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Physician-assisted suicide: a survey of attitudes among Swedish physicians

Anna Lindblad, Rurik Lfmark and Niels Lyne Scand J Public Health 2008 36: 720 DOI: 10.1177/1403494808090163 The online version of this article can be found at: http://sjp.sagepub.com/content/36/7/720

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Scandinavian Journal of Public Health, 2008; 36: 720727

ORIGINAL ARTICLE

Physician-assisted suicide: a survey of attitudes among Swedish physicians

ANNA LINDBLAD, RURIK LOFMARK & NIELS LYNOE

Unit of Medical Ethics, LIME, Karolinska Institutet, SE-171 77 Stockholm, Sweden

Abstract Aims: To investigate the attitudes of Swedish physicians towards physician-assisted suicide. Design: A postal questionnaire on the respondents opinion of physician-assisted suicide was sent to a randomly selected sample of physicians in Sweden. The respondents were given the opportunity of furnishing arguments of their own and of prioritizing arguments. They were also asked about possible influence on their own and patients trust in the healthcare system if physician-assisted suicide was to be legally accepted. Participants: 1,200 physicians from six specialties, approximately 200 individuals each in: general practice, geriatrics, internal medicine, oncology, psychiatry and surgery. Setting: The study was commissioned by the Swedish Medical Society and its logo was printed on questionnaires and envelopes. Results: The total response rate was 74%, ranging between 63%80% among the specialties. On average 34% were pro physician-assisted suicide, 39% against it and 25% were doubtful; 2% per cent did not respond to the question at all. Psychiatrists were significantly more accepting than oncologists, who were the most restrictive specialty. Older physicians (w50 years) provided a significantly more accepting attitude than younger ones ((51 years). Conclusions: Despite the fact that the World Medical Association condemns physician-assisted suicide as unethical, the present survey indicates that there is no clear majority for or against physician-assisted suicide among Swedish physicians, and that significantly more elderly physicians have an accepting attitude towards physician-assisted suicide. There is a need for further research explaining the differences between the age groups as well as the variation between specialities.

Key Words: Attitudes, clinical ethics, patient autonomy, physician assisted suicide, terminal-ill patients

Introduction In recent years at least three Swedish decisioncompetent patients suffering from chronic neurological diseases have travelled to Switzerland for help to commit suicide. Accordingly there have been discussions both publicly in the newspapers and among healthcare professionals about patients rights and physician-assisted suicide (PAS). Suicide is not a crime in Sweden, nor is assisting a person to commit suicide under certain well-defined conditions. However, healthcare professionals risk losing their licence if, at the request of a terminally ill patient, they prescribe a lethal dose of drugs for selfadministration, this being regarded as negligence [1]. Since suicidal behaviour is usually interpreted as

a symptom of psychiatric illness, even a terminally ill patient suffering from unbearable pain or discomfort and repeatedly asking for assisted suicide is not supposed to be helped by physicians; such an action is also condemned as unethical by the World Medical Association (WMA), who also stress that a physician ought not to participate in PAS regardless of whether it is legalized or not [2]. But even though PAS is a controversial ethical action, it is not a criminal offence in Sweden, and in this sense PAS is less controversial than active euthanasia, which is a criminal offence punishable by at least one years imprisonment. In a Swedish context, then, it seems reasonable to distinguish between PAS and euthanasia, the latter being defined as a physician administering a lethal dose of drugs and intending

Correspondence: Niels Lynoe, Unit of Medical Ethics, LIME, Karolinska Institutet, SE-171 77, Stockholm, Sweden. Tel: +46 8 5248 6058. Fax: +46 8 34 51 28. E-mail: niels.lynoe@ki.se (Accepted 28 January 2008) # 2008 the Nordic Societies of Public Health DOI: 10.1177/1403494808090163

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Physician-assisted suicide the death of the patient both at the request of a terminally ill patient [1]. Since the attitudes of Swedish physicians to PAS are not known, this lacuna formed the starting point of the present study. Methods The survey was commissioned by the Swedish Medical Society in January 2007 in order to investigate attitudes towards PAS in six different specialties: psychiatry, surgery, general practice, geriatrics, internal medicine and oncology. After a pilot study of colleagues and co-workers in the department, 1200 physicians, 200 in each group, were randomly selected and received a postal questionnaire. They were asked for their opinion on PAS, given that certain criteria were met (see Box 1). The list of criteria, which might have been composed otherwise, was constructed against the backdrop of the criteria in Holland and in Oregon but adapted to a possible Swedish setting. The main response-options were: Yes, No or Doubtful. The respondents were also asked to prioritize between different arguments for and against or to give their own arguments. Finally they were asked whether or not PAS, if allowed, might influence their own trust or patients trust in the healthcare system. Two reminders were sent two weeks and four weeks later respectively, resulting in a response rate of 61%. A short version, including only the same background information and the main question of whether or not to accept PAS, was finally mailed a few weeks later, resulting in an additional 13% responses. The data were registered and analysed using Epi Info 6, and regression analyses were run using the SPSS software. When calculating p-values we used Chi-square tests, and when comparing proportions we used 95% confidence intervals. In accordance with Swedish legislation, the present study was not assessed by a research ethical committee.

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rejection or uncertainty. The respondents mean age was 50 years, ranging from 2684 years. In the senior group (w50 years), significantly more were males (p50.0003), which corresponded to the demographic data. The balance of the sexes also matched the demographic data of the average malefemale ratio of physicians [3]. Non-respondents had a mean age of 50.5 years, ranging from 2878 years. The sexes were fairly evenly balanced, with a slight majority of men (53%). The group of senior physicians responded more promptly compared to their younger ((51 years) colleagues (p50.001); this was a response-pattern recognized when comparing the responses from those who got the whole questionnaire and from those receiving the short version. There was also a tendency for those in doubt to reply later, but no difference in this respect between those receiving the original and the short version of the questionnaire. Compared to the older physicians, the young ones tended to be more in doubt (p50.06).

Main outcome Of the 877 respondents, 34% were for PAS, 39% against it and 25% doubtful of its acceptability; 2% did not respond to the question at all. There was a significant difference in attitude (p50.01) between psychiatrists and oncologists, but no significant differences between the other specialties (see Figure 1). Comparing age groups, we found that senior physicians had a more accepting attitude: 39% versus 30% were pro-PAS, 38% versus 42% against it and 23% versus 28% uncertain. No association was found between sex and attitude such associations were merely connected to specialties where the sex distribution varied (see Table I). Trust We asked whether PAS (if allowed) would influence the respondents trust in the healthcare system and if they believed that patients trust may also be affected. Those expressing a restrictive attitude stated that their own trust in the healthcare system would decrease, as well as their perceived estimation of patients trust; an accepting attitude was associated with an increase or no influence in own trust as well as in patients trust (see Table II). Arguments for/against PAS The respondents were asked to evaluate and prioritize between the different arguments for/against PAS (see

Results Participants Of the 1200 questionnaires mailed, 17 were returned as undeliverable. The total response rate, including the short questionnaire, was 74%, ranging between 63%-80% among the specialties (see Table I). There was no difference in response pattern between those receiving the full questionnaire and the short version regarding the main question of acceptance,

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Box 1. The box shows the content and structure of the questionnaire. 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) For: Respecting the patients right to autonomy % Very important % Fairly important % Fairly unimportant % Completely unimportant 3) Against: Patients in these situations are not aware of their own good % Very important % Fairly important % Fairly unimportant % Completely unimportant 4) For: The purpose is to minimize suffering, not to shorten the patients life % Very important % Fairly important % Fairly unimportant % Completely unimportant 5) Against: Patients trust in physicians may be put at risk % Very important % Fairly important % Fairly unimportant % Completely unimportant? 6) For: The patients autonomy should take precedence over the principle of non-maleficience % Very important % Fairly important % Fairly unimportant % Completely unimportant 7) Against: The principle of non-maleficience should take precedence over the patients autonomy % Very important % Fairly important % Fairly unimportant % Completely unimportant? 8) For: The patient may resort to other more painful methods of committing suicide % Very important % Fairly important % Fairly unimportant % Completely unimportant? 9) Against: Patients who perceive themselves as burdens may experience pressure to ask for PAS % Very important % Fairly important % Fairly unimportant % Completely unimportant 10) For: Adequate palliative care is not available % Fairly important % Fairly unimportant % Completely unimportant % Very important 11) Against: Adequate palliative care is available % 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 healthcare system would be affected if physician-assisted suicide was allowed under the criteria set forth above? % would decrease a lot % would decrease rather much % would decrease slightly % would increase slightly % would increase rather much % would increase a lot % would not be affected at all

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Comment: Do you think that your own trust in the healthcare 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!

Box 1 and Table III) and among physicians with an accepting attitude respect for patients autonomy predominated. Those displaying a restrictive attitude chose the principle of non-maleficience and arguments such as fear of decreased trust in physicians and risk of pressure from relatives. Of those in doubt, 43% prioritized an argument for and 57% an argument against. Compared to the senior physicians (w50 years), significantly more of the younger ones stressed that the non-maleficience principles should precede patients autonomy (p50.0002). Compared to younger physicians, senior physicians seem to stress respect for patients autonomy argument when weighing it with the non-maleficience principle should precede patients autonomy argument (see Table III). On average, 13% of the respondents presented arguments of their own and the majority of these were contra-arguments focusing on possible negative consequences of PAS. Religious aspects such as the sanctity of life and uncertainty regarding the criteria given in the questionnaire were also mentioned. Personal comments were also encouraged and among those with

a restrictive attitude fierce expressions and remarks on the study were common. Among those with an accepting attitude grateful comments prevailed.

Discussion Validity aspects Even though the percentage of non-respondents was 26%, there was no difference between respondents and non-respondents regarding mean age and sex; males predominated in both groups. The purpose of the short version of the questionnaire was to examine whether the original response pattern of non-responders regarding the main outcome differed from that of respondents to the original one. In principle, those responding to the short version of the questionnaire (13%) were exposed to another questionnaire. However, the short version was identical to the first page of the original questionnaire, which they had received previously. No discrepancies in response-pattern

Table I. This table shows the response rate as well as the sex and age breakdown within the different specialities. One respondent did not disclose his/her sex. Group size after randomization (n) 194 195 200 200 197 198 1184 Response rate (%) 71.6 74.9 77.5 63.0 80.2 77.3 74.1 Sex M/F (%) 50/50 81/19 57/43 39/61 67/33 52/48 58/42 Mean age and range (yrs) 54 48 52 52 47 47 50 (2684) (2875) (2768) (2974) (2774) (2970) (2684)

Specialty Psychiatry General surgery General practice Geriatric medicine Internal medicine Oncology All groups

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Figure 1. The balance between the yes-/no-/in doubt groups within each specialty. Those who did not answer whether physician-assisted suicide is acceptable (n518) have been excluded resulting in n5859. There is a significant difference in attitude (Chi2; p50.01) when psychiatrists are compared to oncologists, but no significant differences between the other specialties.

between the original and the short questionnaire were identified and we therefore believe it reasonable to include the latter group when discussing the main outcome. As younger physicians ((51 years) tended to respond more slowly and were, compared to senior colleagues, more in doubt, we take these findings to express uncertainty. End-of-life-measures such as PAS can trigger strong feelings. Critical commentaries from those restrictive about PAS may indicate a wish to avoid discussing the matter, and thus a reason for not answering the questionnaire. However, the response rate (80%) among one of the most restrictive groups, internal medicine, contradicts this assumption. Another explanation for the response rate may be that the questionnaire clearly specified a list of six criteria for accepting or rejecting PAS. Even though the criteria were listed in order to minimize the risk of misinterpretation, it might have appeared a difficult questionnaire to answer. Apart from the group of

geriatrics specialists, the response rate seems acceptable, at least when compared to other similar studies.

Principal findings Previous research in Sweden has not addressed PAS specifically and the attitudes of Swedish physicians were previously unknown. When compared to a tenyear-old study on physician-assisted death (PAD), the present survey suggests that physicians are more accepting of PAS than of PAD [4]. This possibly reflects the legal difference between the measures, but on the backdrop that the WMA strongly condemns PAS as unethical, an attitude also endorsed by the Swedish Medical Association, the present results may appear as a surprise, particularly since WMA stresses that it condemns PAS even if legalized. The study indicates that it is difficult to maintain that there is a clear majority against PAS.

Table II. This table illustrates the responding physicians (n5626) presumed influence on patients and their own trust in the healthcare system if PAS were to be allowed in Sweden. The answers are related to the respondents general attitudes towards PAS and presented as proportions of those who believe that patients trust on one hand will decrease very much, rather much or rather little, and on the other will increase rather little, rather much or very much; or not influence trust at all. The results are presented as percentages and with a 95% confidence interval (CI) for proportions. Attitude towards PAS Yes Doubtful No Decrease patients trust (%, CI) 22 (1727) 70 (6377) 90 (8694) Increase patients trust (%, CI) 35 (2941) 10 (510) 1 (02) No influence on patients trust (%, CI) 43 (3749) 20 (1426) 9 (513)

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Table III. The table displays different fixed arguments for PAS among two age groups: the younger physicians ((50; n5325) and the senior ones (w51; n5329). The results are presented as those who agreed completely or partly with the opinions stated, with a 95% confidence interval (CI) for proportions. Afterwards the respondents were asked to make prioritizations between the arguments. Arguments Respect for patients autonomy Patients do not know their own good in such cases The purpose is to minimize suffering, not shorten life Risk of jeopardizing trust in physicians The patients autonomy overrules the non-maleficience principle The non-maleficience principle takes precedence over patients autonomy Alternative actions patients might use are painful Risk of pressure on patients who do not want to become a burden to relatives Palliative care is lacking in your region Palliative care in your region is well established Own suggestions Age groups Younger Senior Younger Senior Younger Senior Younger Senior Younger Senior Younger Senior Younger Senior Younger Senior Younger Senior Younger Senior Younger Senior % (CI) 89 89 58 56 84 89 72 74 49 60 66 52 37 52 85 81 25 53 47 49 (8692) (8692) (5363) (5161) (8088) (8692 (6777) (6979) (4454) (5565) (6171) (4757) (3242) (4757) (8189) (8191) (2030) (4660) (4252) (4454) Prioritizations 27% 29% 4% 4% 18% 22% 8% 12% 2% 2% 23% 13% 0.3% 0.3% 8% 7% 0.3% 1% 2% 6% 8% 5%

International studies regarding PAS reflect variation in design, specialties concerned, questions, results and point in time for conducting the surveys [516]. In the UK, different studies have presented a range of attitudes from 25% to 56% pro-PAS, but those studies spanned a period of more than five years [911]. The results of the present survey regarding an accepting attitude seem to be in accordance with at least one of the international surveys [15]. It is not surprising that physicians in Switzerland and Oregon as well as in Belgium and The Netherlands where PAS is more or less legalized have a more accepting attitude [1720]. It is worth noting that there are certain differences between medical specialties and especially that psychiatrists are the least restrictive group. Psychiatrists are supposed to protect patients with mental disorders from committing suicide, but in this setting they seem to accept it. Compared to oncologists the most restrictive group, who have experiences of dying cancer patients psychiatrists usually do not have such experiences. On the other hand, psychiatrists are often consulted when a terminally ill patient becomes depressive and expresses a wish to die. The psychiatrists may be aware that such patients are suffering, and other than palliative care no treatment is available not even psychiatric treatment. If knowledge about the possibilities of palliative care influences the attitudes this might explain why oncologists are more restrictive compared to, e.g., psychiatrists.

Arguments and trust The main argument for accepting PAS was respect for patients autonomy, and a restrictive attitude was associated with the opinion that the nonmaleficience principle should precede respect for patients autonomy argument. The Swedish ethical rules for physicians stress that the physician is never supposed to act in a way that may actively hasten death. A possible explanation why young physicians tend to support non-maleficience taking precedence over the autonomy argument may be that, being less experienced, they are likely to be more apt to follow rules and guidelines, clinical as well as ethical; the older ones, who are usually more detached from such rules and inclined to improvize, may thus emphasize more situation-related arguments [21]. One common argument against PAS is that it is perceived as having a negative influence on patients trust in the healthcare system. This argument, however, is debatable, as international studies have indicated that a majority of the general public have an accepting attitude towards PAS [6,17]. It is interesting that those who accept PAS tend to believe that patients trust will not decrease; at least not to the same degree as those expressing a restrictive attitude. Is the attitude towards PAS a result of the idea of a negative influence on patients trust or is it the idea that brings about the attitude?

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A. Lindblad et al. attitudes among young and elderly physicians, as well as different specialties. Conclusion Despite the fact that the WMA condemns physicianassisted suicide as unethical even if legalized the present survey indicates that there is no clear majority for or against PAS among Swedish physicians, and that significantly more senior physicians have an accepting attitude towards physicianassisted suicide. There is a need for further research explaining the differences between the age groups as well as the variation between specialties. Acknowledgements The present study was financially supported by the Swedish Society of Medicine and the questionnaire was developed with the Swedish Society of Medicines Delegation of Medical Ethics. References
[1] Materstvedt LJ, Kaasa S. Euthanasia and physician-assisted suicide in Scandinavia with a conceptual suggestion regarding international research in relation to the phenomena. Palliat Med 2002;16:1732. [2] WMA policy. Available at: http://www.wma.net/e/policy/ p13.htm. [3] Lakarfakta 2006. Available at: http://www.slf.se/upload/ 17777/L%C3%A4karfakta_2006.pdf. [4] Nilstun T, Melltorp G, Lofmark R, Sjokvist P. Oenighet bland lakare om aktiv dodshjalp. 245 lakarsvar i svensk enkat speglar osakerhet [Disagreement among physicians about active euthanasia. 245 answers from a Swedish questionnaire reflect uncertainty]. Lakartidningen 1996;93: 13501. [5] Ryynanen OP, Myllykangas M, Viren M, Heino H. Attitudes towards euthanasia among physicians, nurses and the general public in Finland. Public Health 2002;116:32231. [6] Clark D, Dickenson G, Lancaster CJ, Noble TW, Ahmedai SH, Philp I. UK geriatricians attitudes to active voluntary euthanasia and physicians-assisted death. Age Ageing 2001;30:3958. [7] McGlade KJ, Slaney L, Bunting BP, Gallagher AG. Voluntary euthanasia in Northern Ireland: general practitioners beliefs, experiences, and actions. Br J Gen Pract 2000;50:7947. [8] Pasterfield D, Wilkinson C, Finlay IG, Neal RD, Hulbert NJ. GPs views on changing the law on physician-assisted suicide and euthanasia, and willingness to prescribe or inject lethal drugs: a survey from Wales. Br J Gen Pract 2006;56: 4502. [9] Kmietowicz Z. Doctors favour legalising assisted suicide for dying patients. BMJ 2004;329:939. [10] Grassi L, Magnani K, Ercolani M. Attitudes toward euthanasia and physician-assisted suicide among Italian primary care physicians. J Pain Symptom Manage 1999;17:18896. [11] Muller-Busch HC, Oduncu FS, Woskanjan S, Klaschik E. Attitudes on euthanasia, physician-assisted suicide and

The original reason why a patient asks his or her doctor for PAS is supposed to be that alternative actions are considered as dramatic, painful and worrying for the relatives in a tormenting and shameful way. Accordingly, it is interesting that a pro-argument not prioritized at all was that patients alternative actions to PAS are considered as painful; would patients and relatives prioritize differently? In the general literature about PAS many other possible arguments pro et contra can be found. The presented fixed options were meant as examples, and we expected that responders would provide their own arguments. But apart from the few arguments presented (sanctity of life and uncertainty of fulfilling the criteria), we did not observe other common arguments such as risk of slippery slope etc. Aspects of age and specialties It is not surprising that younger physicians tend to be more in doubt compared to senior colleagues. However, it is interesting that younger physicians have a more restrictive attitude compared to older ones or that older physicians tended to have a more accepting attitude than younger ones. Apart from the idea that younger physicians are more dependent on rules and guidelines, they may also have a more ambitious attitude towards the whole enterprise of medicine in terms of saving and protecting lives. On the other hand, elderly physicians are closer to the end of life and may also have recognized the limitations of medicine and therefore adopted a more accepting attitude. Another hypothesis is that we may suppose senior physicians to provide a more paternalistic attitude and younger ones to respect autonomy. Two of the most prioritized arguments regarding autonomy aspects were the pro-argument respect for patients autonomy and contra argument the non-maleficience principle should take precedence over respect for patients autonomy. When comparing these two arguments it is obvious that younger physicians, compared to the senior physicians, tend to let the non-maleficience principle override the autonomy principle. The senior physicians tend to provide a more respect for patients autonomyattitude compared to younger physicians and accordingly there is no evidence supporting the abovementioned hypothesis. Since the principle of autonomy has been stressed as the most important of all ethical principles [21] the present study indicates a need to investigate these discrepancies further. Future research should focus on possible explanations to the various

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terminal sedation a survey of the members of the German Association for Palliative Medicine. Med Health Care Philos 2004;7:3339. Whitney SN, Brown BW, Brody H, Alcse KH, Bachman JG, Greely HT. Views of United States physician and members of the American Medical Association House of Delegates on physician-assisted suicide. J Gen Intern Med 2001;16: 2906. Craig A, Cronin B, Eward W, Metz J, Murray L, Rose G, et al. Attitudes toward physician-assisted suicide among physicians in Vermont. J Med Ethics 2007; 33:4003. Emanuel EJ, Fairclough D, Clarridge BC, Blum D, Bruera E, Penley WC, et al. Attitudes and practices of US oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med 299;133:52732. ONeill C, Feenan D, Hughes C, McAlister DA. Physician and family assisted suicide: results from a study of public attitudes in Britain. Soc Sci Med 2003;57:72131.

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[16] Lee MA, Nelson HD, Tilden VP, Ganzini TA, Tolle SW. Legalizing assisted suicide views on physicians in Oregon. N Engl J Med 1996;334:31015. [17] Marini MC, Neuenschwander H, Stiefel F. Attitudes toward euthanasia and physician assisted suicide: a survey among medical students, oncology clinicians, and palliative care specialists. Palliat Support Care 2006;4:2515. [18] van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Buiting HM, van Delden JJ, Hanssen-deWolf JE, et al. Endof-life practices in the Netherlands under the Euthanasia Act. N Engl J Med 2007;356:191113. [19] Ganzini L, Nelson HD, Lee MA, Kraemer DF, Schmidt TA, Delorit MA. Oregon physicians attitudes about and experience with end-of life care since passage of the Oregon Death with Dignity Act. JAMA 2001;285:23639. [20] Leach DC. Competence is a habit. JAMA 2002;287:2434. [21] Gillon R. Ethics needs principles four can encompass the rest and respect for autonomy should be first among equals. J Med Ethics 2003;29:30712.

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