Achi news desk-
This study reveals new and more detailed information about doctors’ actions when faced with a request for assisted death in a country where euthanasia and PAS are not legal. Doctors have adopted different ways of dealing with a request for assisted death, as they also have different attitudes towards euthanasia and PAS.
In our study, only 13% completely agreed with the statement “We can help a patient in suicide”. In previous studies, willingness to perform euthanasia or PAS among doctors has varied widely from 2 to 16% in Germany, 8% in the United States, and 30% in Italy [30,31,32]. A recent Swedish questionnaire study showed that 33% of respondents were prepared to prescribe the drugs needed to carry out assisted suicide in 2020 [5]. On the other hand, in the Netherlands and Belgium, where assisted death has been legal for decades, 86% and 81% of doctors could imagine circumstances where they could participate in the practice of euthanasia or PAS. [3].
Most participants agreed that euthanasia should only be accepted in difficult physical symptoms in the final stage of disease. Difficult physical symptoms have been one of the reasons for euthanasia or PAS in many countries [30, 31]. Others include for example, loss of function, dependency or loss of independence, deterioration, loss of dignity, and despair [33, 34]. In a study from Oregon, as many as 57% of patients cited loss of independence as a reason for requests for PAS [33]. In our study, only 3% completely agreed with the statement “If euthanasia were legalized in Finland, life becoming an unbearable burden, should also be accepted as a reason for euthanasia”. Men and doctors who had faced these requests fully or partially agreed more often (16% in both groups) with this in our study. The aim of this question was to ask whether the respondent thought that euthanasia with unbearable suffering without unbearable physical symptoms would be an acceptable reason for euthanasia. In many countries ‘unbearable suffering’ is a criterion for euthanasia, but only when it occurs together with disease. The complexity of intolerable suffering is reflected in the ongoing debates about whether euthanasia and assisted suicide should be allowed for psychiatric disorders. In some countries, including Belgium and the Netherlands, it is legal to carry out assisted dying based on psychiatric disorders [30]. A 2020 systematic review showed that articles providing ethical rationales and opinions for or against assisted death based on psychiatric disorders were evenly distributed. [35].
In our study, male and young doctors thought more often that they could assist in suicide, which probably reflects the generally more positive attitude in these groups regarding the practice of PAS and euthanasia. [4, 5, 32]. In addition, if a doctor had faced a request for assisted death, he was more likely to have positive attitudes towards euthanasia and PAS. No previous studies were found to support this finding.
The amount of experience caring for dying patients was associated with less agreement with assisted suicide and with the general opinion that physicians should not assist suicide. In a German study, doctors with special qualifications in palliative care were more reluctant to hasten a patient’s death by euthanasia or PAS. [30], which is in line with our findings. It is also known from previous studies, that doctors with the most experience of end-of-life care and palliative care have been most reluctant to euthanasia and PAS. [36, 37], and this finding is repeated again in this study. The reasons behind this have not been studied in detail. However, it can be argued that knowledge and experience with palliative and end-of-life care can provide more options to care for the patient. It might also be better understood among doctors experienced in dealing with end-of-life issues that a patient’s wish to hasten death does not always imply a genuine wish to die. [38,39,40]. It could be the result of overwhelming physical, psychological, social and existential suffering, all of which affect the patient’s sense of self, dignity and meaning in life. [38,39,40].
This study showed that doctors face the request for assisted death in their daily practice even if it is not legal in Finland. However, the requests were not very common, as only 16% of the participants said they had received a request for euthanasia or assisted suicide. In a Swedish study, half of the doctors who took part in that study had heard their patients express a wish to die, but only a few had requested euthanasia or assisted suicide. [21]. In an older English study, as many as 45% of doctors who responded to a questionnaire said they had been asked about euthanasia [20].
Doctors mentioned various ways of responding to the request and the steps they took in meeting the request for assisted death. There is relatively little research into requests for assisted dying when it is not legal. It is known that the patient’s wish for euthanasia could persist for at least a year despite the refusal of the wish. [41]. In addition, a small qualitative study from the Netherlands found that the wish to die is not abandoned, even though the request has been refused [42]. Based on these results, ongoing discussions and suggestions for practice are needed when these requests are faced in countries where assisted dying is not a legal option or when the request is refused in countries that allow assisted dying. help.
In the qualitative data results of this study, many physicians expressed that information about the possibility of palliative sedation at the end of life could comfort patients who fear suffering at the end of life when assisted death is not a legal possibility. Very little information is available on the relationship between assisted dying and palliative sedation. In a Swiss study, continuous deep sedation was not considered an alternative to assisted suicide, but temporary or intermittent sedation was sometimes administered in response to a request for assisted suicide. [43].
In this study, the request was sometimes also seen as a possibility to improve the care and find the underlying reasons for the death wish. The results also showed that doctors are looking for alternatives to alleviate suffering, including improving symptom control, maintaining hope and a sense of meaning in life, and providing an appropriate place of care and adequate support for the patient. In a Swedish study, some respondents answered that a request for euthanasia could express wishes for symptom relief or wider communication: after speaking, these requests disappear [21].
Ignoring the request was one way of dealing with the request in our study. However, ignoring the request for assisted dying could indicate that the reasons behind the death wish are being ignored [41]. Therefore, it could be stated that refusal without further discussion or support is not the best course of action when meeting the request for assisted death.
Some doctors responded to comply or partially comply with the request, eg describing drugs or recommending contact with a clinic in Switzerland. In Scandinavia, doctors rarely report euthanasia or assisted suicide [21, 44,45,46]. This is understandable, as euthanasia is under the criminal code in all Scandinavian countries.
Some fears about whether someone’s actions hastened the patient’s death were reported in this study. Hastening a patient’s death or the fear of doing so while alleviating severe symptoms or withdrawing treatment, is a much more difficult and ethically challenging question, and is sometimes confused with euthanasia or PAS. [47]. A large international study conducted in 2005 found that there was general approval for symptom relief with potentially life-shortening treatment among physicians. [48]. Similar findings were found in a European study from six different countries, where 57-95% of doctors were willing to intensify the drug therapy to relieve pain and/or other symptoms, even though they considered there was a probability or certainty that this would shorten a patient’s life [49].
Some of the doctors expressed mixed feelings about what would be the right course of action when faced with a request for assisted death. This calls for recommendations or guidelines on how to act in meeting the request. Only a few recommendations have been published where practical guidelines are provided on how to respond to the request for assisted death and some of them apply to countries where assisted death can only be practised. [50,51,52]. The most important recommendation for healthcare professionals in these articles is to try to understand the meaning behind the request and to be able to face the difficult emotions that the request provokes in the patient and in the professionals. [50,51,52].
Strengths and limitations
The study population is a large and representative sample of Finnish doctors [53], although the response rate is rather low, and a possible tendency of non-response must be considered. The sampling, data collection and analysis process was reported in detail, which increases the reliability of the study. The sample included doctors from different backgrounds, such as different specialties and experiences. Therefore, it can be assumed that the study population provides a large and versatile view of doctors’ attitudes towards assisted death and how they act when faced with a request for assisted death. Furthermore, reliability was strengthened by presenting the figure of all the categories (Fig. 1), and validity was strengthened by providing authentic extracts from the data. It should also be noted that the researchers constantly discussed the analysis throughout the study. The confirmation was strengthened by focusing on the obvious content during the analysis when it can be assumed that the results would represent the opinions of the doctors. [28].
There are also a number of limitations in this study. Non-response bias may have affected the results, but the number of respondents was, however, substantial. Furthermore, there was no possibility to return the qualitative findings to the doctors for comments or corrections [24]. The questionnaire used in this study is the same as that used in a series of surveys and in order to maintain comparability, the questions and statements were similar to the previous ones. [4]. There are clear differences in the ethical and practical issues between euthanasia and PAS, but in the open-ended question and some other parts of our results, these two methods of assisted death were combined. This should be taken into account when interpreting our results. However, the application for assisted death can be submitted without a specific definition of PAS or euthanasia and both are not legalized in Finland. Therefore, we believe that the answers of the respondents reflect the general opinion of the Finnish doctors regarding assisted death and experiences when faced with the request for this.
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