EUTHANASIA: AMERICAN ATTITUDES TOWARD THE … · Euthanasia: American attitudes toward the...

Pergarnon Sm. Sri. Med. Vol. 40, No. 12, pp. 1671-1681, 1995

Copyright Q 1995 Elsevier Science Ltd Printed in Great Britain. All tights reserved

0277-9536195 $9.50+0.00

EUTHANASIA: AMERICAN ATTITUDES TOWARD THE PHYSICIAN’S ROLE

DAVID P. CADDELL’, and RAE R. NEWTON’ Department of Sociology, Seattle Pacific University, Seattle, WA 98 I 19, U.S.A. and 2Department of Sociology, California State University, Fullerton, CA 92634, U.S.A.

Abstract-This is a study of American public opinion toward euthanasia and the physician’s role in performing it. The authors examine how these attributes are affected by religious affiliation, religious self-perception, political self-perception and education. The data include 8384 American respondents from years 1977, 1978, 1982, 1985 and 1988 of the General Social Survey conducted by the National Opinion Research Center. The findings suggest that highly educated, politically liberal respondents with a less religious self-perception are most likely to accept active euthanasia or suicide in the case of a terminally ill patient. The data also show that Americans tend to draw a distinction between the suicide of a terminally ill patient and active euthanasia under the care of a physician, preferring to have the physician perform this role in the dying process. The tendency to see a distinction between active euthanasia and suicide was clearly affected by religious affiliation and education.

Key words--euthanasia, death and dying, professional codes of ethics

INTRODUCTION THE SOCIAL CONTEXT OF EUTHANASIA

Historically, medicine and other spheres of social life have been closely related. In preliterate cultures, the holy person and healer were often one and the same [ 11. Technology, however, has largely differentiated the task of healing into its own separate sphere. This distinction raises many questions regarding the relationship between religious beliefs, political ideol- ogy and education and modern medical issues. One such issue is the question of merciful care for terminally ill patients experiencing severe pain during their last days. This study examines the relationship between these spheres of social life and attitudes of Americans toward the role of the physician in performing euthanasia at the request of the terminally ill.

Perhaps the most familiar name in the current euthanasia debate is Dr Jack Kavorkian. He has assisted several terminally ill patients to commit suicide using an apparatus he designed to allow them to die painlessly. After one incident, murder charges were filed [lo] and subsequently dropped [ 1 l] because there were no clear legal guidelines regarding euthanasia. Kavorkian’s license to practice medicine in Michigan was suspended after he assisted in the deaths of two more patients, violating a court injunction against the use of his apparatus [12]. After several more cases involving Kavorkian, the Michigan legislature passed a law making assisted suicide a felony.

Issues concerning the sanctity of life have been the subject of much recent debate in the United States, especially as it relates to abortion [2-61. With few exceptions [7, 81 euthanasia has not been included in much of the discussion within the social sciences. Despite the fact that abortion has dominated social science research concerning health and life issues, euthanasia and assisted suicide have become more pervasive in public discourse. There is no reason why the debate regarding euthanasia should be considered any less important [9] or social research in this area any less fruitful. Problems originating from the use of life-sustaining technology and the lack of consistent social policy regarding the treatment of the terminally ill highlight the importance of academic research which examines the relationship between medical science and other social spheres.

The United States legal system has experienced similar difficulties in deciding other cases like Kavorkian’s [ 131. California physicians Robert Nedjl and Neil Barber faced murder charges for disconnect- ing a ventilator and intravenous fluids. All charges were dismissed in a court of appeals. Michigan doctor Donald Caraccio pled guilty to euthanizing a terminal patient and received a sentence of five years probation. California physician Richard Schaeffer was arrested after euthanizing a patient by lethal injection. No charges were ever filed. In the context of such inconsistent legal definitions, it is clear that physicians receive little guidance from the law regarding these types of cases.

ACTIVE VERSUS PASSIVE EUTHANASIA

The legal system currently recognizes what many perceive to be an important distinction between types

1671

1672 David P. Caddell and Rae R. Newton

of euthanasia. The most common distinction is that which differentiates between active (intentional killing) and passive (letting die) forms of euthanasia. In the case of active euthanasia, a specific action is taken to kill the patient, such as an injection of a lethal dose of morphine or some other drug. Passive euthanasia, which appears to be more acceptable to Western society, involves the withholding of treatment which would prolong the patient’s life.

This issue touches medicine at its very moral center; if this moral center collapses, if physicians become killers or are even merely licensed to kill, the profession-and therewith, each physician-will never again be worthy of trust and respect as healer and comforter and protector of life in all its frailty. For if medicine’s power over life may be used equally to heal or to kill, the doctor is no more a moral professional but rather a morally neutral technician (p. 27).

Many authors [14-191 have engaged in the debate concerning whether there is any real ‘moral difference’ between active and passive euthanasia. On one side of this debate Rachels [l&18] states that there is no moral difference between the intentional killing of a patient and intentionally letting them die. According to this perspective, the decision to intentionally hasten a patient’s death is the crucial factor, and not the method used to do so. Therefore, these authors assert that once the decision has been made to hasten the patient’s death, the morally correct action is that which eases the patient from life to death in the most merciful way possible. In many cases, this would include an active form of euthanasia.

These authors suggest that even if public opinion favors legalizing euthanasia of any kind, someone else besides physicians should be charged with carrying it out. This study examines whether or not Americans maintain a moral distinction between suicide (in the case of terminal illness) without the help of a physician and active euthanasia in which a physician takes part in assisting a terminal patient to die.

Research concerning public attitudes toward the physician’s role in euthanasia is important because doctors currently have very little consistent social policy from which to obtain guidance on this issue. Even the various ethical statements which guide physicians are somewhat ambiguous. In the Hippo- cratic tradition, doctors are forbidden to take part in intentionally killing a patient. As is stated in the Hippocratic Oath:

DEFINING EUTHANASIA

Euthanasia is likely to receive different definitions and invoke diverse mental images among different individuals. For the purposes of this research, we define active euthanasia as any treatment initiated by a physician with the intent of hastening the death of another human being who is terminally ill and in severe pain or distress with the motive of relieving that person from great suffering. This definition avoids value laden definitions which equate euthanasia with murder or tie the definition to a particular political or religious position. We define suicide as the terminal patient taking steps to end their own life independent of a physician’s assistance for the purposes of shortening their suffering. Differentiating between suicide and active euthanasia in this way allows examination of attitudes toward the physician’s role in euthanasia, not simply attitudes toward the act itself.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. In purity and holiness I will guard my life and my art.

In contrast, the code of professional ethics espoused by the American Medical Association does not directly forbid an act of euthanasia on moral grounds, but encourages the physician to remain within the law while treating the patient with compassion and dignity. It is not difficult to imagine the moral dilemmas dealt with by physicians when faced with the choice between vague directives in the law, professional ethics and the wishes of a suffering terminal patient and his or her family. The euthanasia debate rests on the question concerning the ability of medical technology to bar the passage to death and what the members of a society believe should be the doctor’s role in allowing (or assisting) the dying patient to make that passage.

ANOTHER DISTINCTION: ACTIVE EUTHANASIA VERSUS THEORETICAL ORIENTATION SUICIDE

Another distinction concerns whose role active euthanasia would become should it be legalized. This study is designed to investigate whether or not Americans accept euthanasia in the abstract, or if they draw a moral distinction based upon the presence or absence of a physician. Is the act of terminating a terminally ill patient’s life more acceptable if performed by a physician rather than allowing the patient to resort to suicide? Many authors [20] maintain that expecting physicians to participate in legalized active euthanasia would destroy the role of physician in society. As Gaylin ef al. [20] state:

We approach the question from the perspective of symbolic interactionism [21-241, which asserts that people adopt symbolic meanings from groups which they identify with psychologically (reference groups) in addition to the attitudes of significant others, and their own self-perceptions. We contend that the attitudes of individuals toward medical care and euthanasia are affected by the membership of various reference groups (including religious, professional and political), the strength of their association with those reference groups, and the degree to which their own self-perception is derived from those groups.

Euthanasia: American attitudes toward the physician’s role 1673

Religious groups differ in the symbols they utilize and the meanings they attach to symbols/situations they encounter. The same is true regarding symbols used in interpreting the role of physicians in the dying process. An individual’s perception of death and their own role (or lack of one) in managing it is likely to be influenced by the sacred explanations espoused by their own religious orientation. There are, however, many questions regarding what meanings various American religious traditions actually transmit to their members.

The Judeo-Christian tradition and euthanasia

The dominant religious ethos in the United States concerning issues of life stems from the Judeo-Chris- tian tradition [25]. With few exceptions (such as Christian Science), groups originating from this tradition tend to believe that it is consistent with their faith to allow physicians to play an extensive role in their lives. However, the traditional Christological perspective does not allow for physicians to play a large role in managing the dying process. The argument that God should decide who lives and who dies is paramount from this perspective. The idea that the physician who engages in the practice of euthanasia is ‘playing God’ encourages the physician (or anyone else) to stay out of the dying process. This common argument also promotes the attitude that human beings, especially physicians, are not to be the stewards over death, and thus makes euthanasia an unacceptable alternative.

AjZiation. Religious groups originating from the Judeo-Christian tradition tend to have varied stances on many moral issues [26, 271. Using a symbolic interactionist perspective, we examined the role of religious group membership in determining one’s definition of the role of physicians in the dying process. We suggest that some religious groups, such as mainline Protestants, tend to face the issue with a perspective which emphasizes the role of human beings as god’s agents in reducing suffering. Conversely, conservative religious groups tend to promote an approach which defines the dying process as ‘God’s dominion.’

Previous research [28, 81 has found that membership in various religious groups has strong effects on attitudes toward many social, political and moral issues [27-30, 81. Likewise, Protestants have been found to hold different attitudes concerning active euthanasia than Catholics [8,28]. In a sample of Protestant and Catholic clergy, Nagi et al. (281 found great differences in opinion between Protestants and Catholics. Among Protestant clergy, 39% accepted active euthanasia as a viable option, as opposed to 7% of the Catholic clergy.

In a study of health care professionals in the field of oncology, Anderson and Caddell [8] found that Protestants tended to favor active euthanasia more often than Catholics. These findings are logical

considering the official stance regarding euthanasia taken by the Catholic Church, but the effects of religion still need to be viewed in the context of public attitudes toward euthanasia.

In its Guidelines for Legislation on Life-Sustaining Treatment [31], the National Conference of Catholic Bishops of the United States of America set out to “reaffirm public policies against homicide and assisted suicide.” They went on to state that:

Medical treatment legislation may clarify procedures for discontinuing treatment which only secures a precarious and burdensome prolongation of life for the terminally ill patient, but should not condone or authorize any deliberate act or omission designed to cause a patient’s death.

These guidelines set forth by American Catholic bishops support the teachings of the Second Vatican Council, which stated that euthanasia “is opposed to life itself’ and “violates the integrity of the human person” [32, 331. Thus, while there is thought to be no moral obligation to continue useless treatment for a hopelessly ill patient, the Catholic view considers active euthanasia as “morally identical with either suicide or murder” [34].

Historically, the major faiths in the United States have held to a common morality which lasted into the 1960s when pluralism began to increase [27]. Ethically speaking, since the 1960s there has emerged a gap between conservative and liberal Protestants. Liberal Protestantism tends to maintain a ‘this worldly’ perspective on social issues. Thus, liberal Protestants focus on social action to relieve human suffering in this life rather than a distinct focus on the afterlife. Because of this focus, we expect that voluntary euthanasia fits within the normative system of a greater number of liberal Protestants.

Conservative Protestants have tended to focus on ‘other worldly’ concerns related to moral absolutes. As was stated by Baptist minister Jerry Falwell.

We desperately need a genuine revival of spiritual righteousness in our land. America needs the healing touch of God because of her sins. Legakedabortion hasclaimed the lives of I5 million babies since the 1973 Supreme Court decision Infanticide and euthanasia are threatening both our children and our aged America is in trouble and only God can save her [35].

While the above issues are indeed social and not strictly theological, they are continuously related to ‘other worldly’ concerns such as the state of the nation in the eyes of God. This illustrates that not only do conservative Protestants disagree with liberal Protes- tants on many ethical issues, they also disagree on what the important issues are. Conservatives focus their ethical stances on fulfilling absolute moral principles, while liberal Protestants tend to focus on ethical issues in reducing human suffering in the present life. Based on the different ethical perspectives between various religious groups, we expect that:

Hl: Liberal Protestants, Jews, and those with no religious affiliation are likely to find both

David P. Caddell and Rae R. Newton 1674

H2:

suicide and active euthanasia more acceptable than conservative Protestants or Catholics. Catholics and Conservative Protestants will tend to classify suicide and active euthanasia as ‘morally identical’ and are likely to recognize a lesser distinction between them.

Religious self-perception. Because of the degree of opposition in the history of the Judeo-Christian tradition, one would expect to find little acceptance of suicide and active euthanasia among those with a high degree of religious commitment within the religious groups stemming from that tradition. Previous pilot studies have found this to be the case [36,8]. Among both Protestants and Catholics, people with higher levels of religious commitment tended to accept euthanasia to a lesser degree than those with lesser religious commitment.

We expect this to be supported by our study as well. Those with stronger religious self-perceptions are more likely to adhere to an ‘other-worldly’ perspective which defines death as God’s business in which people should not interfere. Those with self-perceptions which are less religious would tend to define death as a human problem to be managed by people. Therefore, we hypothesize:

H3:

H4:

Respondents who perceive themselves as having strong religious commitment will find both suicide and active euthanasia less acceptable than those who perceive themselves as less religious. Because they will be opposed to both suicide and euthanasia, those who perceive themselves as having strong religious commitment will view less of a difference between suicide and euthanasia than those who perceive themselves to have weaker religious commitment.

Political self-perception. Like religious conservatives, political conservatives in the United States tend to resist rapid change in social policy. While they tend to possess a strong preference for individual liberty, they are also willing to limit this liberty to preserve “traditional values” [37]. We suggest that conservative reverence for traditional views is consistent with an anti-euthanasia and anti-suicide position.

Americans identifying themselves as politically liberal tend to favor social change because they have greater faith in human reason to manage human affairs [37]. This is markedly different from political conservatives and will lead to a greater confidence in the role of human beings to manage their own ‘end of life’ decisions.

H5: Those who perceive themselves as politically liberal will be more accepting of suicide and active euthanasia than those who perceive themselves as conservative.

H6: Because they are likely to find both equally objectionable, a lesser distinction between suicide and active euthanasia will be found among those who believe themselves to be politically conservative rather than liberal.

Education. Educational level has been found in previous research [7] to affect acceptance of euthanasia, and we expect it to have an important impact on attitudes toward the physician’s role in this process. From a symbolic interactionist perspective, education affects how patients perceive themselves. This self-perception impacts how patients view their physician and the assessment made by patients regarding the physician’s role in their health care.

Highly educated patients are likely to better understand medical directives, and thus, have a more complete grasp of health-care information. This understanding and the recognition of it by the physician is likely to increase the patient’s preference for autonomy (especially in terminal cases) by strengthening the patient’s estimation of their own capacity to make some decisions without deference to a physician. To highly educated patients, the physician appears less ‘god-like,’ not always able to be the healer. This will result in making the choices of suicide and active euthanasia more equally acceptable options in the estimation of people with higher levels of education.

A rival hypothesis could state that highly educated people are more likely to see a distinction between suicide and active euthanasia because education sharpens one’s ability (or tendency) to make such distinctions. While education may result in a greater awareness of the philosophical differences between suicide and active-euthanasia, this awareness will not necessarily translate into a distinction when discussing the acceptability of these options if the patient perceives they have the autonomy to choose either.

The lack of a distinction in the acceptability between suicide performed by the individual and active euthanasia performed by a physician among the highly educated stems from the expectations shared by the physician and educated patient. Like Freidson [38], we suggest that a highly educated patient shares more of the physician’s culture than the less educated patient, resulting in similar expectations in doctor-patient interactions regarding diagnosis and treatment. In many cases, this results in greater cooperation among educated patients, which may explain why upper class patients (usually with higher levels of education) are also more likely to be viewed in a positive manner by physicians [39,40]. The less educated patient is more likely to be unaware of possible options or to expect treatments not indicated by the doctor’s training [38]. Because the educated patient receives a greater degree of affirmation of his own diagnosis and treatment expectations, greater confidence in his own ability to reason through various options is the result. As Freidson [38] states, “the patient may be educated in


health affairs so as to be more in agreement with the doctor, but education also equips him to be more self-confident in evaluating the doctor’s work and seeking to control it.” This is supported by Haug and Levin [41,42] who found that more highly educated people tend to desire more information from physicians and desire more involvement in the decision-making within the physician-patient relationship. It is logical to hypothesize that while highly educated people may be more cooperative with physicians during the treatment process, they are more likely to assert their own autonomy. This is especially true when the treatment is perceived by patient and physician as futile, with all decisions unlikely to avoid the patient’s death. We suggest that in these situations, highly educated people are more likely to view a personal solution (suicide) as equally acceptable as a solution in which the doctor participates, Thus, we hypothesize:

H7: Acceptance of active-euthanasia and suicide will increase as education increases, but the tendency to hold a distinction between the acceptability of them will decrease as education increases.

THE DATA

The data used in this study consists of 8384 respondents to the General Social Surveys (National Opinion Research Center) from years 1977 (n = 1418), 1978 (n= 1433), 1982 (n= 1704), 1983 (n= 1476), 1985 (n= 1449) and 1988 (n =904). These surveys were chosen because they included questions regarding passive and active euthanasia for the terminally ill. The data included 548 liberal Protestants (6.5%), 1555 moderate Protestants (lS.S%), 1770 conservative Protestants (21.1 X), 2112 Catholics (25.2%), 177 Jews (2.1%) and 628 with no religious affiliation (7.5%). Ages of respondents ranged from 18 to 89, with a mean age of 44.8 years (SD= 17.8). The sex ratio was 44% male (n= 3685) to 56% female (n=4699).

THE DEPENDENT VARIABLES

Two dependent variables were used in this study: acceptance of active euthanasia and acceptance of suicide in the case of terminal illness.

Acceptance of active euthanasia

The respondents acceptance of active euthanasia was measured by a question (LETDIE 1) asking ‘When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his family request it? Response categories for this item were ‘unacceptable’ (coded 0) and ‘acceptable’ (coded 1).

Acceptance of suicide

Attitudes toward suicide were measured by a question (SUICIDEl) asking ‘Do you think a person has the right to end his or her own life if this person has an incurable disease?’ Response categories for this item were ‘unacceptable’ (coded 0) and ‘acceptable’ (coded 1).

THE INDEPENDENT VARIABLES

The following were used as independent variables in this study: survey year; religious affiliation; religious self-perception; education; and political self- perception.

Survey year

To control for potential changes in attitudes over time, General Social Survey data from years 1977, 1978, 1982, 1983, 1985 and 1988 were used. These years were chosen because the questions measuring attitudes toward euthanasia were included in these surveys and they reflect a ten year change in opinion.

Religious afiliation

Religious affiliation was measured using the following categories: Catholic; liberal Protestant (Presbyterian and Episcopalian); moderate Protestant [American Baptist Church (U.S.), Methodist and Lutheran]; conservative Protestant (American Baptist Association, Southern Baptist Convention and other Baptists); Jewish; Other; and None. For use in discriminant function analysis, each of these categories was dummy coded and entered as distinct independent variables.

Religious self-perception

The General Social Survey measure of strength of religious association (RELITEN) is an indicator of self-perception of one’s association with a denomina- tion. Respondents were asked, ‘Would you call yourself a strong (preference) or a not very strong (preference)? Response categories included: strong; not very strong; somewhat strong; and don’t know.

Education

Level of education was measured by a question (DEGREE) asking ‘Do you have any college degrees? What degree or degrees?. The response categories included: less than high school; high school; associate/junior college; bachelors degree; and graduate degree.

DATA ANALYSIS

We began by examining the bivariate relationships among all the independent variables and attitudes toward active euthanasia and suicide by breaking down the level of acceptance of each among respondents in each religious, political and educational category. To examine how great a distinction


Table 1. Agreement and disagreement with active euthanasia and suicide

Independent variables Agree active Agree suicide N

Total sample

Year 1911 1978 1982 1983 1988 Religious a@iliation Liberal Protestants Moderate Protestants Conservative Protestants Catholics Jews No preference Religious self-perception Not very strong Somewhat strong Strong

Education Less than high school High school Junior college Bachelor’s degree Graduate degree

Political self-perception Extremely Liberal Liberal Slightly Liberal Moderate Slightly Conservative Conservative

62.8 44.9 8384

62.4 39.7 1418 59.6 40.3 1433 51.7 43.1 1704 65.9 50.5 1416 68.7 52.9 904

13.2 59.1 548 66.4 44.8 1555 54.1 33.2 1770 63.1 42.7 2112 81.4 80.2 177 82.8 78.3 628

73.5 42.1 3648 60.8 54.5 641 41.1 27.4 3196

52.8 31.2 2430 66.0 46.6 4318 72.2 56.9 299 68.3 61.0 900 70.5 63.6 420

61.3 54.9 173 69.0 53.9 807 65.5 50.1 1070 66.0 43.9 2826 62.1 44.4 1224 57.0 36.8 989

Extremely Conservative 52.4 32.7 208

respondents hold between suicide and active euthanasia, paired t-tests were calculated comparing mean acceptance of active euthanasia and suicide among the respondents in each category. Discriminant function analysis was then used to determine which variables were helpful in differentiating between these attitudes. Discriminant function analysis was chosen because both dependent variables were dichotomous

and estimates of the contributions of each discriminating variable was desired [43,44].

RESULTS

Agreement with euthanasia/suicide

Table 1 presents the breakdowns of agreement with euthanasia by the various categories within the discriminant variables. Overall, 62.8% of the respondents found active euthanasia acceptable, while 44.9% believed an individual should have legal right to commit suicide in the case of terminal illness. This difference suggests that many respondents do maintain a moral distinction between cases when a physician plays a role in the process. A majority of the respondents found the ending of a terminally ill patient’s life more acceptable when the physician is an active participant.

Acceptability of active euthanasia decreased between 1977 (62.4%) and 1982 (57.7%) before increasing in the middle-late 1980s. By 1988,68.7% of the respondents believed it was acceptable for a physician to participate in ending a life if the terminal patient or their family requested it. While the percentage of Americans accepting suicide is smaller, a similar pattern exists. Between 1977 and 1988 the proportion accepting suicide increased from 39.7 to 52.9%.

Acceptance of active euthanasia and suicide varied by religious affiliation as we hypothesized. Among Protestants, liberal adherents showed the greatest acceptance of both active euthanasia (73.2% agreement) and suicide (59.1% agreement). Conserva- tive Protestants were least accepting of either option, with 54.1% agreeing with active euthanasia and 33.2% finding suicide acceptable. Catholics were less accepting of active euthanasia (63.1% agreement) and

Table 2. Differences in acceptance of active euthanasia and suicide

Group Mean active Mean suicide Difference t P

Religious afiliation Liberal Protestants 0.73 0.59 0.14 6.24 <O.OOl Moderate Protestants 0.66 0.45 0.21 16.21 <O.OOl Conservative Protestants 0.54 0.33 0.21 17.35 <O.OOl Catholic 0.63 0.43 0.20 18.32 <O.OOl Jew 0.81 0.80 0.01 0.34 0.733 Religious self-perception Somewhat strong 0.61 0.42 0.19 9.10 <0.0001 Not strong very 0.73 0.54 0.19 22.14 <O.OOOl Strong 0.47 0.27 0.20 22.30 <O.OOOl Political self-perception Liberal and extremely Liberal 0.68 0.54 0.14 9.45 <O.OOOl Slightly Liberal 0.66 0.51 0.15 9.57 co.oOO1 Moderate 0.66 0.51 0.15 9.57 <0.0001 Slightly Conservative 0.62 0.44 0.17 12.51 < 0.0001 Conservative and

extremely Conservative 0.56 0.36 0.20 13.65 <O.OOOl Education High school 0.53 0.32 0.21 20.72 <0.0001 High school graduate 0.66 0.47 0.19 25.04 <0.0001 Junior college 0.72 0.57 0.16 5.54 <O.OOOl College degree 0.68 0.61 0.07 4.94 <O.OOOl Graduate dearec 0.70 0.63 0.06 2.85 0.005

Euthanasia: American attitudes toward the physician’s role

suicide (42.7% agreement) than liberal Protestants, but more accepting of both than conservative Protestants.

Jewish adherents and those with no religious affiliation were most accepting of euthanasia. Among Jews, 81.4% agreed with active euthanasia and 80.2% agreed with suicide. Among those with no religious preference, 82.8% agreed with active euthanasia and 78.3% found suicide acceptable.

As hypothesized, acceptance of both forms of euthanasia decreased as religious self-perception increased, with those perceiving themselves as having strong religious attachments being the least likely to accept active euthanasia (47.1%) and suicide (27.4%).

There was also a linear relationship between political self-perception and attitudes toward euthanasia. Acceptance of both suicide and active euthanasia was greater among those who viewed themselves as liberal than among those who considered themselves conservative.

As expected, acceptance of active euthanasia and suicide increased as education increased. Among those with less than a high school education, 52.8% agreed with active euthanasia and 3 1.2% agreed with suicide. Those with graduate degrees were most accepting of both active euthanasia (70.5%) and suicide (63.6%).

All but one of the religious groups in our sample maintained a distinction between suicide and active euthanasia (Table 2). Among Protestant and Catholic respondents, liberal Protestants saw the smallest distinction (t = 6.24, P < 0.001) while moderate Protestants (t= 16.21, P < O.OOOl), conservative Protestants (t= 17.35, P-c O.OOOl), and Catholics (t=18.32, P<O.OOOl) tended to see a greater distinction. This does not support our hypothesis that conservative Protestants and Catholics would find both options equally objectionable and maintain virtually no symbolic distinction between suicide and active euthanasia. They were, however, joined by moderate Protestants, who held a similar distinction (t = 16.2 1, P < 0.001). Among the Jewish respondents, there was virtually no difference between the acceptability of either active euthanasia or suicide (2=0.34, P=O.733).

Contrary to our hypothesis, those who perceived themselves as having strong religious commitment did not see less of a distinction between active euthanasia and suicide. While those with lesser religious commitment accepted both active euthanasia and suicide more often, the difference in acceptability between them was virtually the same across all categories of religious self-perception.

The findings regarding the impact of political self-perception on the tendency to see a difference between active euthanasia and suicide did not support our hypothesis. Respondents who perceived themselves as politically liberal tended to accept both active euthanasia and suicide more often, but political self-perception had no discernable impact on the likelihood of seeing a distinction between them.


Table 4. Discriminant function analysis results for active euthanasia and suicide

Agreement with active euthanasia Agreement with suicide Correlation Correlation

Variable with function F Sig. F with function F Sig. F

Relative self-perception -0.90 628.00 <O.OOOl -0.78 875.80 <0.0001 No religious affiliation 0.43 146.30 <O.OOol 0.54 423.50 <o.o001 Conservative Protestant -0.27 56.51 <O.OOOl 0.54 423.50 <O.OOOl Education 0.24 45.09 <O.OOOl 0.44 277.90 <O.OOOl Political self-perception -0.22 37.89 <O.OOOl -0.22 72.53 0.2589 Jewish 0.16 20.97 co.0001 0.23 75.28 <O.oOOl Liberal Protestant 0.16 20.42 <0.0001 0.18 47.24 to.0001 Moderate Protestant 0.10 7.21 0.0073 -0.00 0.03 0.8592 Catholic -0.02 0.48 0.4860 -0.07 7.91 0.0048 Other religious affiliation 0.01 0.07 0.7861 0.04 2.30 0. I294 Year 0.14 16.18 0.0001 0.17 41.75 <O.OOOl

Canonical correlation 0.31 0.41 Eigenvalue 0.11 0.20 x’ 732.33 1320.11

(Pt0.0001) (P<0.0001)

As hypothesized, education had a distinct impact on the degree of difference our sample saw between active euthanasia and suicide. Among those with less than a high school education, the difference in the mean acceptability of active euthanasia and that of suicide was 0.21 (r=20.72, P<O.OOOl). This difference decreased as education increased, with those who have completed a graduate degree showing a difference of 0.06 (t=2.85, P=O.O05).

DISCRIMINANT FUNCTION ANALYSES

The means, standard deviations and zero-order correlations among the variables used in the discriminant function analyses are presented in Table 3. Table 4 shows the univariate F-ratios and the structure matrix of correlations between the discriminating variables and each canonical discriminant function. The canonical correlation of 0.31 (x*=732.33, P<O.OOOl) indicates that the discriminating variables are useful in differentiating between those who find active euthanasia acceptable and those who do not. The canonical correlation of 0.41 (x*=1320.11, P<O.OOOl) suggests the same for the variables in differentiating between those who do and do not accept suicide in the case of terminal illness.

Among the variables in the analyses, religious self-perception was the strongest predictor of attitudes toward active euthanasia (r = - 0.90, f= 628.00, P<O.OOOl) and suicide (r= -0.78, f=875.80, P<O.OOOl). These suggest that those who perceive themselves as having a strong attachment to their religious group tend to have a generally negative interpretation of euthanasia/suicide. Not only do they tend to disagree with allowing the terminally ill patient to take steps to end their life, they also find it unacceptable to allow a physician to assist in the dying process even if one’s motive is to shorten the suffering of the patient.

Religious affiliation was also an important predictor. When viewed in conjunction with the previous finding, it is not surprising that respondents

with no religious affiliation tended to be more supportive of active euthanasia (r = 0.43) and suicide (r = 0.54). Likewise, Jewish and liberal Protestants were more likely to accept both forms of euthanasia, while conservative Protestants were likely to reject them.

Education was also related to acceptance of euthanasia and suicide, particularly suicide (r = 0.44). This lends support to our hypothesis that more highly educated respondents will tend to support allowing a terminally ill patient to end their own life.

Finally, the discriminant function analysis was used to predict the attitudes of respondents toward active euthanasia and suicide using religious affiliation, religious self-perception, political self-perception and education as predictors (Table 5). Because the dependent variables were dichotomous (unacceptable or acceptable), chance would dictate that 50% of the respondents would be classified correctly. If the independent variables are successful in discriminating between those who accept active euthanasia or suicide and those who do not, the percentage of cases correctly classified should improve. Using our four predictors, approx. 68% of the cases were classified correctly for both active euthanasia and suicide, suggesting that this

Table 5. Classification results

Actual attitude Predicted attitude

N Unacceotable Acceotable

Suicide Unacceptable 2484 1015

40.9% Acceptable 4185 778

18.6% Ungrouped cases 699 162

23.2%

Percent correctly classified: 68.16 Actiw uuthattsia Unacceptable

Acceptable

Ungrouped

2524 1029 40.8%

4586 806 17.6%

699 189 27.0%

Percent correctlv classified: 67.64

1469 59. I %

81.4% 537

76.8%

1495 59.2% 3780

82.4% 510

73.0%


model is useful in assisting us to predict respondent’s attitudes.

Desirability of the physician’s role

SUMMARY AND CONCLUSIONS

Over 62% of our sample found active euthanasia acceptable. This confirms previous research regarding American public opinion. Meanwhile, 44.9% of our respondents found suicide an acceptable alternative for a terminally ill patient. The difference in acceptability between the two suggests that a substantial percentage of Americans draw a distinction between death inflicted by oneself and cases when a physician participates. When discussing the possibility of euthanasia performed by a physician or suicide, Americans favor the participation of a physician.

The profile of those who tend to accept active euthanasia is quite similar to the profile of those who find suicide acceptable. Above all, individuals who perceive themselves as not having strong religious attachments tend to accept suicide and active euthanasia. In addition to a less religious self-perception, those who accept active euthanasia and suicide tend to be highly educated and claim no religious affiliation. Among those who do claim to be affiliated with a religious group, they tend to be Jewish or members of Liberal Protestant denominations.

The greater acceptability of active euthanasia suggest that many Americans would prefer that a physician play a role in the dying process for a terminally ill patient who requests assistance in dying rather than resorting to suicide. When examining the progression of the physician’s role in American society, it is not surprising that many Americans prefer the physician to play a part in euthanasia rather than resort to suicide in the case of terminal illness. Americans have traditionally held physicians in high esteem, viewing them as more than someone to help them when they are ill. The number and types of conditions now considered to be of medical concern illustrates the expansion of the role of the physician. Substance abusers are now labeled as ‘sick’ rather than as ‘morally deficient.’ Physicians now involve themselves in conditions that historically were not labeled as medical abnormalities from baldness to wrinkles, from small breasts to antisocial behavior [52]. It is conceivable that American attitudes could continue to shift in favor of expanding the physician’s role once again to include assistance in the dying process.

The importance of religion

The importance of religion in determining Ameri- can attitudes toward euthanasia and suicide is not surprising. Although the United States has secularized many of its public institutions, Americans do not appear to be secularizing to a great extent [45]. Overall, Americans consider themselves to be very religious and often view the world through a religious lens. A substantial proportion of Americans believe in a ‘God,’ attend religious services at least once per month, and pray on a regular basis [46].

The distinction between active euthanasia and suicide is clearly affected by affiliation with a religious reference group and education. Contrary to our hypothesis, Catholics and Conservative Protestants did not view active euthanasia and suicide as equally unacceptable. Americans claiming affiliation with both these groups saw the largest distinction between suicide and active euthanasia found among any of the groups in this study. In both groups, greater acceptability was found for a death in which the physician participates.

Changes in American religion are likely to affect the euthanasia debate in the United States. American religion (and politics) has been undergoing a ‘restructuring’ process in which the religious landscape has become increasingly polarized into ‘conservative’ and ‘liberal’ camps [47]. Conservative religious groups have been successful in recruiting and retaining members, resulting in much growth. Meanwhile, liberal religious groups have experienced marked decline [48-5 11.

Our hypotheses regarding political self-perception were actually more accurate when applied to religious affiliation. Our findings support the idea that Americans claiming to be liberal Protestants seem to possess more confidence in an individual’s capacity to make decisions when considering end of life issues. Not only did 73% of liberal Protestants accept euthanasia when performed by a physician, but almost 60% accepted individual suicide without the aid of a physician. This was surpassed only by Jewish respondents, who saw virtually no distinction in the acceptability of either suicide or active euthanasia. In contrast, a majority ofconservative Protestants (54%) and Catholics (63%) accepted active euthanasia when performed by a physician, but possessed less faith in the individual desiring to commit suicide without the aid of a doctor.

An important question for future research concerns Perhaps the clearest relationship is that between the impact of these religious trends on the outcome of education and the tendency to see a distinction the euthanasia debate. In states where initiatives have between the acceptability ofactive euthanasia and that been placed on the ballot for a vote, conservative of suicide. As education increased, the tendency to see religious and political groups have maintained a vocal a difference in the acceptability between the two clearly opposition. In each election, propositions to legalize diminished. This lends support to our hypothesis that some form of active euthanasia have been defeated. education increases an individual’s willingness to


consider suicide as well as active euthanasia assisted by a physician. This demonstrates the plausibility of the explanation that education increases the value a patient places on autonomy by increasing their ability to understand and reason through various options once they are explained by a physician. Thus, the physician is viewed with less intimidation in considering the moral option the patient finds most acceptable. When the physician is less intimidating in the eyes of the patient, active euthanasia is perceived as a viable option to the terminally ill patient, but individual suicide performed by the patient rather than physician is often viewed in a similar fashion.

As the movement to bring social science into American medical schools [38] illustrates, continued inquiry into patient characteristics may be a valuable contribution in assisting physicians and other health care professionals in defining their role in interaction with patients, especially those nearing the end of their lives. It should prove useful for subsequent research to continue examining factors in the physician-patient relationship which may affect the perception of the physician’s role in the eyes of the patient.

Acknowledgements-The authors are grateful to Larry Hall, Norma Baker, Marty Bell, and anonymous reviewers for their helpful comments on earlier drafts of this paper.

REFERENCES

1. Nelson J. B. and Rohricht J. A. S. Caring for human health. In Human Medicine: Ethical Perspectives on Today’s Medical Issues. Augsburg Publishing House, 1984.

2. Harris R. J. and Mills E. W. Religion, values and attitudes toward abortion. J. Scient. Study Religion 24, 137, 1985.

3. Jelen T. G. Respect for life, sexual morality, and opposition to abortion. Rev. Religious Res. 25 (3), 1984.

4. Jelen T. G. Changes in the attitudinal correlations of opposition to abortion, 1977-1985. J. Scienr. Study Religion 27, 211, 1988.

5. McIntosh W. A. and Alston L. T. and Alston J. P. The differential impact of religious preferences and church attendance on attitudes toward abortion. Rev. Religious Res. 20, 195, 1979.

6. Williams D. G. Religion, beliefs about human life, and the abortion decision. Rev. Religious Res. 24,40, 1982.

7. Alston J. P. Three current religious issues: marriage of priests, intermarriage, and euthanasia. J. Scient. Study Religion 15, 75, 1976.

8. Anderson J. G. and Caddell D. P. The attitudes of medical professionals toward active euthanasia. Sot. Sci. Med. 37, 105, 1993.

9. Koop C. E. The right to die: the moral dilemmas. In Euthanasia: The Moral Issues (Edited by Baird R. M. and Rosenbaum S. E.). Prometheus Books, Buffalo, New York, 1989.

IO. Wilkerson I. Doctor charged with murder in suicide by device he invented. New York Times December 4, 1990.

11. Lewin T. Judge clears doctor of murdering woman with a suicide ma&ine. New York Times December 14, 1990.

12. Suicide Doctor has License Pulled. Associated Press, November 21, 1991.

13. Humphry D. Luwfil Exit: The Limits of Freedom for Help in Dying. The Norris Lane Press, Junction City, OR, 1993.

14. Beauchamp T. L. and Childress J. F. Principles of Biomedical Ethics, 2nd edn. Oxford University Press, Oxford, 1983.

15. Devine P. E. The Erhics of Homicide. Cornell University Press, London, 1978.

16. Rachels J. Active and passive euthanasia. N. Engl. J. Med. 292, 78, 1975.

17. Rachels J. The End of Life: Euthanasia and Morality. Oxford University Press, Oxford, 1986.

18. Rachels J. Active and passive euthanasia. In Euthanasia: The Moral Issues (Edited by Baird R. M. and Rosenbaum S. E.). Prometheus Books, Buffalo, New York, 1989.

19. Sullivan T. D. Active and passive euthanasia: an impertinent distinction? In Euthanasia: The Moral Issues (Edited by Baird R. M. and Rosenbaum S. E.). Prometheus Books, Buffalo, New York, 1989.

20. Gaylin W., Kass L. R., Pellegrino E. D. and Siegler M. Doctors must not kill. In Eufhanasia: The Moral Issues (Edited by Baird R. M. and Rosenbaum S. E.). Prometheus Books, Buffalo, New York, 1989.

21. Blumer H. Society as symbolic interaction. In Human Behavior in Social Process (by Rose A. M.), pp. 179-192. Houghton Mifflin, Boston, 1962.

22. Stryker S. Contemporary symbolic interactionism: a statement. In Symbolic Interactionism: A Social Structural Version (by Stryker S.), pp. 51-85. Benjamin/ Cummings, Menlo Park, CA, 1980.

23. Rosenberg M. The self-concept: social product or social force. In Social Psychology (by Rosenberg and Turner), pp. 593-624. Basic Books, New York, 1981.

24. Stryker S. and Serpe R. T. Commitment, identity salience, and role behavior: theory and researchexample. In Personality, Roles, and Social Behavior (by Ickes W. and Knowles E. S.), pp. 199-218. Springer-Verlag, New York, 1982.

25. Vaux K. L. The theologic ethics of euthanasia. In “Mercy, murder, and morality: perspectives on euthanasia,” a special supplement of The Hastings Center Report (Edited by Campbell C. S. and Crigger B. J.), 1989.

26. Lenski G. The Religious Factor. Doubleday, Garden City, New York, 1963.

27. Roof W. C. and McKinney W. American Mainline Religion: Its Changing Shape and Future. Rutgers University Press, New Brunswick, 1987.

28. Nagi M. H., Pugh M. D. and Lazerine N. G. Attitudes of catholic and protestant clergy toward euthanasia. Omega 8, 1977.

29. Olson D. and Carroll J. Theological and political orthodoxy among american theological faculty. An unpublished paper presented at the annual meetings of the Society for the Scientific Study of Religion and the Religious Research Association, Salt Lake City, Utah, October, 1989.

30. Davidson J. D. and Caddell D. P. Religion and the meaning of work. J. Scient. Sru<b! Religion 33 (2), 1994.

31. National Conference of Catholic Bishops of the United States of America. Guidelines for Legislation on Life-Sustaining Treatment, 1984.

32. Abbott W. The Documents of Vatican II. New Century Publications, Piscataway, NJ, 1966.

33. Coleman G. D. Assisted suicide: an ethical perspective. Issues Law Med. 3 (3). 1987.

34. Munson R. Inrerrenrion and Reflection: Basic Issues in Medical Ethics, 4th Edn. Wadsworth, Belmont, CA, 1992.

35. USA Today June 7, 1985. 36. Caddell D. P. Moral Education in the College

Environment. Unpublished masters thesis, California State University, Fullerton, 1989.

37. Sargent L. T. Contemporary Political Ideologies: A Comparative Analysis, 8th edn. Brooks/Cole, Pacific Grove, CA, 1990.

38.

39.

40


Freidson, E. Dilemmas in the doctor-patient relation- 45. Hadden J. Toward desacrahzing secularization theory. ship. In The Healing Experience: Readings on the Social Sot. Forces 65, 587, 1987. Conrext of Health Care (Edited by Komblum W. and 46. Stark R. and Bainbridge W. S. The Future of Religion. Smith C. D.), pp. 1617. Prentice Hall, Englewood Cliffs, University of California Press, Berkeley, CA, 1985. NJ, 1994. 47. Wuthnow R. The Restructuring of American Religion. Dungal L. Physicians’ responses to patients: a study of Princeton University Press, Princeton, NJ, 1988. factors involved in the office interview. J. FamiIy Practice 48. Roof W. C. and McKinney W. American Mainline 6, 1065, 1978. Religion: Its Changing Shape and Future. Rutgers Crutcher J. E. and Bass M. J. The difficult patient and the University Press, New Brunswick, 1987. troubled physician. J. Family Practice 11, 933, 1980. 49. Hoge D. and Roozen D. Understanding Church Growth

41. Haug M. and Lavin B. Practitioner or patient-who’s in and Decline. The Pilgrim Press, New York, 1979. charge? J. HIth Sot. Behav. 22, 212, 1981. 50. Kelley D. M. Why Conservariue Churches are Growing.

42. Haug M. and Lavin B. Consumerism and Medicine. Sage Mercer University Press. Macon, GA, 1986. Publications, Beverly Hills, CA, 1983. 51. Finke R. and Stark R. The Churching of America,

43. Pedhazer E. J. Multiple Regression in Behavioral 17761990: Winners and Losers in Our Religious Research: Explanation and Prediction, 2nd Edn. Holt, Economy. Rutgers University Press, New Brunswick, Rhinehart and Winston, Inc, Fort Worth, TX, 1982. 1993.

44. Tabachnick B. G. and Fidel1 L. S. Using Multivariate 52. Calhoun C., Light D. and Keller S. Sociology, 6th Edn. Statistics. Harper and Row, New York, 1983. McGraw-Hill, New York, 1994.

SSM 40,124

EUTHANASIA: AMERICAN ATTITUDES TOWARD THE … · Euthanasia: American attitudes toward the...

Documents

Transcript of EUTHANASIA: AMERICAN ATTITUDES TOWARD THE … · Euthanasia: American attitudes toward the...