During the past decade, the debate about legalising euthanasia has grown in many developed countries, including France. Medical journals have reflected this: surveys have assessed doctors' attitudes toward euthanasia and bioethics articles have discussed the pros and cons. Supporters of legalisation argue that euthanasia is a continuation of palliative care and that doctors must respect patients' autonomy, including a wish to die.1 The latter argument suggests that cultural differences shape opinions about euthanasia, because the emphasis on autonomy is greater in English speaking countries than in other developed countries.2,3
We assessed French doctors' opinions toward euthanasia and collected data about their attitudes and practices. We compared medical specialties which demand different amounts of palliative care and different amounts of empathy toward and communication with terminally ill patients.
Participants, methods, and results
In 2002, the Regional Center for Disease Control of South-Eastern France and the Health and Medical Research National Institute did a telephone survey of a sample of doctors, stratified by specialty. We selected general practitioners, oncologists, and neurologists randomly from all French doctors, kept on file by the National Health Insurance Fund.
We investigated respondents' involvement in end of life care and palliative care, their attitude toward terminally ill patients, and whether “euthanasia should be legalised, as in the Netherlands.” We compared medical specialties with Pearson's χ2.
We contacted 1552 doctors, and 917 (59%) agreed to participate. Response rate was greater for oncologists (217/261; 83%) and neurologists (198/287; 69%) than for general practitioners (502/1004; 50%). Doctors who did not respond were generally too busy; they did not differ in sex, age, or size of town from respondents.
Only a minority of respondents were trained in palliative care, especially neurologists (24/198; 12.1%). Oncologists treated more terminally ill patients during the past year (mean 26.3 patients v 9.4 for neurologists and 7.0 for general practitioners; P < 0.05), and general practitioners practised less often in palliative care units (table). Oncologists were less likely to feel uncomfortable with terminally ill patients (7.8% v 16.7% among general practitioners and 27.8% among neurologists; P < 0.001) and more prone to systematically communicate the objectives of treatment (65.9% v 57.2% among general practitioners and 47.0% among neurologists; P < 0.01) and the diagnosis to competent terminally ill patients. Oncologists were also less in favour of legalising euthanasia (35.5% v 44.8% of general practitioners and 46.5% of neurologists; P < 0.05).
Table 1.
French doctors' involvement in end of life care and palliative care, their attitude to and communication with patients, and their opinion on legalising euthanasia, 2002. Values are numbers (percentages) unless otherwise stated
| General practitioners (n=502) | Oncologists (n=217) | Neurologists (n=198) | Total (n=917) | P value* | |
|---|---|---|---|---|---|
| Women | 153 (30.5) | 94 (43.3) | 69 (34.8) | 316 (34.5) | <0.01 |
| Age (years): | |||||
| <40
|
124 (24.8)
|
102 (47.0)
|
78 (39.3)
|
303 (33.0)
|
<0.001 |
| 41-50
|
239 (47.6)
|
70 (32.3)
|
82 (41.3)
|
393 (42.9)
|
|
| >50 | 139 (27.6) | 45 (20.7) | 38 (19.4) | 221 (24.1) | |
| Mean | 45.3 | 42.3 | 42.8 | — | — |
| No of terminally ill patients cared for in previous year: | |||||
| 0-12
|
421 (83.9)
|
104 (47.9)
|
157 (79.3)
|
682 (74.4)
|
<0.05 |
| 13-24
|
49 (9.8)
|
28 (12.9)
|
18 (9.1)
|
95 (10.4)
|
|
| >25 | 32 (6.3) | 81 (37.2) | 23 (11.6) | 140 (15.3) | |
| Mean No of terminally ill patients cared for | 7.0 | 26.3 | 9.4 | — | — |
| Specialised training in palliative care, algology, or geriatry | 103 (20.5) | 43 (19.8) | 24 (12.1) | 170 (18.5) | <0.01 |
| Practising in a palliative care unit | 34 (6.8) | 64 (29.5) | 47 (23.7) | 145 (15.8) | <0.001 |
| Feel uncomfortable with terminally ill patients | 84 (16.7) | 17 (7.8) | 55 (27.8) | 156 (17.0) | <0.001 |
| Systematically communicate diagnosis† | 44 (8.8) | 38 (17.5) | 13 (6.6) | 95 (10.4) | <0.001 |
| Systematically communicate treatment† | 287 (57.2) | 143 (65.9) | 93 (47.0) | 523 (57.0) | <0.01 |
| Euthanasia should be legalised, as in the Netherlands‡ | 225 (44.8) | 76 (35.5) | 92 (46.5) | 394 (43.0) | <0.05 |
Pearson's χ2 testing the independence hypothesis between each row and the medical specialty.
To competent patients.
Agreed or strongly agreed.
Comment
Many French doctors want euthanasia to be legalised. This opinion is more common among general practitioners and neurologists than among oncologists, who are more experienced in end of life care, more frequently trained in palliative care, and show greater comfort and better communication with terminally ill patients. Because most proponents of legalisation argue that euthanasia is a continuation of end of life care and that doctors should respect patients' autonomy, including a wish to die, we expected to find the reverse.
Our study has several limitations. Answering questions about a sensitive topic on the telephone can be difficult, a questionnaire with a fixed choice of answers prevented doctors from qualifying or justifying their responses, and we lacked detailed information about doctors who did not respond.
Previous studies found similar patterns, but the French counterparts to Italian general practitioners and US oncologists were more in favour of legalising euthanasia.3,4 Our findings contradict the argument that opinions on euthanasia are related to cultural differences in English speaking countries; comparative studies are needed.2 In France, the support shown for euthanasia may be due to a lack of professional knowledge on palliative care.5 Improving such knowledge would improve end of life care and may also clarify the debate over euthanasia.
We thank H Granier, Y Obadia, B Planchet-Barraud, F Ravallec, M Rotily, and O Priolo.
Contributors: MKB, HP, JML, RF, and AG designed the survey and reviewed and improved the paper. JPM and PP-W did the statistical analysis and wrote the paper. PP-W is guarantor.
Funding: Departmental Centre of Private Health Professionals (grant from the fund for improving ambulatory care), Assistance Publique-Hôpitaux de Marseilles (within the hospital programme for clinical research), and Cancer Research Foundation (ARC).
Competing interests: None declared.
Ethical approval: Not needed.
References
- 1.Hermsen MA, ten Have HA. Euthanasia in palliative care journals. J Pain Symptom Manage 2002;23: 517-25. [DOI] [PubMed] [Google Scholar]
- 2.Seale C. Changing patterns of death and dying. Soc Sci Med 2000;51: 917-30. [DOI] [PubMed] [Google Scholar]
- 3.Grassi L, Magnani K, Ercolani M. Attitudes toward euthanasia and physician-assisted suicide among Italian primary care physicians. J Pain Symptom Manage 1999;17: 188-96. [DOI] [PubMed] [Google Scholar]
- 4.Emanuel EJ, Fairclough D, Clarridge BC, Blum D, Bruera E, Penley WC, et al. Attitudes and practices of US oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med 2000;133: 527-32. [DOI] [PubMed] [Google Scholar]
- 5.Ben Diane MK, Pegliasco H, Galinier A, Lapiana JM, Favre R, Peretti-Watel P, et al. Prise en charge des malades en fin de vie en médecine générale et spécialisée [Terminal care of patients by the general practitioner and the specialist: results of the French survey “attitudes and practices in palliative treatment—2002”]. Presse Med 2003;32: 488-92. (In French.) [PubMed] [Google Scholar]