Attitudes of health care professionals, relatives of advanced cancer patients and public towards euthanasia and physician assisted suicide

Abstract

Objectives

Nowadays, euthanasia has the meaning of the direct administration of a lethal agent to the patient by another party with a merciful intent after patients’ request. Physician assisted suicide refers to the patient intentionally and wilfully ending his or her own life with the assistance of a physician. The objectives of the manuscript were to investigate the opinions of Greek physicians, nurses, lay people and relatives of advanced cancer patients on euthanasia and physician assisted suicide.

Methods

The final sample consisted of 215 physicians, 250 nurses, 218 relatives and 246 lay people. A survey questionnaire was used concerning issues such as euthanasia and physician assisted suicide. The survey instrument included 13 questions and described issues such as religious and spiritual beliefs, euthanasia, physician assisted suicide and decision-making situations.

Results

43.3% physicians and 41.3% relatives would agree in advance that in case of heart and/or respiratory arrest there would not be an effort to revive a terminally ill cancer patient. 20.5% physicians had a request for euthanasia. Significant associations were found between physicians (9.3%), relatives (1.8%, p = 0.001) and lay people (3.7%, p = 0.020) on their opinions regarding withdrawing treatment.

Conclusions

The majority of the participants were opposed to euthanasia and physician assisted suicide. However many would agree to the legalization of an advanced cancer patient's hastened death.

Introduction

The concept of euthanasia (EUT) has its roots on Homerian epics with the meaning of a good or painless death (from the Greek eu, “good”, and thanatos, “death”) [1], [2]. Nowadays, EUT means a death that is perpetrated or accelerated with the assistance of medicine [1], [3]. It is widely acknowledged that according to the Hippocratic Oath, physicians are forbidden to take part in the intentional killing of a patient as those years individuals did not have to face issues such as EUT in its current meaning [4], [5].

Euthanasia has been classified as “active” or “passive”. Active EUT refers to the direct administration of a lethal agent to the patient by another party with a merciful intent [3], [6], [7], [8]. This might involve the physician injecting intravenously a quick-acting sedative followed by a paralytic agent to halt respiration. Active EUT may be voluntary (requested or agreed by the patient), involuntary (when the agreement of the patient could be obtained but is not), or nonvoluntary (in which the agreement of the subject cannot be obtained because of his or her physical or mental state, thus, the patient has offered no opinion) [6]. Additionally, passive euthanasia is defined as withholding medical treatment with the intention of causing the patient's death [7], [8].

Physician assisted suicide (PAS) refers to the patient intentionally and wilfully ending his or her own life with the assistance of another party [3], [6], [9].

Furthermore, it is not an assisted death in case where the intention is the relief of symptoms and not to hasten a patient's death [6]. Although many still believe that high-dose opioids pose a serious risk of fatal respiratory depression, palliative specialists know that this very seldom occurs [10]. Withdrawing or withholding life-sustaining treatment are widely accepted today. Some examples include withdrawing a ventilator from a patient in end-stage emphysema, forgoing the use of antibiotics in a patient with terminal cancer and suspected pneumonia, and refusal of tube feeding by a patient with an end-stage neuromuscular disease [10].

It is ethically and legally acceptable only when the competent patient is fully informed and freely chooses this option or has clearly documented these choices in an advance care plan document [6].

There are different definitions and explanations of terminal sedation. “Palliative sedation” is the intentional use of pharmacological agents to induce and maintain a deep sleep, but not deliberately cause death [11], [12]. Opponents of palliative sedation state that the death occurs from malnutrition and/or dehydration, not from the underlying disease, although most patients have stopped eating and drinking prior sedation, opposing the argument of clinician-induced food and fluid deprivation. Nevertheless, if patients or family members wish to continue tube feedings, most clinicians discuss the futility of nutritional supports complying to such requests and initiate palliative sedation [13].

Euthanasia is accepted by the law and in certain terms in the Netherlands and Belgium [12], [13], [14]. Luxemburg became the third country where EUT is also legal from March 16th 2009 [14], [15], [16], [17], [18]. More specifically, in Belgium, EUT or PAS occurred almost in 1.3% of cases and life-ending drugs use without explicit patient request in 1.6% of cases [19]. Life-ending drug use without explicit patient request was also found to be relatively high in previous studies in the Dutch-speaking community of Belgium [20], [21]. Additionally, in Oregon physician assisted suicide is allowed if applied by a physician [22]. In the Netherlands, where there is legal sanction for physician assisted suicide (PAS) and EUT instances of inappropriately hastening death are common [3]. Additionally, PAS is legally performed in Switzerland since 1990 [18], [23].

The Dutch experience illustrates how social sanctions promote a culture that transforms suicide into PAS and EUT and encourages patients and doctors to see assisted suicide and EUT-intended as an unfortunate necessity in exceptional cases. Euthanasia is preferred by physicians and patients as a safer and more certain way of assuring death so that suicide is now used relatively infrequently [24]. Additionally, in Scandianavian countries, physicians do not accept excessive measures for prolonging life in people who are virtually dead, but neither do they encourage people to choose death prematurely [24]. Active and passive EUT and PAS are prohibited in countries like Norway and Greece [25].

In the Greek law the term EUT is only used in order to legalize painless death of severely diseased animals [1], [4]. The Greek court has applied the article 300 of the Penal Code in which: “anyone who decided and executed homicide after an intense and persistent demand of the victim and due to mercy for the patient suffering from an incurable and unbearable disease, is punished by imprisonment”. Moreover, article 2071/92 refers to the right of the patient to refuse treatment [4], [26].

Debate concerns whether the right to ask for euthanasia is strictly personal and should involve only the terminally ill patient [7]. Due to the fact that there is little research concerning EUT and PAS in Greece and more specifically regarding health care professionals’, lay people's and relatives’ of terminally ill cancer patients opinions on these ethical issues, in the current study we aimed to explore these issues.