its respect for human dignity’.
Some physicians explicitly ask for alternatives, for example: ‘Patient autonomy is axiomatic, but doubtful whether physicians should do it [i.e. PAS]’; ‘It should not be carried out by palliative physicians but by special “executioner institutes” as in Switzerland/the Netherlands’. It is clear from the many comments that a considerable number of physicians do not want this kind of duty; some because they think it should not be handled by physicians in the regular health-care system and others because they do not want to do it themselves. Some of those expressing these views state that they are not generally opposed to assisted suicide.
Then again, some physicians are explicitly against assisted suicides as such or because they fear that an introduction of PAS would lead to a slippery slope with concerns other than patient interests eventually gaining the upper hand.
Agreement concerning PAS requirements
In spite of the differences in attitudes towards PAS, there is considerable agreement among proponents and opponents about requirements that should be met before PAS could be considered ethically acceptable. The questionnaires revealed that the respondents most frequently reported the following five conditions as important factors in the ethical practice of PAS (Table 2 shows the complete list of requirements):
Minimize the risk of wrong diagnoses, leading to ‘unmotivated’ suicides; Verify that an expressed wish to die is genuine and not caused by underlying depression or pressure/perceived expectations from relatives, health-care staff or society; Guarantee that there will be no slippery slope regarding criteria; Make sure that patients concerned: (1) will be able to use the prescribed drugs as intended; and (2) will not use them for other purposes; Use PAS in a manner that maintains public trust in health care. Stated conditions for PAS to be acceptable
The disagreement between proponents and opponents of PAS can, at least partly, be explained by a difference in views regarding the chances of these requirements being met in Swedish health care. Opponents of PAS commonly argue in the following manner: ‘Requirements X, Y and Z must be fulfilled for PAS in health care to be acceptable; X-Z will not be fulfilled; therefore PAS is not acceptable’. Proponents are considerably more optimistic in this regard.
Discussion
Religious views seem to have little influence on Swedish attitudes towards PAS. The reasoning found in our questionnaires centres on patient autonomy, pain and suffering, professional roles and responsibilities, risks, and trust in physicians and health care in general. In addition, self-interest is reflected in comments from the respondents. Many responses from the public deal with the patients' situation, while many physicians focus on what it would be like for physicians to work in an environment where PAS is established. The population seems largely happy with the idea that physicians handle PAS in the regular health-care system, while more physicians experience this as problematic. Furthermore, a majority in the population sample do not see any risks of undesirable developments if PAS were to be introduced as impending, while many physicians do. There is, of course, a difference in responsibility that might affect judgment: physicians know that if PAS is introduced, it will to a considerable extent be their responsibility to make sure that the system does not fail. It should be noted that many physicians nevertheless express support for PAS in the questionnaire. There are also quite a few among the population who oppose it.
Mainly a disagreement about who should do it?
The main disagreement concerning PAS might actually concern who should do it, i.e. who should assist by prescribing the lethal drugs, rather than the ethical status of assisted suicide. The P rather than the AS in PAS seems to be the main target for PAS opponents. This raises the issue whether assisted suicides can be handled in some other way that preserves the advantages while excluding the disadvantages. A few respondents suggest that the use of special institutes, or appointed PAS specialists, would eliminate or reduce the downside of allowing PAS by limiting the number of institutions and/or health-care staff that would be involved in the practice. However, many physicians argue that PAS interferes with palliative care: ‘It is important to maximize palliative care before this action (PAS) is considered’.
Is there a need for PAS?
Some physicians argue that it is unnecessary to allow PAS since patients who may want PAS have access to drugs that would kill them if overdosed, and since patients rarely kill themselves this way, this shows that they do not really want to. However, this argument does not consider that a public system for PAS would help to legitimize suicide as an exit from unbearable illness and therefore make it easier for both patients and their relatives to accept. One PAS proponent states that ‘assisted suicide would be more merciful for the patient and particularly for relatives’. Another proponent writes that it would be ‘worse for the family to accept other forms of suicide’. That a public system for PAS would contribute to legitimize suicide is also used by opponents as an argument against allowing PAS.
Limitations
This study can probably be said to mirror the attitudes of Swedish physicians in general, given the fairly high response rate (74%) and the random selection of relevant respondents. But the response rate from the population is lower (58%), and the sample is drawn from the biggest Swedish urban area. It is known from the Netherlands that attitudes towards euthanasia and PAS are more positive in urban than in rural areas. 14 It can also be assumed that the foreign-born population (>15% in the Stockholm County area) may account for a smaller proportion of respondents since there were complaints about difficult language in the survey. Moreover, there is a high proportion of Muslims among foreign-born residents with a supposedly negative PAS attitude.
Conclusions
Swedish physicians and the Swedish public seem to have different attitudes concerning PAS, with the public largely in favour of it and physicians opposing it. Yet proponents and opponents agree that several conditions must be met in order for PAS to be acceptable. This includes minimizing risks for mistaken diagnoses, that there will be no slippery slope regarding criteria, that patients will be able to use prescribed drugs as intended and that PAS is used in a manner that maintains public trust in health care. However, they disagree as to whether these conditions are likely to be fulfilled in practice. They also disagree on the relative importance of respecting patient autonomy.
Physicians fear that if PAS is introduced in regular health care, this could negatively affect people's trust in the system. Physicians also fear that they will have to assist patients to commit suicide against their own conviction and understanding of their professional role.