Euthanasia, assisted suicide and end-of-life care: attitudes of students, residents and attending physicians.
Derecho de morir
Derecho de morir (Investigacion cientifica)
Derecho de morir (Aspectos morales y eticos)
Estudiantes de medicina (Investigacion cientifica)
Estudiantes de medicina (Capacitacion, entrenamiento y formacion)
Suicidio asistido (Investigacion cientifica)
Suicidio asistido (Analisis de casos)
Suicidio asistido (Aspectos morales y eticos)
|Publication:||Name: Puerto Rico Health Sciences Journal Publisher: Universidad de Puerto Rico, Recinto de Ciencias Medicas Language: Spanish Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2006 Universidad de Puerto Rico, Recinto de Ciencias Medicas ISSN: 0738-0658|
|Issue:||Date: Dec, 2006 Source Volume: 25 Source Issue: 4|
|Geographic:||Geographic Name: Puerto Rico|
Las actitudes con relacion a los eventos al final de la vida estan evolucionando en las culturas de Occidente. Tratamos de trazar esta evolucion en la cultura relativamente homogenea de Puerto Rico a traves de un cuestionario de 16 preguntas contestadas por 153 estudiantes de medicina 62 residentes de medicina y 84 miembros de las facultades de tres escuelas de medicina. Las 4 preguntas medulares fueron: 1) Accederia usted a una solicitud de eutanasia (E) ? 2) Si fuese legalizada, participaria usted? se opondria a su practica ? Se opondria o no se opondria a que otras practicaran el suicidio asistido (PAS)? 3) Consideria etico recetar las dosis de drogras necesarias para aliviar el dolor, aun sabiendo que esto acortaria la vida? 4) Aceptaria limitar escasos recursos a personas ya en una etapa terminal?
Resultados : Veintiocho porciento de los estudiantes 26% de los residentes y 31% de la facultad accederia a una solicitud de E. Solo 13% de los estudiantes, 18% de los residentes y 11% de la facultad participarian en PAS. Mas hombres que mujeres accederian a una solicitud de E o PAS. Una afiliacion religiosa o la ausencia de ella no influencio la opinion con relacion al apoyo o rechazo de E y PAS. Si acortara el proceso de morir, 86% de los residentes pero solo 65% de la facultad consider6 etico recetar la dosis de drogas necesarias para aliviar el dolor.
Background: Attitudes in regard to end-of life issues are evolving in Western societies. We have sought to trace this evolution in the relatively homogeneous cultural setting of Puerto Rico.
Methods: One hundred fifty-two medical students, 62 medical residents and 84 members of three medical faculties were asked whether in terminally ill patients they: 1) would support a request for euthanasia(E); 2) if legalized, would engage in, would oppose or would not be opposed to others engaging physician-assisted suicide(PAS); 3) would consider ethical to prescribe full doses of drugs needed to alleviate pain, even if they knew it would hasten death; 4) would agree to limit certain resources for the terminally ill. Gender and religious affiliation were also requested.
Results: Twenty-eight percent of the students, 26% of the residents and 31% of the faculty supported E. Only 13% of the students, 18% of the residents and 11% of the faculty would engage in PAS. Men were more willing than women to acquiesce to a request for E or PAS. Religious affiliation or its absence did not influence the support or opposition to E and PAS. If it would hasten death, 86% of the residents, but only 65 % of the faculty considered ethical to prescribe the dose of drugs needed to alleviate pain. More than 2/3 of the students, residents and faculty favored the limiting of certain resources for the terminally ill.
Conclusions: In our cultural and medical environment, men are more willing than women to engage in E or PAS. The attitude towards E and PAS is not influenced by religions affiliation. If it hastens death, some still consider unethical to prescribe full doses of drugs needed to alleviate pain in the dying patient.
Key words: Euthanasia, Physician-assisted suicide, End-of-life care, Attitudes of students, Residents and Physicians
Euthanasia (E), physician assisted suicide (PAS) and end of life management are controversial bioethical issues in many Western societies. The Netherlands and Belgium have legalized voluntary E and PAS. In November 1994, Oregon, through a ballot initiative, became the first state to legalize PAS in the United States. Because of multiple court challenges a revised statute finally became operational in October 27, 1997 (1).
In 1996, the Ohio Supreme Court ruled that PAS was not a crime. At the present time, North Carolina, Utah and Wyoming have ceased to criminalize this physician intervention (2). In Virginia, anyone who assists in a suicide is subject to civil but not to criminal charges. In 2004 the 9th Circuit Court of Appeals refused attorney general Ashcroft's request to reverse the lower court ruling of 1997 that permitted the practice of PAS to continue in Oregon. However, in February 2005 the US Supreme Court agreed to consider the proposals of the Bush Administration to outlaw PAS in Oregon, the case renamed Gonzalez v. Oregon. In January 2006 the United States Supreme Court affirmed the 9th Circuit Court ruling of 2004 which in effect permits the State of Oregon to continue its practice of PAS (www. Supremecourtus.gov/docket/ 04623). Clearly, physician-assisted suicide has become part of the medical practice horizon in the United States.
In 1995, medical students in the first, second and third year of the University of Puerto Rico School of Medicine answered 4 questions about end of life concerns. The sample size was 200 of a total of 309 students (3). Ninety three per cent knew the definition of euthanasia, but only 100 medical students knew the difference between "passive" and "active" euthanasia. Seventy per cent of those who knew the difference between "passive" and "active" euthanasia thought that "active" euthanasia should not be considered murder. Surprisingly, only 61% of third year students thought that physicians should "alleviate suffering when they cannot treat successfully an illness and death is imminent".
Challenged by these observations, in 1996 we administered a 16-item questionnaire, published in 1994 by the American Medical Student Association (4), to 279 medical students, 75 medical residents and 35 internal medicine faculty members from three medical schools in the Commonwealth of Puerto Rico and their affiliated hospitals. At that time 40% of the students, 33% of the residents and 20% of the faculty would support the practice ore (5). Ten per cent of the students, 12% of the residents and 6% of the faculty would be willing to directly engage in PAS. More importantly, 50% of the students, 43 % of the residents and 45% of the faculty, while not willing to engage in PAS, were not opposed to others doing so. Seventy-nine per cent of the residents and 80% of the faculty, but only 54% of the students, would consider ethical to prescribe full doses of drugs needed to alleviate pain in dying patients if they knew it would hasten death.
In order to study the evolution of the attitudes of Puerto Rican medical students and attending physicians on this end-of life issues we thought appropriate to repeat the same cross-sectional survey eight years later, but added a question about religious preference and analyzed the difference in attitude between men and women.
Subjects and Methods
Medical students, internal medicine residents and attending physicians in three medical schools and their affiliated hospitals answered a 16-item questionnaire published by the American Medical Student Association in 1994(4). A 17th item was added to this questionnaire seeking to identify the religious affiliation of the respondents. The questionnaire was handed out and collected individually in teaching rounds and faculty meetings within a two-month period (March 15 through May 15, 2004) in 4 teaching hospitals of three medical schools located in Rio Piedras, Bayamon, Ponce and San German, in the north, south and southwest coast of the island of Puerto Rico.
Subjects were asked whether in terminally ill patients they: 1) would support a request for euthanasia; 2) if legalized, would engage in, would oppose or would not be opposed to others engaging physician-assisted suicide; 3) would consider ethical to prescribe full doses of drugs needed to alleviate pain, even if they knew it would hasten death; 4) would agree to limit certain resources for the terminally ill. For each question they were also given the opportunity to claim ignorance or to not have an opinion. In addition they were asked to comment on their medical education in decisions concerning the end of life, to provide some personal demographic data and to state whether they were Catholic, Other Christian, Jews, Muslim or had no religious affiliation whatsoever. The significance of the observations was established using the Chi-square and Fisher tests. This project was reviewed and approved by the Committee for Human Investigations of the Universidad Central del Caribe.
A total of 313 persons answered the questionnaire. Fifteen questionnaires were excluded because the gender or the level of education was not stated. The questionnaire was fully answered by 152 medical students, 62 medical residents and 84 members of the clinical faculty of Universidad Central del Caribe in Bayamon, University of Puerto Rico School of Medicine in San Juan, the Ponce School of Medicine and Hospital La Concepcion in San German. Sixty three per cent of the interviewees were men (188) and 37% women (110); 67.1% were Catholics, 16.9 % Other Christian, 2.2% Jewish.
Support for the request for euthanasia varied from 28% among medical students, 26% among residents and 31% among the faculty (Table 1). Opposition to the request for euthanasia was 49% among medical students to 52% among residents and to 62% among the faculty. Some claimed to have no opinion on these subjects. Men were much more willing than women to acquiesce to a request for euthanasia (Table 2).
If it were legalized, 13% of the students 18% of the residents and 11% of the faculty would be willing to directly engage in PAS (Table 1). More importantly, 46% of the students, 40% of the residents and 52% of the faculty, while not willing to engage, would not oppose others engaging in PAS. Only 28% of the students, 31% of the residents and 36% of the faculty were flatly opposed to the practice of PAS. A significantly higher percentage of men would be willing to engage in PAS (Figure 1). More women (52%) than men (45%) would not oppose others practicing PAS.
Sixty seven percent of the sample claimed to be Catholics, 19% Other Christian, 2% Jews and 14% claimed no religious affiliation. For purposes of analysis they were divided into three groups: Catholics, Non-Catholics and Not Affiliated. There was no significant difference in regards to their support of E or PAS between Catholics, non-Catholics and those who claimed no religious affiliation (Figure 2).
If they knew it would hasten death, 86% of the residents, but only 66% of the attending staff considered ethical to prescribe the dose of drugs needed to alleviate pain in a dying patient. (Table 1). Eighty percent of the students, 66% of the residents and 85% of the faculty would agree to limit certain resources for the terminally ill.
Compared to a similar survey completed in 1996 in Puerto Rico, the proportion of medical students and residents that would acquiesce to a request for euthanasia has decreased from 40% to 28% among students and 33% to 26% among residents. However, more members of the faculty would accept the request for euthanasia in 2004 (31%) than in 1996 (20%).
Perhaps influenced by the current practice in Oregon, the willingness to practice physician-assisted suicide has had a modest increase in the last 8 years among the three groups questioned: medical students from 10% to 13%, residents from 12% to 18% and the faculty from 6% to 11 %. The practicing faculty acquiescing to a request for euthanasia in PR (31%) remains much less than that reported among physicians in the state of Oregon (55%), (6). In a postal survey answered by 677 members of the American College of Physicians in Connecticut, 38% believed that PAS was ethically appropriate in some circumstances and 78% believed that terminal sedation was appropriate for intractable pain (7). The Puerto Rican faculty is less willing than the Connecticut internists to practice PAS (11%), but the willingness of 66% to prescribe full doses of drugs to alleviate pain in dying patients suggests a similar attitude as the Connecticut internists about terminal sedation.
If legalized, the proportion that would not engage but would not oppose for others to participate in PAS remained similar in 1996 and 2004 for medical students (50% and 46% respectively), residents (43% and 40% respectively) and faculty (45% and 52% respectively). The proportion of medical students who would agree to limit certain resources for the terminally ill increased markedly between the 1996 survey and this survey (61% and 80% respectively). This may be a result of the increased emphasis in advanced directives and the importance of autonomy in end-of-life decisions presently given in our teaching hospitals.
Significant differences are noted between residents (the men in the trenches), who are less willing to limit certain resources from the terminally ill (66%), than the medical students (80%) and faculty (85%).Surprisingly, in this anonymous and non-judgmental setting, there was no significant difference between those claiming a religious affiliation and those who did not in regard to their support or tolerance of E or PAS.
The marked difference between men and women in regard to their willingness to engage in the practice of E and PAS was a surprising finding and of importance in a medical community progressively more in the hands of women. A similar observation has been recently made in a teaching hospital in Nigeria (8). In a sample of 67 clinicians with 5 or more years of practice 1 of 11 females would support PAS while 8 of 56 males would. This outstanding gender difference in attitude merits further study.
The attitude of Puerto Rican medical students is much more conservative than that of Dutch medical students, as many as 80% of them are in favor of PAS (9). Their attitude resembles that voiced by fifth and sixth year students from the Medical School of the University of Ferrara in Northeast Italy where 28.3% of the students were somewhat in favor or strongly in favor of E or PAS (10). The opinion of our medical students is not too dissimilar to students with a Christian faith from the University of Oslo: For patients with terminal illness, 30% supported E and 39% PAS. Their opinion differed markedly from University of Oslo students with another faith or no definable faith: 57% of them favored E and 65% would engage in PAS (11).
In the pursuit of the moving target of moral excellence in end-of-life management, the concern about hastening death while relieving pain in the dying patient remains an issue for 14% of the residents and 34% of the faculty. While the guidelines for the treatment of acute and cancer related pain published in 1995 have dramatically improved pain assessment, they have had a limited effect in the outcome of pain management (12). Still, muscular injections of meperidine hydrochloride on an as needed basis remain a common practice. Practicing physicians need to integrate new knowledge and behavior into day-to-day pain management (13).
The authors are indebted to Dr. Robert F. Hunter-Mellado for his review of the manuscript and the statistical analysis. Supported in part by NHI/RCMI grant number G1RR03035.
(1.) Oregon Death with Dignity Act, Oregon Revised Statute 127.800-127.995.
(2.) Okie S: Physician-assisted suicide--Oregon and beyond. N Eng
JOSE RAMIREZ-RIVERA, MD, MACP *; JUAN CRUZ, MD ([dagger]); FRANCISCO JAUME-ANSELMI, MD, FACP ([double dagger])
* Professor of Medicine and medical resident, Universidad Central del Caribe, ([dagger]) Director Department of Medicine, Hospital de la Concepcion, ([double dagger]) From the Departments of Medicine of the Universidad Central del Caribe, the University of Puerto Rico and the Ponce Schools of Medicine and La Concepcion Hospital
Address correspondence to: Jose Ramirez Rivera, MD, FACP, Professor of Medicine, Universidad Central del Caribe, Summit Hills, 1657 Adams St., San Juan, PR 00920-4361. E-mail: firstname.lastname@example.org Fax: 787-775-9342 J Med.2005;352:1627-1630.
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(4.) Euthanasia and Physician-Assisted Suicide. The New Physician 1994; May-June: 35.
(5.) Ramirez-Rivera J, Rodriguez-Perez R, Otero-Igaravidez Y: Attitudes toward euthanasia, assisted suicide, and termination of life-sustaining treatment of Puerto Rican medical students, residents and faculty. Bol Ass Med PR. 2000;92:18-21.
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(7.) Kaldjian LC, Jekel JF, Bernene JL, Rosenthal GE, Vaughan-Sarrazin M, Duffy TP. Internists attitudes towards terminal sedation and end of life care. J Med. Ethics 2004;30:499-503.
(8.) Gharoro ET, Igberase GO, Okubor PO, Onakewhor JU. Caring for the terminally ill: What do the doctors think? Afr J Med Sci. 2003;32,377-80.
(9.) Muller MT, Onwuteaka-Philipsen BD,Krigman DMV, Van der Wal G Voluntary active euthanasia and doctor-assisted suicide: knowledge and attitudes of medical students. Med Educ 1996; 30:428-433.
(10.) Grassi L, Agostini M, Rossin P, Magnani K. Medical students opinion of euthanasia and physician-assisted suicide in Italy. Arch Intern Med 2000;160:2226-2227.
(11.) Schioldborg P. Students' Attitudes toward active euthanasia, assisted suicide and proposed amendments to the penal code. Tidsskr No Laegeforen 2000;120:2283-8.
(12.) American Pain Society Quality Improvement Guidelines for the treatment acute pain and cancer pain. JAMA 1995; 274:1874-1880.
(13.) Gordon DB, Dahi JJ, Miaskowski C, et al. American Pain Society Recomendations for Improving the Quality of Acute and Cancer Pain Management. Arch Intern Med 2005; 165:1574-80.
Table 1. Opinions of medical students, residents and faculty about euthanasia, assisted suicide, prescribing full doses of drugs to alleviate pain in dying patients and limiting resources for the terminally ill. Issues Students Residents n (%) n (%) Support request for euthanasia 42 (27.6) 16 (25.8) If legalized, would engage in 20 (13.2) 11 (17.7) physician-assisted suicide If legalized, would not oppose 70 (46.1) 25 (40.3) others engaging in physician- assisted suicide If legalized, would oppose others 42 (27.6) 19 (30.6) engaging in physician-assisted suicide Prescribed full doses of drug to 116 (76.3) 53 (85.5) alleviate pain in dying patients Agree to limit certain resources 122 (80.3) 41 (66.1) for the terminally ill. Issues Faculty p-value n (%) Support request for euthanasia 26 (31.0) 0.773 If legalized, would engage in 9 (10.7) 0.634 physician-assisted suicide If legalized, would not oppose 44 (52.4) 0.346 others engaging in physician- assisted suicide If legalized, would oppose others 30 (35.7) 0.438 engaging in physician-assisted suicide Prescribed full doses of drug to 55 (65.5) 0.019 * alleviate pain in dying patients Agree to limit certain resources 71 (84.23) 0.026 * for the terminally ill. * Statisticaly Significant Table 2. Opinions about euthanasia and assisted suicide, by gender Men Women Issues n (%) Support request for euthanasia. 64 (34.0) 20 (18.2) If legalized, would engage in 35 (18.6) 5 (4.5) physician-assisted suicide. If legalized, would not oppose 85 (45.2) 57 (51.8) others engaging in physician- assisted suicide. If legalized, would oppose 56 (29.8) 35 (31.8) others engaging in physician- assisted suicide Total p-value Issues n (%) n (%) Support request for euthanasia. 84 (28.2) 0.005 * If legalized, would engage in 40 (13.4) 0.001 * physician-assisted suicide. If legalized, would not oppose 142 (47.7) 0.281 others engaging in physician- assisted suicide. If legalized, would oppose 91 (30.5) 0.794 others engaging in physician- assisted suicide Figure 1. Willingness to Engage in Physician Assisted Suicide, if Legalized, by Gender Men Women Would 19 4 Would not oppose 45 52 Would not oppose 30 32 Don't know 4 10 Do not respond 2 2 Note: Table made from a bar graph. Figure 2. Support of Euthanasia and Willingness to Engage in Physician Assisted Suicide by Interviewees With or Without Religious Affiliation. Physician Euthanasia Assisted Suicide Catholic 28 12 Non Catholic 25 16 Not affiliated 34 17 Note: Table made from a bar graph.
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