Physician and family assisted suicide: results from a study of public attitudes in Britain

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Abstract

Legalisation of assisted suicide presents a dilemma for society. This arises because of a lack of consensus regarding the precedence to be accorded freedom of choice versus the inviolability of human life. Several factors including improvements in medical technology, population ageing and changing perceptions about quality of life serve to make a re-examination of attitudes to this issue appropriate at this time. Within this context, data from the 1983, 1984, 1989 and 1994 British Social Attitudes Surveys (BSAS) were examined. These demonstrate a slight increase in support for physician-assisted suicide (PAS) from around 75% to around 84% over the 11-year period in Britain. A much lower level of support (54%) was recorded in relation to family-assisted suicide (FAS). A logistic regression analysis of data from the 1994 survey was undertaken to establish the relationship between attitudes toward legalisation of PAS and FAS and the characteristics of the respondent. Strength of religious affiliation was found to be a significant determinant of opposition to legalisation of both. Religious denomination was found to be marginally significant in relation to PAS but not FAS. Members of the Church of England, non-Christian faiths and those of no faith were found to be marginally more likely to support legalisation of PAS, than Roman Catholics or those of other Christian faiths. Education, income, sex, marital status, long-standing illness and age were not found to be significant predictors of attitude. In relation to FAS age was also found to be significant predictor of opposition. Findings here suggest that if Britain continues to become a more secularised society, support for legalisation of PAS (and FAS) is likely to increase. As health care costs continue to grow and the ability to extend life (even where the quality of that life may be poor) increases, pressure for legalisation of PAS may increase.

Introduction

As health care technology increases in sophistication, so too does its ability to maintain life in the presence of significant morbidity. While such developments are to be welcomed, they also create choices where formerly no choice existed—do I want my life to be sustained when it becomes unbearable?, do I want assistance in terminating my life in these circumstances?—and thus spawn a range of ethical, legal and policy dilemmas for individuals and societies. A particular dilemma relates to the preparedness of many Western societies to accommodate a patient's desire for assistance in termination of their life (i.e. assisted suicide) where there is disagreement as to the balance that should be accorded respect for individual autonomy on the one hand and the sanctity of life on the other. 1 While this is by no means a new issue confronting many societies, societies whose diversity of approaches needs acknowledging (Hayry, 1997; Seale, 2000), a combination of factors has served to throw it into sharper focus in recent times.

First, treatment of the terminally ill is now more likely to occur in an institutional setting than was formerly the case (Fraser & Walters, 2000). This has meant that any request for assistance in suicide is less likely to remain the affair of the parties immediately involved in the decision (the patient, the physician and the family), and more likely to be subject to public exposure (and require its de facto complicity). For example, it is estimated that between 80% and 85% of Americans die not at home but in institutions where the circumstances of death are, to a much greater extent, in the public domain than would otherwise be the case (State of Washington, 1996)). As treatment of the terminally ill shifts increasingly into an institutional setting, so it becomes more difficult for society to ignore the issue of assisted suicide and more important for societal views on it to be examined.

Second, population ageing, together with advances in medical technology, have increased the frequency with which decisions regarding prolonged treatment of the terminally ill arise. Not only have these expanded the range of circumstances in which life may be extended, but they have served to increase the financial burden continuation of care can present (Kaplan & Schneiderman, 1997; Ward, 1997). Both factors—frequency and cost—again make the issue of requested assistance with suicide more difficult to ignore. Given these trends, for example, the apparent incongruity of denying assistance in suicide in one case, while denying access to care in another because of financial pressures, become increasingly evident.

Finally, as societies have become more secular and multicultural, so it has become increasingly unsatisfactory to rely on the “certainties” of a single (even if dominant) religious belief system or cultural tradition to frame a policy response to this issue. Increasing diversity of values, together with a need and willingness to accommodate pluralism, makes it easier for differing opinions to be espoused, as well as more difficult for them to be ignored in policy debates. Indeed a range of recent discourses, including bioethics and quality of life assessments, have isolated specific issues such as “futility” of medical treatment, “end of life” decision-making, and euthanasia at the centre of health policy debate. Some indeed have argued that progressive calls for euthanasia principally in the Western world represent a new social movement (McInerney, 2000).

Different options exist by which assistance could be proffered and support for legalisation of these is likely to vary. At one end of the scale assistance could be confined to the provision of information and support up to and including the point of suicide. At the other end it could include not just advice and support, but tangible assistance in securing and supervising the means by which a person ends their life. Similarly, options exist in relation to who should provide assistance. One option might be for assistance to come primarily via a physician familiar with the patient's prognosis, wishes and the practicalities of administering different drugs in lethal dose. Another might be for assistance to come primarily via the individual's family—family-assisted suicide (FAS). Both have attributes to recommend them which, depending on how these are viewed, could affect support.

Results from past surveys of attitudes in Britain show varying degrees of support for assisted suicide. These also provide some insights into the factors that influence individual support (McLean & Britton, 1996; Seale and Addington-Hall 1994, Seale and Addington-Hall 1995a, Seale and Addington-Hall 1995b; Wise, 1996). In relation to PAS, a survey by Social and Community Planning Research in 1996 reported 82% of respondents agreed that doctors should be permitted to end a life when someone requested it (Wise, 1996). Other surveys, such as those by McLean and Britton (1996), record a lower level of support—67% of respondents stating that human beings should have a right to die, but only 55% wanting PAS legalised—while others raise the possibility that individual attitudes may not be immutable when confronted with the impending reality of death, i.e. that opposition may decline (Seale & Addington-Hall, 1994).

In other countries, support, while varying, similarly appears strong. (In making comparisons here differences in the phraseology of questions, as well as how this may be interpreted, must be borne in mind.) In Oregon in 1997 (Dietz, 1997), the United States (US) in general in 1994 (State of Washington, 1996)) and Australia in 1995 (Albanese, 1996), 61%, 75% and 73%, respectively, of the populations surveyed favoured legalisation of PAS. Similarly, it is interesting to note that a slight increase in support evident in British data—see below—echoes that found in the US (Caddell & Newton, 1995). To the best of our knowledge public attitudes to legalisation of FAS have not been reported in the literature.

The literature details a range of personal characteristics that affect individual attitudes. Several studies, for example, have demonstrated the existence of a relationship between strength of religious affiliation and attitudes (Bachman, 1996; Baume, O'Malley, & Bauman, 1995; Jorgenson & Neubecker, 1981; Kalish, 1963; Suarez-Almazar, Belzile, & Bruera, 1997; Ward, 1980). Studies by Bachman (1996), Suarez-Almazar et al. (1997) and Ward (1980), among others, have shown a strong positive correlation between strength of religious affiliation and opposition to euthanasia—indeed Bachman (1996) found this to be the strongest personal characteristic predicting opposition. Similarly, membership of a particular faith (whether or not one is a practising member) has been found to be an important determinant of attitudes (Anderson & Caddell, 1993; Caddell & Newton, 1995). Thus Caddell and Newton (1995) found a greater percentage of “Conservative Protestants” (Baptist other than American Baptist Church) and Roman Catholics opposed to euthanasia than “Liberal Protestants”(Episcopalian and Presbyterian) or Jews—though it should be noted that religious denomination has not been found in all studies to be correlated with attitudes (Seale and Addington-Hall 1994, Seale and Addington-Hall 1995a, Seale and Addington-Hall 1995b).

In relation to other factors, studies have shown education (Caddell & Newton, 1995) and age (Bachman, 1996; Caddell & Newton, 1995; Littlejohn & Burrows-Johnson, 1996; Seidlitz, Duberstein, Cox, & Conwell, 1995) to positively correlate with support for euthanasia. In the US those with higher educational qualifications were found to be more likely to support euthanasia than those who are less well educated (Caddell & Newton, 1995), and those in older age groups to be more likely to support it also (Littlejohn & Burrows-Johnson, 1996; Seidlitz, Duberstein, Cox, & Conwell, 1995)—though evidence again here is mixed (Bachman, 1996).

Others such as Seale and Addington-Hall 1994, Seale and Addington-Hall 1995a, Seale and Addington-Hall 1995b, focusing specifically on the recently bereaved, found requests for euthanasia and attitudes to timeliness of death to be correlated with perceived access to and quality of care, as well as the nature of the respondent's relationship with the deceased. For example, in relation to quality, these authors found that among those who had deceased, requests for euthanasia were significantly related to perceived quality of general practitioner services (1995a). Similarly, in relation to aspects of unmet need (such as additional help with self-care) and requests for euthanasia (as well as a familial perception that an earlier death would have been preferable), significant correlations were found. These suggest that attitudes are framed in a context that includes availability of resources.

Against this backdrop and within a context where several countries have considered or de facto legalised PAS (Chin, Hedberg, Higgonson, & Fleming, 1999; Kissane, Street, & Nitschke, 1998; Muller, Kimsma, & van der Wal, 1998; State of Washington, 1996); van der Wal & Dillmann, 1994) and where its proscription in Britain was the subject of a recent legal challenge, we are concerned to establish and critically examine societal attitudes in Britain. Given the existence of FAS as a possible alternative to PAS, we were also concerned to examine the relative support for this and the extent to which the factors influencing support are shared across the two. Finally, we were concerned to compare our findings with those of others studying attitudes to assisted suicide.

Section snippets

Methods

Data were extracted from the British Social Attitudes Survey (BSAS) (Jowell, Curtice, Brook, Ahrendt, & Park, 1994). This is an annual survey that examines public attitudes to a range of social issues including social integration, work practices, race relations and family life. Data on the socio-economic characteristics and religious affiliation of respondents are also collected in the survey and thus allow researchers to relate respondent attitudes to such factors. The numbers surveyed vary

Results

In all 3469 households were surveyed in the 1994 BSAS, 984 being questioned on attitudes regarding PAS. Of the 984, 21 did not answer the question and 7 replied “don't know”. Both the latter groups were eliminated from the analysis. Attitudes of the remaining 956 are detailed in Table 1. Attitudes of the same group to legalisation of FAS are also detailed in Table 1. (One additional observation was available here.) A majority of respondents favoured legalisation of assisted suicide in both

Discussion

Three main issues, together with some minor points arise from our findings. First, our findings support those of others in relation to the role of strength of religious affiliation in attitudes to assisted suicide, whether suicide is physician or family assisted (Bachman, 1996; Baume et al., 1995; Jorgenson & Neubecker, 1981; Kalish, 1963; Suarez-Almazar et al., 1997; Ward, 1980). Respondents attending church at least once a week were significantly more likely to oppose legalisation of PAS or

Conclusion

The data here display that a clear majority of the British public supported legalisation of PAS in 1994. It also displays a slight rise in support for this overtime, a rise that, given increasing secularisation, may continue. Older individuals, those with long-standing illness and those worried about their health, appear to be no less in favour of legalisation of PAS than individuals who are younger, healthier or less worried about their health. This could be interpreted as indicating that

Acknowledgements

The support of Dr. O'Neill during preparation of this manuscript by a Harkness Fellowship Grant from the Commonwealth Fund and of Dr. Hughes by a National Primary Care Career Scientist Award from the Research and Development Office, Northern Ireland is gratefully acknowledged. The authors would also like to thank the editor and referees of this journal for their useful comments on earlier drafts of the paper.

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