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Volume 12, Number 2

Original Article
Beliefs of Alberta Physicians Concerning Active Euthanasia: Analysis of Qualitative Data Collected in the Alberta Euthanasia Survey

Marja J. Verhoef, PhD; T. Douglas Kinsella, MD, FRCPCA; Stacey A. Page, MSc

Often the type of information collected in surveys of physicians' opinions about active euthanasia has not revealed their experiences and the rationale(s) they use in arriving at their opinions. This paper presents a qualitative analysis of comments made in a large survey of Alberta physicians' opinions about active euthanasia to identify issues physicians have commented upon, and to explore the rationale(s) behind their opinions. This information adds an important qualitative perspective to the current debate about euthanasia and assisted suicide.

Several recent surveys have examined physicians' opinions about euthanasia.1-5 While this information is of great importance to those shaping health policy and health education, often it does not tell us much about the rationale(s) physicians use in arriving at their opinions.

In 1991, we surveyed a random sample of Alberta physicians to determine their opinions about the morality, legalization, and medicalisation of active euthanasia (AE).1,2 This survey defined AE as the intentional termination of the life of a human being, who is ill, by means of an overdose of medication given by a physician or surgeon when requested by the recipient.

Of the 1391 physicians who completed the questionnaire, 44% believed that sometimes it would be morally right to practice AE, whereas 46% did not, and 10% were uncertain. Twenty-eight percent indicated that they would practice AE if it were legalised, and 51% indicated that they would not.

Although this study records the opinions of Alberta physicians about AE, it does not provide much information about the personal, moral, and ethical reasoning that shaped these opinions. For this reason, we undertook a qualitative analysis of the survey results to identify those issues that physicians felt worthy of comment and to explore the rationale(s) behind their opinions about AE.

Methods

Our mail-out survey consisted of closed-ended questions addressing physicians' opinions about AE. The questionnaire also asked physicians to add any comments they wished to make concerning AE. Forty percent (553) of the respondents volunteered comments that totalled about 200 double-spaced typewritten pages.

These textual data were analysed using Ethnograph.6 The data were "cleaned" by removing all illegible comments and comments that did not pertain directly to opinions and beliefs about AE. Then these comments were divided into three categories: those responding yes, no, and uncertain to the question, "Do you believe it is sometimes right for a doctor to practice active euthanasia?" The final analysis was limited to those supporting and those opposing AE.

Coding categories were developed following detailed observation of the data. The comments then were reviewed and coded accordingly. Two of the investigators discussed comments that were not easily classified until they reached agreement.

Results

We found no significant differences between physicians who made comments and those who did not with respect to age, sex, specialty area, belief about the morality of AE, and willingness to practice legalised AE.

Physicians' comments were grouped into six categories (Table 1). Compared to the comments of those supporting AE, the comments of those opposing AE tended to be much longer and to cluster in different categories.

Category 1: Ethical principles

Typically, comments relating to the physician's moral duties included references to the Hippocratic Oath and to the Canadian Medical Association's Code of Ethics. Statements objecting to the practice of AE indicated that this act is inconsistent with the basic premise of medicine, that of "do no harm" (i.e., the principle of nonmaleficence). By contrast, those supporting the practice believed AE was an extension of the physician's duty to alleviate pain and suffering (i.e., the principle of beneficence).

The principle of autonomy is concerned primarily with the belief that individuals have the right to determine the nature and length of their existence.

Interestingly, comments made by both physicians supporting AE and those opposing AE indicated that "the wishes of a competent, properly informed, adult patient, in regard to euthanasia, are paramount." One physician opposing AE commented: "... they [my opinions] are based on my view that all life is God-given ... and that, as physicians, we should not be asked to end life. I do feel that sustaining life against the patient's wishes is wrong, however." Often they considered that competence must be demonstrated before one could raise the issue of individual rights. Some physicians supporting AE referred to the usefulness of living wills.

Also considered under the principle of autonomy was the physicians' right to exercise their personal moral beliefs. In this regard, a subset of physicians on both sides of the debate recognised that, while they could support AE in principle, they could not be involved in the practice.

Table 1.
Categories of qualitative data emerging from the Alberta Euthanasia Survey

Response Categories Number of Comments
Physicians Supporting Active Euthanasia Physicians Opposing Active Euthanasia

Ethical Principles
Moral duties of physicians
13 66
Patient/physician autonomy
17 17
Sanctity of life (vs. quality of life)
25 36
Total
55 119

Moral Distinctions
Commission or omission
11 25
Intentionality
4 12
Total
15 37

Consequences
Patient
12 62
Physician
18 9
Societal
3 20
Total
33 91

Implementation
Fees
26 25
The agent
9 13
Decision process
76 16
Total
111 54

Alternatives
Palliative care
3 32
Assisted suicide
* 6
Total
3 38

Anecdotes
32 9

*This issue was not commented on separately but included in other comments.

Only those opposed to AE made comments about sanctity of life, and they based their arguments mainly on moral, legal, or religious grounds. Morally, they emphasised the value of human life. In contrast to the principle of autonomy, they said that the value of an individual life was a societal concern (e.g., "I do not believe that society should ever condone killing"). Often AE was equated with murder, and thus they objected to it on legal grounds. Finally, arguments based on religious belief held that all life is "God-given" and therefore, only "God ... has the sole right to decide when it will end."

Frequently, those supporting AE mentioned quality-of-life considerations, as distinct from quantity of life.

Category 2: Moral Distinctions

Within this category, physicians distinguished between acts of active and of passive euthanasia. Whereas active euthanasia is an act of commission; passive euthanasia implies an act of omission such as the withholding or withdrawal of treatment.7

Those opposing AE appeared to be more accepting of passive euthanasia. A number of physicians, both those supporting and opposing AE, remarked that, while they could not personally administer an agent that would cause death, they were comfortable with withdrawing life support (e.g., ventilators), not initiating various therapies, or not attempting to resuscitate patients in distress.

Similarly, many physicians drew attention to a (perceived) moral distinction between prescribing narcotics to relieve suffering with the knowledge this may hasten a patient's death (principle of double effect) versus prescribing agents for the sole purpose of bringing about death.8 While they condoned and even practised the former, they could not accept the latter.

The comments of some physicians showed that they did not make a clear distinction between active and passive euthanasia: for example, one wrote, "Letting nature take its course is probably my concept of AE. Actively doing nothing." There was similar confusion around the legality of the two practices: "Getting a little ahead of yourself, aren't you? What about legalization and ethics of passive euthanasia first?" Also certain physicians did not seem to be aware that it is the patient who makes the request for euthanasia and that the request for AE assumes that the patient is conscious and competent.

Category 3: Consequences

Many physicians opposing AE feared the possibility of abuse-that individuals would be terminated against their wishes or without their consent, especially the elderly or the incompetent. A number of physicians felt that the request for AE might be made by a cognitively compromised patient (e.g., depressed, confused, irrational). Also they feared that, if AE were carried out, patients would miss "finding a cure the day after" or a spontaneous recovery. Concern was voiced that AE would be used to clear hospital beds, to avoid expensive treatments, or to enrich surviving heirs. Also, they drew attention to the difficulty of controlling and regulating the procedure, and voiced the fear that AE would become "routine."

Many commented on the impact of AE on physicians themselves, that practising AE would have a psychologically destructive effect, eventually inducing a callousness and possibly encouraging a "God-like" omnipotence among physicians. Others believed the practice of AE may relieve them of their perceived responsibilities to save life at all costs, and would allow them to feel more humane and focus on quality of life.

With respect to concerns about societal consequences, opponents of AE felt that its practice would serve to create widespread mistrust, fear, and disrespect of the medical profession.

Category 4: Implementation

Compared to those who opposed AE, those who favoured it frequently suggested that a fee should be levied. Typically, this was justified on the grounds that many hours of counselling would be required before and after AE and not for the act itself. Physicians had a variety of opinions concerning who should carry out the procedure. Those who opposed the practice often asserted that the procedure should be carried out by a physician with special training working with others (e.g., clergy, family members, other medical personnel).

Most of the comments concerning the decision-making process centred on who should participate, emphasizing that each case should be considered to be unique, and that the patient should be competent. The bulk of these came from those who supported AE. Although a few physicians said that the decision should rest solely with the doctor and the patient, most supported some type of third-party involvement (e.g., other family members, clergy, a consulting physician, a hospital review board or bioethics committee), particularly when the patient's competence was in doubt. While some thought it important to involve a lawyer to protect both physicians and patients, others believed the legal system had no place in such matters.

Category 5: Alternative

Most of the comments in this category were made by those opposing AE and related primarily to palliative care, although a few referred to assisted suicide. Most respondents seemed to believe that medical science could relieve all pain and suffering and, if this were done, there would be no need for AE.

Often, assisted suicide or suicide was mentioned as an alternative in the context of individual rights and of absolving the physician of a direct role in the process.

Category 6: Anecdotes

Anecdotes about the personal experience of physicians came chiefly from those in favour of AE. Many acknowledged that AE is practised at the present time. Some said they had practised "passive euthanasia," or, on occasion, had prescribed analgesics in doses that would hasten the death of the patient. A few described occasions in which AE had been practised.

Summary

This analysis shows that proponents of AE were more likely to emphasise the physician's role as one of beneficence and compassion, and to consider hastening an impending death as a humane act. Opponents of the practice were likely to stress the role of physicians as one that should cause no harm (nonmaleficence) where bringing about death is seen as the ultimate harm. Similarly, those supporting AE believed that a life filled with pain and suffering was not one worth living (quality of life), whereas those opposing AE believed life should be revered no matter what that experience entailed (sanctity of life). Most of those who supported AE spoke about the pragmatics of implementation, whereas those who opposed it feared that the practice would be abused. Whether they supported or opposed AE, both groups of physicians showed considerable compassion for their patients and respect for individual autonomy.

Limitations

We should stress that these physicians were asked to comment, if they wished, concerning AE and, thus, using this qualitative strategy, we could not uniformly assess specific issues and concerns within the euthanasia debate. Also, only 40% of these physicians responded to the request for additional information. Thus, this is not a random sample, and therefore, we cannot generalise and can make only cautious comparisons between supporters and opponents of AE. Lastly, we note that the data reflect only opinions and cannot be held to predict future behaviours.

Conclusions

Although physicians supporting and opposing AE made a variety of comments, the submissions by both sides could be accommodated in the same categories, indicating a considerable consensus about the main issues within the euthanasia debate. Moreover, physicians on both sides showed considerable confusion about the defining characteristics of AE, which sometimes made it difficult for the observer to draw clear conclusions.

There seems to be a continuum of moral beliefs about euthanasia rather than a simple pro/con dichotomy. Individual physicians vary considerably over what, as individuals, they find morally acceptable along that continuum. As a result, one encounters the belief that life must be preserved at all costs, followed by an acceptance of withholding or withdrawing treatments, to prescribing analgesics in such doses to potentially interfere with respiratory function, to supporting assisted suicide, and finally, to condoning the deliberate bringing about of death via lethal injection. While some physicians may be able to support some or all of these actions in principle, many are not willing to carry out these actions in practice. Legislation aside, the decision to practice AE is heavily influenced by complex, personal value systems, which will always provoke controversy.

The strong response to our solicitation of comments and the wide variety of issues brought forward by physicians demonstrated the importance they attach to the subject and reflect the need for further education and deliberation before changes in the law may be introduced.

References

  1. Kinsella TD, Verhoef MJ: The Alberta Euthanasia Survey: Part l. Physicians' opinions about the morality and legalization of active euthanasia. CMAJ 1993; 148: 1921-1926
  2. Verhoef MJ, Kinsella TD: The Alberta Euthanasia Survey: Part II. Physicians' opinions about the medicalization and reporting of active euthanasia. CMAJ 1993; 148: 1929-1933
  3. Kuhse H, Singer P: Doctors' practices and attitudes regarding voluntary euthanasia. Med J Aust 1988; 148: 623-627
  4. Cohen JS, Fihn SD, Boyko II, et al: Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med 1994; 331: 89-94
  5. Fried TR, Slein MD, O'Sullivan PS, et al: Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia. Arch Intern Med 1993; 153: 722-728
  6. Seidel JV, Kjolseth R, Seymour E: The Ethnograph. A User's Guide. Quails Research Associates, Littleton, Colorado, 1985
  7. Sawyer DM, Williams IR, Lowy F: Canadian physicians and euthanasia: 2. Definitions and distinctions. CMAJ 1993; 148: 1463-1466
  8. Beauchamp TL, Childress JF: Principles of Biomedical Ethics, (4th ed) Oxford University Press, New York, 1994: 206-211
Marja J. Verhoef and Stacey A. Page, Department of Community Health Sciences; T Douglas Kinsella, Office of Medical Bioethics, Faculty of Medicine, The University of Calgary, Calgary, Alberta, Canada.
This analysis was supported by the Research and Development Committee of the Calgary General Hospital.
Correspondence and reprint requests to: Dr Marja Verhoef Department of Community Health Sciences, The University of Calgary, 3330 Hospital Drive NW Calgary, AB T2N 4N1