Physician-Assisted Dying: Acceptance by Physicians Only for Patients Close to Death

There is a tremendous discussion on euthanasia and physician-assisted suicide (PAS) worldwide (e.g., [1]; for definitions see Table 1 [2]). The debate centers on questions of dignity, self-determination, or pain [3]. Some European countries, like the Netherlands, Belgium, Luxemburg, and Switzerland, have a liberal legislation. Unlike these countries, Germany has not yet passed any legislation regarding details of end-of-life (EOL) practices. It remains unclear to which group of patients the EOL practices under discussion should be accessible. Is a restriction to terminally ill patients sensible or would any limitation be in conflict with the patients’ autonomy? Physicians caring for patients at the end of their life or with an incurable illness are a central group that may be faced with these questions. In the light of the actual discussion and the commencement of the legislative process, a survey among German physicians engaged in the field of palliative care and pain medicine was performed. The recruitment of the respondents took place at a pain symposium and a palliative care congress. The survey aimed to discover the attitudes of those physicians targeted as doctors in EOL care toward PAS and euthanasia. Using practical scenarios rather than questions about ‘euthanasia’ or ‘PAS’, the survey aimed at finding out more about the details that are crucial for EOL decision making.

An anonymous questionnaire was handed out to the participants of a palliative care congress and a pain symposium in 2012 (Table 2). Attendants were physicians and nurses; however, the presentation here is limited to the physicians. Regarding personal data, the questionnaire asked about gender, age, occupation, religiousness, and whether the person had attended the death of a patient before. The questionnaire consisted of eight questions, of which the first four are presented here. According to a questionnaire by Seale [4], we asked about the support of the legalization of euthanasia or PAS. Question one and two were related to patients with a terminal illness, questions three and four were related to patients with a non-terminal illness. In addition, the illness was described as “painful” to allude to the physical suffering of the patient in question. The terms ‘euthanasia’ or ‘PAS’ were not used explicitly (see Table 2).

The results of this study are part of a study among nurses and physicians submitted in part elsewhere (Zenz J, Tryba M, Zenz M. Euthanasia and physician-assisted suicide: Attitudes of physicians and nurses. Submitted). A total of 317 eligible questionnaires were returned from nurses (n = 180) and physicians (n = 137). The response rate of physicians was 49%. This article focuses on the responses given by physicians (Table 3).

Our study demonstrates that the general support for euthanasia and PAS is rather high in Germany, even among physicians engaged in palliative care and pain medicine. This is in line with figures from the UK where similar questions were asked to general practitioners [4]. There were virtually no differences between the UK data from 2009 and the German data 5 years later. The definite acceptance of euthanasia in terminal illness was 6.6% in our study and 8.6% in the UK, and in non-terminal illness acceptance was 2.2% and 3.5%, respectively [4]. Compared to the on-going legislative discussion on PAS, both surveys were obtained at the same stage. In England and Wales, the legislation was clarified in the Debbie-Purdy case in 2009. In 2010, the End of Life Assistance Bill was rejected by Scottish Parliament. In Germany, the legislative process started this year (2014) and induced a broad general discussion. Nevertheless, the group of respondents of the two studies differs in that the UK study included general practitioners, while our study focused on the participants of conferences on pain or palliative care. Compared to a study performed among palliative care specialists in Germany ten years ago [5], the support has increased. Previously, only 10% of the physicians asked supported the legalization of euthanasia [5].

It is noteworthy that the definite support was also quite low within our study. The considerable differences in general and definite support show the importance of the phrasing of questionnaires, which can affect the results [6]. We selected concrete questions as opposed to explicitly asking about ‘euthanasia’—from the Greek for ‘good death’, and in German ‘Sterbehilfe’, that is, ‘help to die’. These phrases are often misunderstood and may give false-positive figures [2]. This has to be kept in mind when evaluating polling results during the legislation process. On the other hand, the perception of the word ‘euthanasia’ can be influenced by history and tradition [7]. This may affect answers, especially in Germany [8]. About 70% of the German population support euthanasia, but 57% do not know the legislation on euthanasia [9].

Not surprisingly, a lower support rate for euthanasia and PAS can be detected among palliative care specialists [4, 10‐13]. However, some studies concerning Belgian physicians found no influence of training in palliative care on attitudes toward euthanasia and PAS [14, 15]. In Belgium, a “synergistic relationship between palliative care and euthanasia” is seen by some colleagues [16]. Euthanasia is thus seen as a possible option within a palliative care setting complementing, for example, symptom control and psychological support. This holds true in Germany only for a minority of the members of the German Society for Palliative Care [17]. General practitioners both in Germany and the UK feel unprepared for the care of patients at the end of their life [18]. A study among newly qualified physicians showed alack of exposure to patients with a terminal illness during education at medical school [19]. Doctors with more contact to EOL patients (e.g., oncologists, geriatrists) focus more on symptom control rather than accepting discussions on ending their patient’s life [13].

The question of the target group of patients could be partially answered by our study. The acceptance of life-ending treatments is significantly lower in the case of a patient with a non-terminal illness. This shows that the respondents classify euthanasia and PAS as treatments for patients with a terminal illness. This is in line with the legislation of Oregon [20]. One of the safeguards in Oregon, for example, is that the physician is convinced that the patient only has a life expectancy of 6 months or less. This is in contrast to the Netherlands, where one of the criteria is unbearable suffering with no prospect of improvement without life expectancy limits [21]. However, the law does not define what “unbearable” suffering is. This leaves room for interpretation. In a seminal decision in 1984 (Schoonheim case), the Dutch Supreme Court declared that “unbearable suffering” includes a “loss of dignity” [22]. Since the concept of dignity is a personal one, it remains unclear what unbearable suffering entails. Another important decision by the Supreme Court (Brongersma case, 2002) stated that psychological suffering is also included in the scope of unbearable suffering [22]. “Dignity” was a main reason for euthanasia requests in more than half of the patients [23]. Over the last decades, pain has decreased as main reason for euthanasia requests, whereas deterioration has increased and represents the main reason for requests for euthanasia and PAS in Dutch general practice [24]. Depression is highly associated with the wish to die and the request for euthanasia [25]. In Oregon, in 2013, the top three reasons for people making use of the Death with Dignity Act were: loosing autonomy (93%), being less able to engage in activities making life enjoyable (88.7%), and loosing dignity (73.2%) [26]. This is in line with data from the Netherlands, where pain no longer is the main reason for euthanasia requests [24]. However, it is noteworthy that more than 50% of all EOL decisions are made without discussion with patient or family [27].

Dignity, as one of the key aspects of the discussion about EOL decision making, is a vague criterion. Advance directives can be a way to ensure that the patients’ wishes are respected in situations when the patient himself cannot communicate. However, in a study among general practitioners from Northern Ireland, only 50% of the respondents found these directives to be of use in clarifying the situation regarding euthanasia [28]. The questionnaire mentioned did not ask about reasons why the physicians did not find the advance directives useful. Therefore, it remains unclear whether the reluctance refers to advance directives in general or whether this hints to possible difficulties in understanding and implementing the patients’ will because of vague or outdated advance directives. Another important aspect is a possible change in the patient’s attitudes in the course of illness [28, 29]. Dignity is not a fixed concept but can develop and change over time. The increase of autonomy of the patient with all its consequences regarding EOL care may also increase the medical power of the health care professionals [29]. This is underlined by studies demonstrating that life-ending drugs are also administered to patients without their explicit request [27, 30]. Euthanasia and PAS should not be a consequence of poor EOL care [31]. For patients in pain and other physical symptoms improved palliative care provision could reduce euthanasia requests [32].

Our study demonstrates—similar to the data of Seale [4]—that physicians are prepared to accept a wish to die in patients with a terminal illness but are reluctant in accepting to provide assistance in the case of a non-terminal illness. As well, physicians engaged in palliative care and pain therapy may have an acceptance of life-ending treatment in case of terminal illness. This points to the fact that severe deficits still exist for patients at the EOL. Hospice and palliative care must be integrative parts of any discussion on euthanasia and assisted suicide, but possibly do not pose an alternative in all cases. However, the patient’s right to die may also include a right to refuse certain “treatments” from the doctor and to discuss alternatives.