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Public Health (2002) 116, 322–331 ß R.I.P.H. 2002 www.nature.com/ph

Attitudes towards euthanasia among physicians, nurses and the general public in Finland
¨ nen1*, M Myllykangas2, M Viren3{ and H Heino4{ O-P Ryyna
1

University of Kuopio, Department of Health Policy and Management, 70211 Kuopio, Finland; 2University of Kuopio, Department of Community Health and General Practice, 70211 Kuopio, Finland; 3Kuopio University Hospital, Department of Oncology, 70211 Kuopio, Finland; and 4The Research Institute of the Evangelical Lutheran Church of Finland, FIN 33101 Tampere, Finland

The object of this study was to investigate the attitudes of physicians, nurses and the general public to physician-assisted suicide (PAS), active voluntary euthanasia (AVE) and passive euthanasia (PE) in Finland. Respondents received a postal questionnaire to evaluate the acceptability of euthanasia in five scenarios, which were imaginary patient cases. Age, severity of pain and prognosis of the disease were presented as background factors in these scenarios. This work was carried out in Finland in 1998. The respondents include a random selection of 814 physicians (506 responded, 62%), 800 nurses (582 responded, 68%) and 1000 representatives of the general public (587 responded, 59%). Thirty-four percent of the physicians, 46% of the nurses and 50% of the general public agreed that euthanasia would be acceptable in some situations. Of the scenarios, PE was most often considered acceptable in cases of severe dementia (physicians 88%, nurses 79% and general public 64%). In the same scenario, 8% of physicians, 23% of nurses and 48% of general public accepted AVE. In the scenario of an incurable cancer, 20% of the physicians, 34% of the nurses and 42% of the general public accepted PAS. All forms of euthanasia were generally more acceptable in older, than in younger, scenario patients. This paper conclude that PE was largely accepted among Finnish medical professionals and the general public. Only a minority favored AVE and PAS. Public Health (2002) 116, 322–331. doi:10.1038/sj.ph.1900875 Keywords: ; physician-assisted suicide; active voluntary euthanasia; passive euthanasia; empirical study; attitudes of personnel; attitudes of the general public

Introduction The debate over euthanasia has become increasingly active throughout western societies in recent years. Great technological advances in medicine during the last decades have made it possible to prolong life considerably. One of the nagging ironies of modern medicine is that suffering may actually be increased by extending the natural dying process with such technologies. At the same time, attitudes towards death have changed, too, although euthanasia remains an emotionally charged issue. Euthanasia has been a neglected topic in Finland for many decades. During the last years, however, euthanasia
¨ nen, University of Kuopio, Department *Correspondence: O-P Ryyna of Health Policy and Management, P.O. Box 1627, 70211 Kuopio, Finland. E-mail: ollipekka.ryynanen@uku.fi Accecpted 22 May 2002 { Dr Markku Viren died in a road accident on 17th June 1999. { Dr Rev. Harri Heino died from a complication of cardiac transplantation on 2nd December 1999.

and physician-assisted suicide (PAS) have become issues of public debate. The legalization of euthanasia has been supported by the general public, and also by some physicians. There are presently several associations and movements that are actively applying pressure on politicians to legalize euthanasia in Finland. Among the general public, there may be some fears concerning difficult and painful deaths, in addition to their insecurities regarding medical technology. Subsequently, people are increasingly prepared to take control of their own dying process. The word ‘euthanasia’ literally means ‘a good death’, and is used to indicate a serene and peaceful departure; the kind of death we might all wish for ourselves and others.1,2 In PAS, a physician provides a medical means for death, usually as a prescription for a lethal amount of medication that the patient takes on his or her own. Euthanasia occurs when the physician directly and intentionally administers a substance to cause death.3 In such a case, the euthanasia is considered to be ‘active’. When death is brought about by an inaction, such as non-resuscitation in a case of cardiac arrest, it is called ‘passive’ (passive euthanasia, PE). Some

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ethicists have criticized the subtle division between ‘active’ and ‘passive’ forms of euthanasia, because the ultimate goal and result are, in fact, the same.4 Indirect euthanasia is exemplified by the administration of narcotics to relieve pain, but in such large doses as to eventually cause respiratory depression and, subsequently, the patient’s death.4 Euthanasia is called ‘voluntary’ (active voluntary euthanasia, or AVE) when it is administered to people who have requested it, or who have given their informed consent. Euthanasia is called ‘involuntary’ when it is administered to people who have indicated that they wanted to live, or that they wanted to live and no one had ever bothered to ask. In the case of non-voluntary euthanasia, the patient had not expressed wishes or desires, or it was impossible to obtain such information. Both involuntary and non-voluntary euthanasia have been considered as benevolent, and must be distinguished from murder.4 The discussion concerning both AVE and PAS is important to physicians, nurses and patient, as all groups favor an easing of the dying process by reducing the time of pain and suffering in terminal patients. But attitudes toward AVE vary considerably; some consider AVE as a euphemism for murder, while others view this as a caring act that assists the terminal patient towards inevitable death. Several declarations have condemned AVE and PAS as unethical (World Medical Association Declaration on Euthanasia, adopted by the 39th World Medical Assembly, Madrid, Spain, October 1987, World Medical Association Statement on Physician-Assisted Suicide, adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992, The Handbook of the World Medical Association Policy, http://www.wma.net/e/policy.html). Typically, AVE is rejected on the basis of religious arguments; eg life is considered to be a gift from God, and a human being has no right to take it away, even when asked. Commonly mentioned is the ‘slippery slope’ hypothesis; legalizing AVE may lead to an extension from competent patients to incompetent ones, like children, and those who are mentally ‘incompetent’ or comatose. One strong argument against AVE is that its legalization under voluntary circumstances may permit an exception to become a standard; where chronically ill patients may be pressured, either verbally or by a common attitude, to choose AVE in order to avoid the high costs of their terminal care.4 One remote concern is that consistently rising health care costs could force a community to authorize AVE for economic reasons. It has also been argued that favoring AVE is the result of a paradoxical human hybris; eg a post-modern human being wants to manipulate death by taking the initiative, like Nazi-leader Goering, who avoided execution by committing suicide. In the Hippocratic Oath the physician promises ‘not give a deadly medicine to anyone’, which has engendered a dominant attitude for centuries. Opponents of AVE often remind us about the horrific examples of euthanasia in Nazi Germany, similar to opponents of abortion, which is also

contrary to the Oath. Seldom, however, do individuals carefully consider the opening sentence of the Hippocratic Oath, which states ‘according to ability and judgement’. In short, the physician is to be educated and experienced enough to make these case by case decisions. The idea of AVE appears throughout history. Thomas Moore and Francis Bacon, for instance, recommended euthanasia for patients with incurable diseases. S.D. Williams in 1870, C.E. Goddard in the early 20th century and C.K. Millard in 1931 all proposed the legalization of AVE.4 Some countries, like Oregon State in the United States, Australia and Switzerland have at least partially legalized AVE, but in facto and not in jure. The Netherlands has legalized euthanasia also in jure. Arguments supporting AVE are based on four major claims:4 1. The autonomy of a human being justifies him or her to decide about the ending of one’s own life. 2. AVE is seen as a caring action for a suffering person. 3. Active AVE is not considered as different from passive AVE. If withholding a hopeless treatment is not seen as unethical, then active AVE must be seen as having equal ethical value. 4. Bad experiences from Nazi Germany, or the idea of a ‘slippery slope’, are too abstract and speculative to be used as meaningful examples of AVE for the future. These conflicting opinions are still debated in countries that have taken steps to legalize AVE, as well as in countries that have strictly denied the practice of AVE. Finland is a country where AVE and PAS are completely illegal, and condemned by the majority of medical professionals. PE is accepted, in practice, where it can be disguised as medical decision making. Several studies exist on attitudes concerning AVE. Table 1 presents a summary of such studies that have been published in recent years. In English-speaking countries, most studies show that a slight majority of physicians support AVE, with even larger support among the general public. Also, the majority of seriously ill patients supported AVE, at least in certain situations. In other countries, mostly those on the European continent, physicians are far more critical of AVE, which currently has about 15 – 30% support among this group. In several studies, religious beliefs strongly affect attitudes, and people with religious commitments are less commonly favoring AVE. The elderly, and those more experienced with death, are also supportive of AVE. Some researchers have considered that a simple question about the willingness to perform or legalize AVE or PAS cannot tell the whole truth about individuals’ true attitudes. Therefore, researchers have carried out studies to gauge attitudes towards AVE or PAS through imaginary scenarios. Fried et al5 performed a study where physicians were asked how they would respond in five hypothetical situations. Three scenarios concerned the omission of a hopeless
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Table 1 Summary of main results in selected previous studies on attitudes towards euthanasia and physician-assisted suicide Target group, (number of respondents) Oncology professionals (n ¼ 63) Physicians (n ¼ 938) Main results

Authors, year of publication, country

Anderson and Caddell, 1993, UK Cohen et al,7 1994, Washington, USA

18

Ward and Tate,19 1994, UK Physicians (n ¼ 298) Internists, family practitioners and geriatricians (n ¼ 737) Oncologists (n ¼ 250) 3-year follow-up 1991 – 1994 physicians (n ¼ 866)

Physicians (n ¼ 312)

Stevens and Hassan,20 1994, Australia Shapiro et al,6 1994, Wisconsin, USA

Doukas et al,21 1995, Michigan, USA Verhoef and Kinsella,8 1996, Alberta, Canada

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Bachman et al,22 1996, Michigan, USA

Physicians (n ¼ 1119) General public (n ¼ 998)

Koenig et al,23 1996, USA

Lee et al,24 1996, Oregon, USA DiMola et al,9 1996, Italy

Asch and DcKay,25 1997; Asch,26 1996, USA Psychiatrists (n ¼ 321) Emergency physicians (n ¼ 248) Physicians and students (n ¼ 1028)

Elderly patients (n ¼ 168) Family members (n ¼ 146) (n ¼ 2761) Physician members of Italian society for palliative care (n ¼ 359) Critical care nurses (n ¼ 1139)

Ganzini et al,27 1996, Oregon, USA Schmidt et al,28 1996, Oregon, USA

Siaw and Tan,29 1996, Hawaii, USA

Payne et al,30 1996, Illinois, USA

Neurologists (n ¼ 169) Medical directors (n ¼ 150) Physicians (n ¼ 245) Physicians (n ¼ 974)

Nilstun T et al,12 1996, Sweden

Forde et al,11 1997, Norway

Steinberg et al,31 1997, Australia

Physicians (n ¼ 387); Community members (n ¼ 910)

60% accepted AVE 48% agreed that AVE is never ethically justified; 42% disagreed on AVE being justified at least in some cases; 56% agreed that AVE should be legal; 53% agreed that PAS should be legal; 33% were willing to perform AVE 47% agreed that the law on euthanasia in Britain should be similar to that existing in The Netherlands 45% favored the legalization of AVE 42% agreed that AVE should be limited to competent adults who request it; 30% agreed that AVE should be limited to competent adults with limited life expectancy Legalization of PAS supported by 21% 42 – 44% stated that it is sometimes right to practice AVE; 29 – 55% indicated that they would practice AVE if legalized; 50 – 37% supported legalization of AVE 56% of physicians supported legalization; 66% of general public supported legalization; 22% of physicians volunteered to participate in an AVE procedure Favorable attitudes towards PAS in 40% of patients and 59% of family members; 34% of patients and 56% of family members agreed to legalization of euthanasia 46% were willing to prescribe a lethal dose 32% thought AVE may be correct in some situations; 35% said AVE was wrong in all circumstances 19% had engaged in AVE; 70% believed that AVE is ethical, at least in some cases 65% agreed to legalization of PAS 69% indicated that PAS should be legal; 19% believed legalization immoral 16% were willing to assist PAS, 10% would perform AVE; 78 – 97% accepted different forms of PE; 58% supported legalization 20% considered hastening patient’s death would be ethical if the patient is in permanent vegetative state 39% considered AVE to be ethically justified; 25% favored legalization 17% agreed that a physician should have an opportunity to actively end the life of a terminal patient who is in great pain and requests AVE; 6% of physicians had performed actions to hasten a patient’s death 70% of community members supported legalization of AVE; 33% of physicians agreed

Cartwright et al,32 1997, Australia Suarez-Almazor et al,33 1997, Canada Nurses (n ¼ 1218)

Critical care nurses (n ¼ 231) General population (n ¼ 1240); Physicians (n ¼ 179); Patients with terminal cancer (n ¼ 62)

Kitchener,10 1998, Australia

Radulovic and Mojsilovic,34 1998, Yugoslavia

61% supported legalization of AVE 50 – 60% of the general population and terminal patients agreed with the legalization AVE and PAS; 60 – 80% of physicians were against it 69% believed that AVE should be legal; 66% were willing to be involved in AVE; 14% were willing to administer to lethal dose Legalization of AVE was supported by 61% of lawyers, 43% of oncologists, 30% of family doctors and 23% of medical students

Meier et al,35 1998, USA, nationwide study Emergency medical technicians (n ¼ 343)

Oncologists (n ¼ 30); Family doctors (n ¼ 31); Medical students (n ¼ 31); Lawers (n ¼ 30) Physicians (n ¼ 1902)

Schmidt et al,36 1998, Oregon, USA

Csef and Heindl,37 1998, Germany Ganzini et al,38 1998, Oregon, USA Physicians (n ¼ 336) Students (n ¼ 160)

Physicians (n ¼ 93) Patients with ALS (n ¼ 100); Caregivers of ALS patients (n ¼ 91)

Grassi et al,39 1999, Italy

Grassi et al,17 2000, Italy

Ramirez et al,40 2000, Puerto Rico

11% were willing to hasten patients death; 36% were willing to hasten death if it were legal; 4.7% said they have administered a lethal injection 68% agreed that PAS should be legal; 77% agreed that terminally ill patients have the right to commit suicide; 60% agreed that the law should allow a lethal injection for terminally ill patients; 59% agreed that in some circumstances they would personally consider PAS 82% were against AVE 56% of ALS patients said they would consider PAS; 73% of caregivers said they would accept the PAS of their family member 18% endorsed AVE=PAS; 79% endorsed withholding= drawing of treatment 28% endorsed AVE=PAS; 67% endorsed withholding= drawing of treatment 40% of students, 33% of residents, 20% of faculty members supported AVE

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Helou et al,41 2000, Germany The Netherlands: Internists (n ¼ 67); Oregon: Oncologists (n ¼ 56); Internists (n ¼ 46); Family physicians (n ¼ 50)

Medical students (n ¼ 279); Medical residents (n ¼ 79); Internal medicine faculty members (n ¼ 35) General public (n ¼ 98)

Willems et al,42 2000, Oregon and The Netherlands

Ten hypothetical cases, AVS accepted in 8 – 93% of cases, highest acceptance in a case of terminal cancer Four vignettes: AVE supported by 7 – 24% in Oregon and 14 – 59% in The Netherlands. Corresponding figures for PAS were 22 – 53% and 9 – 56%

AVE, active voluntary euthanasia; PAS, physician assisted suicide; PE, passive euthanasia.

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treatment, while two scenarios were cases where AVE was requested by a terminally ill patient. In the first three cases, 59 – 98% of physicians agreed to withholding hopeless treatment, but in last two cases, only 1 – 9% accepted active AVE. In a study by Shapiro et al,6 three scenarios were presented to the physicians. All of them included a case where a patient asked for AVE; first in a case of stroke, then a case involving serious burns and the last was a case of Alzheimer’s disease. A minority of physicians (2 – 29%) accepted AVE in all cases. Typically, when attitudes have been asked in the form of scenarios, AVE gains less support than in more conventional questions. Although the amount of debate on euthanasia in Finland among the general public and health care personnel is increasing, there is currently not enough information on attitudes towards euthanasia in general, and especially towards different kinds of euthanasia practices. This information is urgently needed before serious discussions on legalizing euthanasia can begin. The aim of this study was to evaluate the attitudes of physicians, nurses and the general public towards AVE, PE and PAS by using five different imaginary patient scenarios.

Material and methods To investigate attitudes towards PAS, AVE and PE, three study groups were established: 1. A random sample of 814 physicians, derived from the national register of the Finnish Medical Association. 2. A random sample of 800 nurses, derived from the national register of the Finnish Nursing Association. 3. A general public sample of 1000 persons, aged 18 – 65 y, which was randomly derived from the Finnish National Population Register. A postal questionnaire was sent to all subjects in the spring of 1998. The questionnaire consisted of two parts: Part 1. A background data sheet asking for information on the sex, age, occupation, professional status, professional satisfaction, self-reported religious beliefs, attitudes to different kinds of ethical issues and impressions of death from the respondents. Questions concerning professional occupation were adjusted according to the target group. Not all the collected background information was used in this study. The theological orientation of the respondents was evaluated by asking one question: ‘Regardless of the fact that you are attending church or not, are you (1) a religious person, (2) not a religious person, (3) an atheist or (4) cannot say.’ Among the list of various ethical issues, there was one question concerning euthanasia. The respondents were asked the question; ‘Are the following issues acceptable
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or not: euthanasia — ending the life of terminally ill patients’. The respondents were able to choose from ten options, from 1 (never acceptable) to 9 (always acceptable) and 10 (cannot say). For the analysis, the responses were divided into two categories, and responses to options numbered from 6 to 9 were taken to indicate that these respondents accepted euthanasia. Part 2. The main questionnaire was the same for all three target groups. This questionnaire included five imaginary patient scenarios; a cancer patient, a patient with severe dementia, a mentally retarded patient, a patient with depression and a paralyzed patient. The age of the imaginary patient was varied randomly, except for the dementia patient, whose age was always 80 y. In the scenario of cancer, the age of the patient was varied from 20, 30, 60 or 80 y in the case of PAS, and 10, 30, 60 or 80 y in the case of AVE and PE. The age of the severely retarded patient was also varied from 10, 30 or 50 y. In the cases of severe depression and the paralyzed patient, the age was 20, 40 or 60 y. Eight different questionnaires were prepared, and each respondent received only one at random. In every scenario, the results were analyzed by cross-tabulating the age and the respondent’s chosen option. Cancer was described differently in two scenarios, which varied randomly. First, the cancer was described to be incurable and painful. In some cases it was only stated that the cancer was incurable. Second, in some cases, the cancer was only described to be fatal and in others it was indicated that death was imminent within a short time. Thus, the prognosis of the disease was presented according to its painfulness and life expectancy. In every patient case, the respondents were asked to reveal their attitudes toward PAS, AVE and PE whenever possible. Concerning each patient’s case, the respondents were asked to indicate their opinion on the acceptability of PAS, AVE and PE as separate evaluations. The respondents were able to rate their decisions on a 5-point scale; (1) totally agree, (2) agree, (3) no opinion, (4) disagree and (5) totally disagree. For the analysis, the options ‘totally agree’ and ‘agree’ were considered to indicate acceptance. The patient cases are presented in Appendix 1. We used the following definitions and examples for PAS, AVE and PE in the questionnaire: 1. PAS means that the physician provides the patient with the means to end his/her life; for example, by prescribing a lethal dose of a medicament, and the patient takes the drug by him or herself. 2. AVE means that the physician ends the patient’s life, based on the patient’s own continuous requests, and in some cases based on the continuous requests of the relatives. 3. PE means that a physician withholds life support or medication, except pain medication, and lets the patient die. For example, the termination of antibiotics for pneumonia.

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The Chi squared test was used to evaluate statistical significances. The linearity of accepting PAS, AVE or PE according to the patients’ age (Table 4) was tested by using the acceptance of PAS, AVE or PE as a dependent variable and the patient’s age as a categorical polynomial covariate in a binary logistic regression. A linear model of P < 0.05 was used as an indicator of statistical significance.

Results The response rate for the questionnaire varied from 59% for the general public to 73% for the nurses (Table 2). The distribution of age, sex and theological orientation for the groups are presented in the same table. In every patient case, PAS or AVE obtained least favor among physicians, and most favor among the general public (Table 3). In the case of PAS and AVE, the differences in attitudes between the three study groups were very large. On the contrary, PE was most commonly supported by physicians and most rarely among the general public, except in the scenario of the paralyzed patient. In this case, nurses accepted PE most often and physicians most rarely. In the case of PE, the differences in attitudes between the three study groups were not so large as in the PAS and AVE scenarios. Among physicians, gender and age were not connected with the acceptability of euthanasia in a statistically significant way. Among the general public, men were more accepting than women in all forms of euthanasia and in every patient scenario, with only a few exceptions. The analysis according to sex was not made among the nurses, because almost all respondents were women. Among nurses, the younger ones (under 50 y) supported euthanasia more often than the older ones (50 y or more) in most of the scenarios and the differences were statistically significant in almost all scenarios of AVE.
Table 2 Characteristics of the groups in the present study Characteristic Sex men, number (%) women, number (%) Age median, y min – max, y Religion religious, number (%) not religious or cannot say, number (%) Response rate (%) Physicians Nurses General public (n ¼ 506) (n ¼ 582) (n ¼ 587) 241 (48) 263 (52) 42 24 – 87 256 (51) 250 (49) 62 37 (6) 540 (94) 38 20 – 63 374 (64) 208 (36) 73 247 (42) 336 (58) 43 18 – 70 330 (56) 257 (44) 59

In every patient case, all forms of euthanasia were more often accepted among nurses by those who perceived themselves as non-religious, when compared to respondents who perceived themselves as religious, and these differences were statistically significant. Also, among physicians and the general public, the non-religious respondents generally favored euthanasia more often than religious respondents, but there were some exceptions, and only some of the differences were statistically significant. There was a slight association between the age of the imaginary patient and acceptability of euthanasia (Table 4). The scenario of severe dementia was excluded from this analysis because the patient was always described as 80 y old. The respondents in all the three study groups accepted PAS, AVE or PE more often for the oldest patient, rather than for the youngest, except in the physicians’ opinion on AVE in scenarios of the severely retarded patient. However, a statistically significant linear association was found between the acceptability of euthanasia and the age of the patient in only a few scenarios. The illness was described as painful in one-half of the scenarios concerning the cancer patient, and all the three study groups more often favored euthanasia in those scenarios. Also, in one-half of the scenarios concerning the cancer patient, a statement indicated that the cancer would lead to death in a short time, and all the three study groups favored PE more often in this scenario. Concerning PAS and AVE, only the attitude of the general public was also more positive when the cancer death was described as imminent. None of these differences, however, were statistically significant. On the general question concerning the acceptability of euthanasia, one-third of the physicians, almost half of the nurses and half of the general public responded positively (Table 5). Among physicians, men accepted euthanasia more often than women ( P < 0.05). In all groups the non-religious respondents and respondents under 50 y of age accepted euthanasia more often than religious or older respondents ( P < 0.05).

Discussion One problem in the study was the pressure of social correctness; that is, when people have a tendency to answer questions on a particular issue according to what they consider to be common and acceptable opinion. We consider a scenario-based methodology to reveal attitudes that are more free from social constraints, and thus reflect real-life situations better than other methods. To acknowledge, this is the first study to evaluate general opinions on AVE or PAS, where patient-related situations were presented as scenarios. The response rates in this study were moderate (physicians 62%, nurses 73%, general public 59%). The questionnaire might have been more thought-provoking for
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Table 3 The percentage of respondents, according to age, sex and theological orientation, who accepted PAS, AVE or PE in five different patient scenarios Patient scenario C Severe mental deficiency Patient scenario D Severe depression PAS (%) 31 4 2 2 4 2 4 64 6 5 43 93 612,4 64 59 60 63 62 61 162,4 17 15 15 17 16 16 AVE (%) 11 1 2 1 2 1 2 44 4 2 23 73 192,4 21 18 165 255 18 20 AVE (%) 81,2 9 8 8 8 53 123 221,4 245 125 193 283 422,4 516 356 44 37 383 473 724 72 70 673 813 762 79 74 76 76 723 813 PE (%) Patient scenario E Paralysis AVE (%) 91,2 10 8 8 11 7 11 211,4 245 135 173 293 362,4 436 326 38 34 35 39 PE (%) 291 28 30 30 25 25 32 351 34 41 313 423 312,4 31 30 275 385 34 28

Patient scenario A Incurable cancer AVE (%) 81,2 10 6 8 7 53 113 221,4 245 115 193 263 422,4 486 376 41 43 39 46 552,4 52 57 56 54 54 57 482,4 556 436 50 44 45 53 642,4 64 64 63 66 64 64 654 66 63 623 713 231,4 255 105 193 313 791,4 78 81 743 873 682 70 67 68 70 623 753 81,2 10 6 7 10 6 10 881,2 89 87 88 89 86 90 PE (%) AVE (%) PE (%)

Patient scenario B Severe dementia

PAS (%)

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Doctors (n ¼ 506) Men Women 749 y 507y Religious Non-religious

201,2 22 18 21 18 133 273

Nurses (n ¼ 582) 749 y 50 – y Religious Non-religious

341,4 375 185 273 453

General public (n ¼ 587) Men Women 749 y 507y Religious Non-religious

492,4 556 446 545 395 433 563

1

2

3

Statistically Statistically Statistically 4 Statistically 5 Statistically 6 Statistically

significant significant significant significant significant significant

difference difference difference difference difference difference

between between between between between between

doctors and nurses, Chi squared P < 0.050. doctors and general public. religious and non-religious respondents. nurses and general public. younger (under 50 y) and older (50 y or more). men and women.

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Table 4 The percentages of respondents who accepted PAS, AVE or PE according to the age of the imaginary patient Patient scenario Incurable cancer PAS Age of the Doctors Nurses General patient (n ¼ 506) (n ¼ 582) public (y) % % (n ¼ 587) %

Table 5 The percentage of respondents who agreed with the question ‘Are the following issues acceptable or not: euthanasia — the ending of life of terminally ill patients’ Physicians Nurses General public (n ¼ 506) % (n ¼ 582) % (n ¼ 587) % Men Women Under 50 y old 50 y or more Religious Non-religious Total of all respondents 391 291 372 252 273 423 34 – – 502 322 403 573 46 50 50 572 382 473 553 50

329

20 30 60 80 Total 10 30 60 80 Total 10 30 60 80 Total

19 21 17 24 201,2 5 5 9 144 81,2 52 64 78 814 682

34 33 32 35 341,3 10 23 21 33 221,3 56 68 64 74 653

45 50 43 58 492,3 27 48 40 52 422,3 48 62 47 65 552,3

AVE

1 Statistically significant difference between men and women, Chi squared P < 0.05. 2 Statistically significant difference between younger (under 50 y) and older (50 y or more). 3 Statistically significant difference between religious and non-religious respondents.

PE

Severe mental deficiency AVE

PE

10 30 50 Total 10 30 50 Total

8 10 7 81,2 73 80 76 762

17 23 264 221,3 66 74 764 723

38 39 48 422,3 55 61 66 612,3

Severe depression PAS

AVE

20 40 60 Total 20 40 60 Total 20 40 60 Total 20 40 60 Total

1 3 4 32 1 1 2 12 7 8 13 91,2 18 31 404 291

5 6 7 63 3 4 5 43 20 22 23 211,3 32 38 36 351

13 16 19 162,3 14 18 264 192,3 33 38 39 362,3 26 30 384 31

Paralysis AVE

PE

1 Statistically significant difference between doctors and nurses, Chi squared P < 0.05. 2 Statistically significant difference between doctors and general public. 3 Statistically significant difference between nurses and general public. 4 Linearity of acceptance of euthanasia by patient’s age tested by binary logistic regression, linear model P < 0.05.

physicians and nurses, but perhaps more difficult for the general public. We considered non-responses to have resulted from a lack of interest or time constraints, and not a significant source of systematic error. Seriously ill persons, for example, may have been more likely to fall into the category of non-responders, and their attitudes may differ from those of healthy people, but they would have been only a small portion of the total population. In previously published studies, we did not find any mention on the reliability of the questionnaire. This could be a significant methodological oversight in the design of studies concerning difficult topics, such as euthanasia. When difficult questions have been presented, the respondents are often not so sure about their own opinions, and their ultimate response may be influenced by minor variations in the verbalization of a question or scenario. Thus, more detailed information on general attitudes towards euthanasia may be unachievable, at least by closed questions. Before performing the study, we carried out two separate pilot studies; first in 50 health care students, who completed the first version of our questionnaire, and did so again after 2 weeks in order to obtain the test – retest reliability. The first results were poor, and reliability testing resulted in kappa values that ranged from 0.0 to 0.4. Subsequently, the questionnaire was completely revised and administered a new test – retest procedure with 70 other students. This new trial brought better results, and kappa values varied from 0.10 to 0.60. We omitted all questions having a kappa value less than 0.35, and some questions were also reformulated for clarity. Overall, high kappa values were achieved in this study, indicating good reliability. In the question about the acceptability of AVE in terminally ill patients, we obtained similar results as in previous studies by Cohen et al7 in the USA, Verhoef and Kinsella8 in Canada, DiMola et al9 in Italy and Kitchener10 in Australia. Forde et al11 reported attitudes towards AVE in Norway, a culture very similar to that in Finland, where opinions seemed to be more negative than in Finland. Also
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in line with previous studies, older age and religious attitudes were significantly associated with less acceptance towards AVE. Compared to earlier scenario-based studies, we obtained similar results as Fried et al,5 where a majority of physicians were reported to have been more accepting of withholding treatment in terminal cases. Compared to the results reported by Shapiro et al,6 Finnish physicians showed a wider acceptance of AVE. Patient’s age12 – 14 and religious beliefs15 – 17 also had a strong effect on attitudes towards AVE, PAS and PE. Compared to previous studies, our results show similarities with results reported from English-speaking countries of the world. In the scenarios of incurable cancer or severe mental retardation, PE was supported by a majority of respondents in all study groups. The general public seemed to accept AVE and PAS more readily than medical professionals. AVE and PAS received minor support when compared to PE, which was defined as withholding treatment. It is important to note that only a few respondents choose the alternative ‘cannot answer’, and most were clearly either for or against euthanasia. We anticipate that legalization on AVE and/or PAS will lead to a more strict dichotomy of opinions and a subsequent controversial situation in the community. Our results do not indicate a present pressure to legalize AVE or PAS in Finland. Concerning PE, the situation seems to be completely different; that is, a vast majority of physicians, nurses and the general public have demonstrated support for PE in many situations. These results suggest that there could be an open and productive discussion on issues concerning medical treatment of the terminally ill in Finland.

References
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Appendix 1 Description of imaginary patient scenarios Patient scenario A: A patient 10/30/60/80 y of age is suffering from a painful and incurable cancer, where death is imminent. Patient scenario B: A patient 80 y of age is suffering from severe dementia, he/she is curled up in a fetal position in his/her bed, and does not make any contact with the immediate environment. Patient scenario C: Many serious and incurable diseases, in addition to severe mental retardation, in a deteriorating patient 10/30/50 y of age who does not make any contact with the immediate environment. Patient scenario D: A patient 20/40/60 y of age is suffering from long-term, severe depression, which has not been relieved, despite all efforts. Patient scenario E: A patient 20/40/60 y of age is paralyzed from the neck down, and this disability considerably weakens his/her quality of life.

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