Healthcare Professionals’ Attitudes About Physician-Assisted Death: An Analysis of Their Justifications and the Roles of Terminology and Patient Competency

Abstract

Context

Healthcare professionals (HCPs) are crucial to physician-assisted death (PAD) provision.

Objectives

To quantitatively assess the favorability of justifications for or against PAD legalization among HCPs, the effect of the terms “suicide” and “euthanasia” on their views, and their support for three forms of PAD.

Methods

Our questionnaire presented three cases: physician-assisted suicide, euthanasia for a competent patient, and euthanasia for an incompetent patient with an advance directive for euthanasia. Respondents judged whether each case was ethical and should be legal, and selected their justifications from commonly cited reasons. The sample included physician clinicians, researchers, non-physician clinicians, and other non-clinical staff at a major academic medical center.

Results

Of 221 HCPs, the majority thought each case was ethical and should be legal. In order of declining favorability, justifications supporting PAD legalization were relief of suffering, right to die, mercy, acceptance of death, non-abandonment, and saving money for the healthcare system; opposing justifications were the slippery slope argument, unnecessary due to palliative care, killing patients is wrong, religious views, and suicide is wrong. Use of suicide and euthanasia terminology did not affect responses. Participants preferred physician-assisted suicide to euthanasia for a competent patient (p<0.0001) and euthanasia for an incompetent patient to euthanasia for a competent patient (p<0.005).

Conclusions

HCPs endorsed patient-centered justifications over other reasons, including role-specific duties. Suicide and euthanasia language did not bias HCPs against PAD, challenging claims that such value-laden terms hinder dialogue. More research is required to understand the significance of competency in shaping attitudes toward PAD.

Introduction

Physician-assisted death (PAD) has remained one of the most contentious topics in medical ethics over several decades.(1–3) With recent legalization efforts succeeding in Canada(4) and California(5) but failing in the U.K.,(6) this debate seems likely to continue for the foreseeable future. In this context, researchers have consistently investigated the attitudes of healthcare professionals (HCPs) since they represent a crucial stakeholder group: PAD has weighty implications for both the duties of certain HCPs as well as the concept of what it means to be a HCP.(7,8) Furthermore, the opinions of HCPs can influence the public in addition to policy makers.(9)

Accordingly, most surveys in this vein attempt to gauge the views of HCPs toward the ethics and legality of PAD or their willingness to practice PAD.(7,10,11) Such studies have confirmed that physicians oppose PAD at a significantly greater rate than the general public.(7) Moreover, attitudes are highly dependent on location, with the majority of physicians approving of PAD in Belgium and the Netherlands, about half in the U.S. and Western Europe, and a minority in Central and Eastern Europe.(7) Other characteristics associated with HCPs’ opinions include medical specialty(12–15) and especially religiosity.(7,12–14,16) Finally, various studies have elucidated the sentiments of particular stakeholder groups, such as Italian primary care physicians,(17) Greek intensive care unit physicians and nurses,(18) former caregivers of people with dementia,(19) and patients with advanced cancer.(20–22)

Here, we analyze HCPs’ views about three distinct forms of PAD: physician-assisted suicide (PAS), in which a physician provides a patient with the means, typically lethal drugs, to take their own life; voluntary active euthanasia for a competent patient (VE-C), in which a physician intentionally ends a competent patient’s life by some medical means according to the patient’s explicit request; and voluntary active euthanasia for an incompetent patient (VE-I), in which a physician intentionally ends an incompetent patient’s life by some medical means according to the patient’s prior explicit request made while competent and typically preserved through an advance directive.(23–25) Currently, PAS is legal in Switzerland, six U.S. states (California, Colorado, Montana, Oregon, Vermont, and Washington), and the District of Columbia;(7) VE is legal in Belgium, Canada, Colombia, Luxembourg, and the Netherlands,(26) though VE-I is much less common than VE-C. Eligibility for and oversight of PAD differ in these countries;(27) for instance, PAD for children is permitted in Belgium and the Netherlands but not in Luxembourg.(28) However, the legal status of PAD is often unclear, as in Germany,(7) and forms of PAD are practiced in countries where it is not explicitly legal.(29)

Furthermore, we supplement the survey literature with two questions about HCPs’ attitudes: what justifications do HCPs provide regarding their views on PAD, and does the use of the words “suicide” or “euthanasia” bias responses? Understanding how HCPs defend their opinions is essential, as these reasons reflect the arguments HCPs have found most important in forming their views; the most prevalent justifications are those likely to be discussed in healthcare settings. Additionally, the terminology used to describe PAD has been controversial, with proponents of legalization arguing that suicide is an inaccurate description of assisted dying(30) and that euthanasia and suicide are value-laden terms that can hinder rational dialogue.(31) In order to begin to resolve these questions, we surveyed HCPs concerning their views on three different forms of PAD, and asked them to provide their most important justifications for supporting or opposing legalization; we also studied the role of terminology by employing two questionnaires with distinct wording.

Methods

The online questionnaire (see appendix) was distributed via one invitation and one reminder email in the summer of 2015 to a convenience sample of HCPs at Yale-New Haven Hospital, with no incentive for participation offered. The study population of 1,624 individuals comprised the 571 HCPs from the up-to-date Department of Surgery email list, 549 from Internal Medicine, 280 from Pediatrics, and 224 from Anesthesia. Of 221 respondents included in the analysis (14% response rate), 172 (78%) completed all survey questions. We collected data anonymously through the Qualtrics survey tool (Qualtrics: Provo, Utah, USA). Yale University’s Human Subjects Committee exempted the study from IRB review (Protocol 1411014933).

Respondents first read a brief paragraph about an elderly, competent patient with cancer who has at most six months to live. Bedridden, unable to care for himself, and in pain, he wishes to end his life with the aid of his physician. Next, respondents read three short scenarios detailing potential outcomes to the patient’s circumstances; the order of these scenarios was randomized. In the PAS scenario, the physician prescribes lethal medication which the patient takes, ending his life. The VE-C scenario is identical, except the patient is unable to take the medication, so the physician administers it. In the VE-I scenario, the patient has lost competence; however, respecting the patient’s advance directive and the wishes of his healthcare proxy, the physician administers the lethal medication. By keeping the scenarios as similar as possible, we attempted to isolate the features distinguishing the forms of PAD: the difference between PAS and VE-C consists in who performs the act of ending the patient’s life, while the difference between VE-C and VE-I consists in the patient’s competency.

Following each of the three scenarios, respondents rated whether they believed the physician’s actions were ethical and whether they felt the practice should be legal using two seven-point Likert scales. Respondents then received a third question if they indicated approval (five, six, or seven on the Likert scale) or disapproval (one, two or three) of legalization: respondents could select the most important reasons for their views concerning legality from a list of potential justifications common in the literature, as well as write in other reasons.

Additionally, respondents were randomly assigned to receive one of two versions of the questionnaire: in one version, every case of PAD was described as “a physician assisting a patient to die,” while in the other, the PAS scenario was described as “physician-assisted suicide,” the VE-C scenario as a physician “performing voluntary euthanasia on a patient,” and the VE-I scenario as a physician “euthanizing a patient based on the patient’s living will and healthcare proxy.”

We performed analyses with SAS 9.4 statistical software (SAS Institute: Cary, North Carolina, USA) to determine how attitudes differed depending on the form of PAD by comparing the answers to the Likert scale questions in the PAS scenario to the VE-C scenario and the VE-C scenario to the VE-I scenario. Since the same participants responded to the different scenarios, a repeated-measures model was employed. While occupation, the order of the scenarios, and the version (terminology) of the questionnaire approached statistical significance, gender and age did not and consequently were excluded from the final statistical models. Adjusting for occupation, order, and terminology, the least squares means for the Likert scale answers and their 95% confidence intervals were calculated and compared.

Furthermore, to evaluate the role of terminology, we used a simple t-test to compare the average response to each Likert scale question from participants who received one questionnaire version to the responses from participants who received the other version. Finally, as a sensitivity analysis, we applied two models to assess the roles of terminology, demographics, and order: in the ANOVA analysis, the Likert scale answers were treated as numerical values, while in the cumulative logistic regression model, they were treated as ordered categories.

Results

Among survey respondents (Table 1), there were more females (48%) than males (31%) and more physician clinicians (48%) than researchers (10%), non-physician clinicians (7%), or other non-clinical staff (13%). For each form of PAD, a majority believed that the physician’s actions were ethical and should be legal; however, respondents were slightly more likely to endorse the legality of PAD than its ethical acceptability across all scenarios (Table 2). Controlling for terminology, order, and demographic factors, we found respondents were significantly more likely to approve of the ethics and legality of PAS than VE-C (p<0.0001) and of VE-I than VE-C (p<0.005) (Table 3).

Table 1.

Respondent demographics

		N (221)	%
Age	Under 29 years	25	11.3%
	Between 30 and 50 years	83	37.6%
	Over 51 years	68	30.8%
	Did not answer	45	20.4%
Gender	Female	107	48.4%
	Male	69	31.2%
	Other identity	0	0.0%
	Did not answer	45	20.4%
Occupation	Physician clinician	105	47.5%
	Non-clinical staff	29	13.1%
	Researcher	22	10.0%
	Non-physician clinician	16	7.2%
	Did not answer	49	22.2%

Table 2.

Attitudes about the ethics and legality of three forms of PAD^a

		PAS (N=179)	VE-C (N=182)	VE-I (N=185)
Ethics	Opposed	45 (25.1%)	60 (33.0%)	42 (22.7%)
	Unsure	15 (8.4%)	28 (15.4%)	28 (15.1%)
	Supportive	119 (66.5%)	94 (51.6%)	115 (62.2%)
Legality	Opposed	37 (20.7%)	54 (29.7%)	44 (23.8%)
	Unsure	19 (10.6%)	22 (12.1%)	15 (8.1%)
	Supportive	123 (68.7%)	106 (58.2%)	126 (68.1%)

^aIn the seven-point Likert scale, a response of one, two, or three demonstrated opposition, a response of four demonstrated uncertainty, and a response of five, six, or seven demonstrated support.

Table 3.

Difference in attitudes about PAS and VE-C and about VE-C and VE-I

		Least squares meana	95% Confidence interval	p-Value
Ethics of PAS and VE-C	PAS (N=171)	5.30	(4.94, 5.66)
	VE-C (N=170)	4.74	(4.38, 5.10)
	Difference	0.56	(0.32, 0.80)	<0.0001
Legality of PAS and VE-C	PAS (N=171)	5.54	(5.16, 5.91)
	VE-C (N=170)	4.99	(4.61, 5.36)
	Difference	0.55	(0.30, 0.80)	<0.0001
Ethics of VE-C and VE-I	VE-C (N=170)	4.74	(4.38, 5.10)
	VE-I (N=172)	5.17	(4.81, 5.53)
	Difference	−0.43	(−0.67, −0.19)	0.0004
Legality of VE-C and VE-I	VE-C (N=170)	4.99	(4.61, 5.36)
	VE-I (N=172)	5.38	(5.00, 5.76)
	Difference	−0.39	(−0.64, −0.14)	0.0022

^aAdjusted for terminology, order, and occupation, which were indicated as significant by a repeated-measures model. Age and gender were not statistically significant, and therefore were excluded from the model.

The favorability of justifications regarding legality remained similar across forms of PAD (Table 4). The only justification opposing legalization to receive majority support was the slippery slope argument;(32) the remaining justifications, in declining order, were that good palliative care renders PAD unnecessary,(33) killing patients is always wrong,(34) PAD is against personal religious beliefs, and suicide is always wrong.(35) The most prevalent justifications in support of legalization were relief of suffering(36) and the right to die,(37) followed by mercy,(38) accepting death as a natural part of life,(39,40) and non-abandonment of patients,(41) with saving money for the healthcare system by far the least common.(42) Those who provided other justifications in opposition mostly referenced additional protections for patients seeking PAD while those in support mostly referenced death with dignity.

Table 4.

Justifications regarding the legality of three forms of PAD^a

Justifications opposing legalization	PAS (N=37)	VE-C (N=54)	VE-I (N=42)
Slippery slope	27 (73.0%)	36 (66.7%)	30 (71.4%)
Palliative care	16 (43.2%)	26 (48.2%)	19 (45.2%)
Killing patients wrong	15 (40.5%)	19 (35.2%)	20 (47.6%)
Religious views	11 (29.7%)	12 (22.2%)	11 (26.2%)
Suicide wrong	7 (18.9%)	7 (13.0%)	4 (9.5%)
Other	4 (10.8%)	7 (13.0%)	0 (0.0%)
Justifications supporting legalization	PAS (N=123)	VE-C (N=106)	VE-I (N=126)
Relieves suffering	97 (78.9%)	86 (81.1%)	101 (80.2%)
Right to die	95 (77.2%)	78 (73.6%)	94 (74.6%)
Merciful	78 (63.4%)	68 (64.2%)	78 (61.9%)
Acceptance of death	71 (57.7%)	62 (58.5%)	78 (61.9%)
Non-abandonment	62 (50.4%)	60 (56.6%)	71 (56.4%)
Saves money	20 (16.3%)	16 (15.1%)	20 (15.9%)
Other	5 (4.1%)	9 (8.5%)	11 (8.7%)

^aSince multiple justifications were allowed, numbers add up to more than the total N or 100%.

The use of suicide and euthanasia terminology did not have a statistically significant effect in the t-test comparing Likert scale answers based on questionnaire version (Table 5); however, for all six questions, suicide or euthanasia language was associated with more approval than “assisting a patient to die” language.

Table 5.

Effect of terminology on attitudes about the ethics and legality of three forms of PAD

		Physician assisting a patient to die terminologya	Suicide and euthanasia terminologya	p-Valueb
PAS (N=179)	Ethics	4.86	5.24	0.21
	Legality	5.11	5.46	0.26
VE-C (N=182)	Ethics	4.41	4.60	0.56
	Legality	4.66	4.89	0.48
VE-I (N=185)	Ethics	4.77	5.04	0.36
	Legality	4.95	5.34	0.20

^aAverage of numerical responses to 7-point Likert scale questions.

^bp-Values were produced by a simple t-test.

In the two statistical models for the Likert questions, terminology, age, and gender were not statistically significant. Overall, occupation was statistically significant, with researchers and physician clinicians most inclined to oppose PAD and non-physician clinicians and non-clinical staff most inclined to support PAD (Table 6). Order was also statistically significant, but there was no clear pattern regarding which order led to increased or decreased approval.

Table 6.

Effect of occupation on attitudes about the ethics and legality of three forms of PAD^a

		ANOVA model			Cumulative logistic regression model
		Difference in average scoresb	95% Confidence interval	p-Value	Odds ratioc,d	95% Wald confidence interval	p-Value
PAS (N=171)	Ethics	1.01	(0.17,1.86)	0.018	0.29	(0.14,0.62)	0.002
	Legality	1.05	(0.16,1.94)	0.021	0.33	(0.15,0.71	0.005
VE-C (N=170)	Ethics	0.79	(−0.12,1.69)	0.087	0.41	(0.20,0.84)	0.016
	Legality	1.45	(0.51,2.39)	0.003	0.31	(0.15,0.67)	0.003
VE-I (N=172)	Ethics	0.92	(0.08,1.76)	0.032	0.31	(0.15,0.65)	0.002
	Legality	1.30	(0.43,2.16)	0.004	0.25	(0.11,0.54)	0.001

^aBoth models incorporate occupation, gender, age, order, and terminology.

^bNon-physician clinician + non-clinical staff minus physician + researcher.

^cNon-physician clinician + non-clinical staff vs. physician + researcher.

^dAn odds ratio less than 1 indicates that non-physician clinicians and other non-clinical staff were more likely to support PAD compared to physicians and researchers.

Discussion

In this survey of HCPs’ attitudes, we confirmed prior findings that HCPs prefer PAS to VE-C,(7,12), but we were surprised that our study group was significantly more approving of the ethics and legality of VE-I than VE-C, even though VE-I is rarely practiced in countries where VE is legal. These results may indicate that HCPs would indeed prefer euthanasia for an incompetent patient than a competent patient, all else equal. Nevertheless, care should be taken in interpreting these data, as participants may have been responding to other features of the VE-I scenario absent from the VE-C scenario: they may have noted the advance directive and healthcare proxy as supplementary safeguards, or considered the patient’s loss of competency relevant insofar as it represents a deterioration in his condition. Even accepting these caveats, however, it is still notable that respondents favored euthanasia for an incompetent patient with an advance directive for euthanasia over euthanasia for a competent patient who is better off only due to his competency.

These findings align with reports that incompetent patients receive less intensive end-of-life care than competent patients(43) and are more likely to have life-sustaining treatment withheld, even accounting for severity of illness and diagnosis.(44) Our results appear to conflict with evidence that advance directives for euthanasia are unlikely to be carried out,(45–47) but such studies focus on patients with dementia.(48–51) It is important to note, therefore, that our findings regarding attitudes toward VE-I are relevant for VE-I for adult patients at the end of a terminal disease process, but are difficult to generalize for other controversial cases of VE-I as they introduce additional concerns, such as the presence of a psychiatric illness or the absence of a terminal illness; similarly, our data cannot be generalized to cases in which death is assisted by someone other than a HCP.(52) We believe the issue of competency warrants further investigation given the difference we report, the lack of prior work on opinions toward and the practice of VE-I for adults without psychiatric illness, and the current acceptance of certain practices for terminally ill, incompetent adults, including withdrawal of life-sustaining treatment and palliative sedation to unconsciousness.(53,54)

Furthermore, our analysis of HCPs’ justifications regarding PAD legality reveals a trend toward favoring patient-centered justifications. The most prevalent justifications approving (relief of suffering, right to die) and disapproving (slippery slope, rendered unnecessary by palliative care) of PAD are focused primarily on the patient’s situation: those in support attend to relieving the patient’s pain and honoring the patient’s right to die as they wish, while those in opposition worry that legalization could lead to unintended consequences for patients and that good palliative care might deliver superior outcomes. Moreover, proponents endorsed these patient-centered justifications over those specific to the physician’s role (mercy, non-abandonment), though a majority backed those as well. While the role-specific(55,56) justification against legalization (killing patients is wrong) garnered less support than patient-centered ones, it did surpass personal or moralizing justifications (against religious views, suicide is wrong). The lack of backing for a religious justification indicates that religious arguments about PAD are rarely used within this HCP community. Since religiosity is a highly predictive demographic factor for attitudes about PAD, (7,12–14,16) further work could elucidate whether religious HCPs in other locations find religious arguments compelling or tend to employ other justifications as did this sample; such a study could clarify how religiosity mediates opinions about PAD. Though listing potential justifications could bias respondents in favor of these over unlisted justifications, this limitation is mitigated by the array of justifications provided and the option to write other justifications, which yielded primarily patient-centered concerns.

Additionally, we found no evidence that the words suicide and euthanasia bias HCPs against PAD; in fact, our results trended in the opposite direction. These findings are aligned with surveys of the public: although the term suicide consistently prejudiced individuals against PAD in polls from 2002 through 2014, this effect disappeared in the latest 2015 Gallup poll.(57) Accordingly, these data cast doubt on the argument that suicide and euthanasia are inappropriate terms due to their potential to prejudice. The trend in our data is likely an artifact of the small sample size, though it could indicate that HCPs are more averse to cases described with “assisting a patient to die” language than the conventional terms of suicide and euthanasia.

Finally, our statistical modeling suggests that not only are physicians more likely to oppose PAD than the general public, they are more likely to oppose it than other HCPs, including other clinicians. Our results also demonstrated that the order in which scenarios were presented affected responses, consistent with prior data.(58)

The major limitations of our study are the low response rate, which was expected because of the survey distribution method, as well as the use of a convenience sample of 221 HCPs from a single location. These problems are mitigated in part by the facts that no differences were found between responders and non-responders in similar surveys about PAD(12,14,59) and that our emails mentioned only end-of-life care, not PAD, lessening the likelihood that those with particularly strong views on PAD participated. Additionally, our sample was mixed and included non-clinicians whose attitudes are not typically studied in similar surveys. Finally, the questionnaire was concise in order to facilitate our analyses, and therefore could not capture the great complexity of and additional considerations involved in actual instances of PAD.

A strength of our study is the use of a questionnaire with scenarios carefully constructed to differ in particular aspects (here, terminology, patient competency, and who ends the patient’s life), which we believe can be of use to investigate specific questions about opinions, intuitions, and biases in the increasingly empirical field(60,61) of medical ethics. While all our novel findings require replication, the data on terminology is most likely to prove robust due to the randomized experiment embedded in our questionnaire.

Conclusion

In this survey of healthcare professionals’ attitudes about physician-assisted death, we report the first quantitative data on their justifications and the role of terminology. We found that respondents were more likely to endorse patient-centered justifications over other justifications, such as role-specific duties. Use of the terms “physician-assisted suicide” and “euthanasia” did not affect their views, challenging the argument that these words are value-laden and can therefore hinder dialogue. Healthcare professionals favored physician-assisted suicide to voluntary active euthanasia for a competent patient, confirming prior reports. However, respondents favored voluntary active euthanasia for an incompetent patient with an advance directive for euthanasia to voluntary active euthanasia for a competent patient; further data are required to assess the effect of patient competency on attitudes toward assisted death.

Appendix: Complete questionnaire

Please note that:

• While each participant received a survey that began with the introduction and ended with demographic questions, the three scenarios were presented in a random order.

• Text in bold below represents one version of the questionnaire; text in italics below represents the second version. Each participant received all three scenarios with the bolded text, or all three scenarios with the italicized text.

• Question three of each scenario only appeared if the participant responded with 1, 2, or 3 to question two of that same scenario. Question four of each scenario only appeared if the participant responded with 5, 6, or 7 to question two of that same scenario. Participants that responded with 4 to question two of a scenario did not receive either question three or four for that same scenario.

Introduction

Please read the following paragraph carefully

Mr. Smith is an elderly man with advanced, incurable cancer. His condition has declined to the point where he is bedridden, unable to care for himself, and requires large doses of pain medication to relieve his pain. He feels that the burden of his disease has become unbearable. He has been told he has at most 6 months to live. He would like, with the aid of his physician, to end his life painlessly and quickly. It has been determined that he is mentally competent.

You will now be presented with three short scenarios describing potential outcomes to Mr. Smith’s circumstances. Each scenario will be followed by several questions concerning your personal opinion about the actions of Mr. Smith’s physician.

Scenario #1

Mr. Smith asks his physician to prescribe medication that can be taken to end his life. The physician agrees to this, and prescribes the lethal medication. Mr. Smith takes the medication and expires shortly thereafter.

1. This is a case of [a physician assisting a patient to die /physician assisted suicide]. Setting aside the question of the legality of such an act, do you think the physician’s actions were ethically justified?

   1 (not at all ethically justified)

   2

   3

   4

   5

   6

   7 (completely ethically justified)

2. Do you think such actions on the part of the physician should be legal under certain well-defined circumstances?

   1 (should not be legal)

   2

   3

   4

   5

   6

   7 (should be legal)

3. Which, if any, of the following statements describes important reason(s) why you think such actions should not be legal.

   Such actions are against my religious beliefs

   Good palliative care should render such actions unnecessary

   Physicians’ participation in killing patients is always wrong

   Suicide is always wrong

   There is a slippery slope in that there would be too many possibilities for abuse if such actions were legal

   Other __________________

4. Which, if any, of the following statements describes important reason(s) why you think such actions should be legal.

   Such actions relieve suffering

   Patients have a right to die as they wish

   Physicians should not abandon their patients even if it means assisting in their death

   Such actions will save money for the health care system

   Such actions are merciful

   Society must accept death as a natural part of life

   Other __________________

Scenario #2

Mr. Smith asks his physician to prescribe medication that can be taken to end his life. The physician agrees to this, and prescribes the lethal medication. Mr. Smith is unable to take the medication by himself, so the physician administers the medication to him, and Mr. Smith expires shortly thereafter.

1. This is a case of [a physician assisting a patient to die / a physician performing voluntary euthanasia on a patient]. Setting aside the question of the legality of such an act, do you think the physician’s actions were ethically justified?

   1 (not at all ethically justified)

   2

   3

   4

   5

   6

   7 (completely ethically justified)

2. Do you think such actions on the part of the physician should be legal under certain well-defined circumstances?

   1 (should not be legal)

   2

   3

   4

   5

   6

   7 (should be legal)

3. Which, if any, of the following statements describes important reason(s) why you think such actions should not be legal.

   Such actions are against my religious beliefs

   Good palliative care should render such actions unnecessary

   Physicians’ participation in killing patients is always wrong

   Suicide is always wrong

   There is a slippery slope in that there would be too many possibilities for abuse if such actions were legal

   Other __________________

4. Which, if any, of the following statements describes important reason(s) why you think such actions should be legal.

   Such actions relieve suffering

   Patients have a right to die as they wish

   Physicians should not abandon their patients even if it means assisting in their death

   Such actions will save money for the health care system

   Such actions are merciful

   Society must accept death as a natural part of life

   Other __________________

Scenario #3

Mr. Smith’s health has deteriorated to the point where he cannot communicate in a meaningful way and is no longer mentally competent. He has a living will which clearly states that if he gets to the point where he can no longer communicate in a meaningful way, he wishes his life to be ended painlessly and quickly with the aid of his physician. Mr. Smith’s health care proxy asks Mr. Smith’s physician to prescribe medication that can be taken to end Mr. Smith’s life. The physician agrees to this, and prescribes the lethal medication. Mr. Smith is unable to take the medication by himself, so the physician administers the medication to him, and Mr. Smith expires shortly thereafter.

1. This is a case of [a physician assisting a patient to die / a physician euthanizing a patient based on the patient’s living will and health care proxy]. Setting aside the question of the legality of such an act, do you think the physician’s actions were ethically justified?

   1 (not at all ethically justified)

   2

   3

   4

   5

   6

   7 (completely ethically justified)

2. Do you think such actions on the part of the physician should be legal under certain well-defined circumstances?

   1 (should not be legal)

   2

   3

   4

   5

   6

   7 (should be legal)

3. Which, if any, of the following statements describes important reason(s) why you think such actions should not be legal.

   Such actions are against my religious beliefs

   Good palliative care should render such actions unnecessary

   Physicians’ participation in killing patients is always wrong

   Suicide is always wrong

   There is a slippery slope in that there would be too many possibilities for abuse if such actions were legal

   Other __________________

4. Which, if any, of the following statements describes important reason(s) why you think such actions should be legal.

   Such actions relieve suffering

   Patients have a right to die as they wish

   Physicians should not abandon their patients even if it means assisting in their death

   Such actions will save money for the health care system

   Such actions are merciful

   Society must accept death as a natural part of life

   Other __________________

Demographic Questions

Please specify your age.

Under 29 years

Between 30 and 50 years

Over 51 years

Please specify your gender.

Male

Female

Other Identity ______________

Please describe your occupation (e.g. Physician, Nurse, Social Worker, Medical Student, etc.). __________________