Beruflich Dokumente
Kultur Dokumente
doi:10.1111/j.1467-8519.2012.01968.x
bioe_1968
402..408
TAL BERGMAN LEVY, SHLOMI AZAR, RONEN HUBERFELD, ANDREW M. SIEGEL AND
RAEL D. STROUS
Keywords
attitudes,
euthanasia,
psychiatrists,
physician assisted suicide
ABSTRACT
Euthanasia and physician assisted-suicide are terms used to describe
the process in which a doctor of a sick or disabled individual engages in an
activity which directly or indirectly leads to their death. This behavior is
engaged by the healthcare provider based on their humanistic desire to
end suffering and pain. The psychiatrists involvement may be requested in
several distinct situations including evaluation of patient capacity when an
appeal for euthanasia is requested on grounds of terminal somatic illness
or when the patient is requesting euthanasia due to mental suffering. We
compare attitudes of 49 psychiatrists towards euthanasia and assisted
suicide with a group of 54 other physicians by means of a questionnaire
describing different patients, who either requested physician-assisted
suicide or in whom euthanasia as a treatment option was considered,
followed by a set of questions relating to euthanasia implementation. When
controlled for religious practice, psychiatrists expressed more conservative
views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated
more conservative views. Differences may be due to factors inherent in
subspecialty education. We suggest that in light of the unique complexity
and context of patient euthanasia requests, based on their training and
professional expertise psychiatrists are well suited to take a prominent role
in evaluating such requests to die and making a decision as to the relative
importance of competing variables.
INTRODUCTION
Euthanasia and assisted suicide are terms used to describe
the process in which a doctor or a close relative of an
either sick or disabled individual (physically or mentally) engages in an activity which directly or indirectly
leads to the death of the individual. This behavior is
engaged by the relative or health care provider based on
their humanistic desire to end suffering and pain. Euthanasia is not a uniform procedure and reflects a variety
of attitudes and practices.1 Euthanasia terminology is
1
Address for correspondence: Dr. Rael Strous, MD,Director Chronic Inpatient Unit Beer Yaakov Mental Health Center, PO Box 1, Beer Yaakov
70350, Israel. E-mail: raels@post.tau.ac.il
Conflict of interest statement: No conflicts declared
2012 John Wiley & Sons Ltd
403
METHODS
Study population and design
For the purposes of this exploratory survey study, a
specially designed questionnaire was presented by two
members of the research team (TB and AS) at a number
of sites and settings including psychiatric hospitals and
general medical hospitals. All participants were Israeli
citizens currently employed by their respective hospitals.
Participants were requested to complete the form anonymously, in a voluntary fashion, and to submit it to the
researcher directly or by mail. Considering the sensitive
nature of the questionnaire and the setting in which it was
administered, the questionnaire was kept as short and
simple as possible in order to ensure confidentiality and a
high response rate.
The survey consisted of a statement explaining the
study, the voluntary nature of the questionnaire, as well
as the commitment to confidentiality. In addition to
demographics, such as age, gender, marital status, occupation and years of experience (calculated from first
year of residency), participants were also asked whether
they regarded themselves as secular/religious/ traditional Jewish or other. The study protocol and instrument was approved by the Beer Yaakov Mental Health
Center and Geha Mental Health Center ethical research
review committee (IRB).
Study questionnaire
3
Ibid.
4
J.R. Williams, F. Lowy, M. Sawyer. Canadian Physicians and
Euthanasia: 1. An Approach to the Issue. Can Med Assoc J 1993; 148:
12931297.
5
P.S. Appelbaum & T. Griso. Assessing Patients Capacity to Consent
to Treatment. New Eng J Med 1988; 319: 16351638.
6
K. Naudts, C. Ducatelle, J. Kovacs et al. Euthanasia, the Role of the
Psychiatrist. Br J Psychiatry 2006; 188: 405409.
The study questionnaire included seven vignettes describing seven different patients who either requested
physician-assisted suicide or in whom euthanasia as a
treatment option was suggested for their condition (See
7
Ibid.
404
Statistical analysis
Severity data were analyzed as ordinal (5-point scale) and
continuous (overall average). Routine sample descriptive
statistics were applied to the data. Dependence between
variables was tested using Pearson correlation coefficients, and 2x2 chi-square tests. The effects of profession
and sex were analyzed using t-tests, and Mann-Whitney
tests, as appropriate according to the variables nature.
Interactions between sex and profession were tested using
2x2 analysis of variance (ANOVA) models. Effect-sizes
(ES) were calculated using Cohens d method. The alpha
levels of .05 were kept, in order to consider all possible
relevant results as leads for further research.
RESULTS
Study sample
The sample included 103 subjects; all were physicians of
different subspecialties in medicine. Sex segregation was
59 males (58.4%) and 42 females (two cases had missing
data). The average age was 43.4 (SD = 10.6, range 2872
years), and the average number of years in practice was
15.3 (SD = 11.9, range 144 years). Most of the subjects
(n = 90, 91%) were married, 6 were single, 2 divorced and
1 a widower. With respect to level of religious affiliation,
most defined themselves as secular (n = 79, 78.2%), 12
were traditional, 8 orthodox, and 2 reported being atheists (2 cases had missing data). The group was divided
into two according to medical subspecialty: psychiatrists
(n = 49, 47.6%) and other subspecialties (n = 54, 52.4%).
Associations with background variables were tested. A
significant association was found between subspecialty
and level of religiosity (c2 = 12.8, df = 3, p = 0.005) with
lower rates of orthodoxy (0%) and the traditional (8.2%)
among psychiatrists compared to other medical subspecialties (15.4%, and 15.4%, respectively). In addition, psychiatrists were older (47.2) and more experienced (20.0)
compared to other medical subspecialties (40.1, 11.1
years, respectively) (t = 3.6, df = 99, p < 0.001; t = 4.0,
df = 100, p < 0.001, respectively). No associations were
found between subspecialty and gender or marital status.
Study questions
The reliability of items on the questionnaire was
tested within each vignette using internal reliability tests
(Cronbachs a coefficient), and was found to be satisfying (all alpha values greater than 0.8). The reliability of
items between vignettes was high, alpha = 0.96. Accordingly, the items within each vignette were summed up
for each subject. A higher sum indicated greater acceptance of euthanasia (i.e. a more liberal attitude). Similarly, a total score was computed for each subject based
on the seven case vignettes. The associations between
the vignettes as well as the total scores were all high and
significant.
DISCUSSION
Observations indicate that when controlled for religious practice, psychiatrists participating in this study
expressed more conservative views regarding euthanasia
than did physicians from other medical specialties.
Overall, physicians who considered themselves religious
orthodox indicated more conservative views concerning
euthanasia in general compared to the subpopulation of
physicians who considered themselves either traditional
or secular. Similarly female physicians indicated more
conservative views on euthanasia compared to male
physicians. None of these associations were related to
age, seniority or marital status.
While these results are certainly interesting, our findings contrast those of Cohen et al.,8 who surveyed a
group of 938 physicians in the state of Washington for
their attitudes towards euthanasia and assisted-suicide.
In their study they noted attitudes of doctors to be polarized, with psychiatrists the most supportive of these two
practices. While the reason for the difference compared to
our study is not completely clear, it may be suggested that
the disparity is most likely due to inherent differences in
emphases in specialty education. Israeli psychiatrists are
nurtured in a professional environment with the specter
and shadow of the activities of the Nazi psychiatrists.
While all medical specialists have grown up in a country
whose foundations arose after the devastation and atrocities of the Holocaust and all citizens are well sensitized to
the scars of that period despite the 65 years or so elapsed,
psychiatrists are especially sensitized to this period. This
is given the central role of psychiatrists during this period
with respect to forced sterilization and euthanasia of the
mentally-ill by means of gassing, shootings, stabbings,
injections and starvation (considered the simplest method
at the time).9 During this time, psychiatrists made special
use of their power and expertise to carry out for the first
time in history mass extermination of their mentally-ill
patients. Thus it may be suggested that Israeli psychiatrists have more internalized the lessons of this period by
virtue of the nature of their patient population and professional activities. It is conceivable that their awareness
of what transpired during this time is very much etched
upon the consciousness of the Israeli psychiatrist by
means of due emphasis made on lessons gleaned from this
period during training and post training academic activities (research and clinical). This would form the basis of
405
406
14
12
J.H. Groenewoud et al. Physician-Assisted death in Psychiatric Practice in the Netherlands. New Eng J Med 1997; 336: 17951801.
13
P.R. Muskin. The Request to Die. JAMA 1998; 279: 323328.
Vignette 2
The second vignette concerns a patient with Amyotrophic Lateral Stenosis(ALS) in an advanced phase of the
disease (complete paralysis, obvious breathing difficulties
however prior to required ventilation). The patient asks
his doctor not to connect him in the future to a ventilating
machine when required but rather to let him die.
1. If this was a legal option would you approve the
patients request?
After a month the patient was admitted and he now
breaths only with the assistance of a ventilator. He asks
the physician to disconnect him from the machine and let
him die. You are then asked:
1. If you had the legal option would you approve of the
act?
2. Would you perform it yourself ?
3. If you had been in the same situation as the patient
would you have asked to be disconnected?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?
407
Vignette 4
The fourth vignette refers to a preterm 24 week-old
neonate. He was diagnosed as having Tay-Sacks disease.
(genetic disease with death usually by age of 5). Due to
premature labor the lungs of the newborn are underdeveloped and requires assistance of a ventilator to breath.
The newborn parents request of the doctor not to
lengthen their childs life unnecessarily.
1. If it was legal would you approve the parents
request?
2. If this newborn was already on a ventilator would
you approve disconnecting the ventilator?
3. Would you perform this yourself?
4. If you were the parent would you have asked to do
the same?
5. Do you share the opinion that for cases such as these
euthanasia should be legal?
Vignette 5
The fifth case refers to a an 80-year-old man with severe
mental retardation who has been living all his life in
institutions. Due to severe retardation he never speaks
however his suffering is notable. Recently he had been
frequently hospitalized due to anemia stemming from
inoperable stomach cancer. He is fed by a nasogastric
tube. His caretakers state that he does not understand
what is happening around him and that he should be
helped to die. The physician is asked:
1. If it was legal would you approve this request?
2. Would you perform this yourself?
3. If you were the patient would you have asked to be
euthanized?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?
Vignette 3
Vignette 6
408
Vignette 7
The final vignette presents the case of a 65 year-old
patient who is diagnosed with chronic paranoid schizophrenia. Although the patient is compliant, his illness is
treatment-resistant. States of complete remission characterized by normal reality testing exist rarely, however
are accompanied by good judgment and complete insight
to the disease. In these relative healthy mental states he
expresses severe emotional suffering due to his illness.
The patient requests his doctor to assist him to die since
he claims not to have strength to cope with the disease,
feels that he is a burden to his family and that the psychiatric profession cannot assist him.
1. If it was legal would you approve this request?
2. Would you perform this yourself?
3. If you were the patient would you have asked to be
euthanized?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?