j med ethics 1994 stevens 41 6

Journal of medical ethics 1994; 20: 41-46

Management of death, dying and euthanasia:attitudes and practices of medicalpractitioners in South AustraliaChristine A Stevens and Riaz Hassan Flinders University of South Australia

Authors' abstractThis article presents the first results of a study of thedecisions made by health professionals in SouthAustralia concerning the management of death, dyingand euthanasia, andfocuses on thefindings concerningthe attitudes and practices of medical practitioners.Mail-back, self-administered questionnaires were postedin August 1991 to a ten per cent sample of 494 medicalpractitioners in South Australia randomly selectedfromthe list published by the Medical Board of SouthAustralia. A total response rate of 68 per cent wasobtained, 60 per cent of which (298) were usablereturns.

It was found that forty-seven per cent had receivedrequests from patients to hasten their deaths. Nineteenper cent had taken active steps which had brought aboutthe death of a patient. Sixty-eight per cent thought thatguidelines for withholding and withdrawal of treatmentshould be established. Forty-five per cent were in favourof legalisation of active euthanasia under certaincircumstances.

IntroductionAdvances in medical knowledge and technology inwestern countries enable the medical profession toexercise greater control over life and death processes,and this capacity creates a number of moral andethical dilemmas. People may live long periods withchronic, painful, debilitating conditions which arenot terminal, or not immediately fatal; while manytreatments, especially those of an invasive nature, orthose used to treat the severely or chronically ill, alsoinvolve some element of risk, pain, and thepossibility of greater or lesser permanent damage ortemporary side-effects. There is increasing tensionbetween the aim and the ability of medicine tosustain life and the requirement to relieve suffering,and in many situations the two objectives havebecome incompatible. There is now considerableuncertainty about what constitute reasonable

Key wordsEthical decision-making; death and dying; euthanasia.

medical standards, and there is wide divergence ofopinion as to when intervention or no treatmentshould occur (1), and no unanimity on the moral andethical status of decisions to forego treatment andactions taken to withdraw or terminate treatment(2). Neither is there consensus on the question ofwhether the deliberate termination of life shouldcontinue to be illegal in all situations (3, 4). Givenmedical ability to influence the manner and timing ofdeath, there is growing public desire for increasedparticipation in medical decision-making, and arecognition that it is no longer appropriate for thelocus of authority in this area to be the soleprerogative of medical practitioners (5).

These issues were addressed by examining theattitudes and practices of health professionals inSouth Australia towards the management of death,dying and euthanasia. The research aimed, firstly, toexamine whether medical practitioners and nurseswere ever asked to hasten the death of patients, andthe ways such requests were handled; and secondly,to investigate how medical practitioners and nursesconsider such requests could be handled, andwhether guidelines should be established to clarifythe current legal position. This article focuses on thefindings concerning the attitudes and practices ofmedical practitioners (6).

MethodsThe list of medical practitioners registered topractise in South Australia, published by theMedical Board of South Australia, was used toobtain a ten per cent sample of 494 medicalpractitioners resident in South Australia. Mail-back,self-administered questionnaires were posted inAugust 1991. Twenty-five questions were includedin the questionnaire, most of which could beanswered with a tick, although five invited writtenresponses. To maintain confidentiality the question-naires were not marked numerically, nor wererespondents required or asked to reveal their namesor addresses. Two reminder/thank you letters weresent to all participants. A total response rate of 68per cent was obtained, 60 per cent of which (298)were usable returns.

group.bmj.com on October 30, 2014 - Published by http://jme.bmj.com/Downloaded from

42 Management ofdeath, dying and euthanasia: attitudes and practices ofmedical practitioners in South Australia

Table 1Have medical practitioners ever suggested withholding or withdrawingtreatment when discussing the options ofmedical treatment available to

patientsWithholdingNumber

- Yes WithdrawingNumber

Age20-29 years30-39 years40-49 years50-59 years60+ years

SexMaleFemale

ReligionC of EOther ProtCatholicOtherNone

Years medical practice30 yearsTotal

1587683227

17058

6537412067

194448385229

231

83-392-681-982-157-4

80-684-1

82-368-583-783-389-3

82-693-692-380-981-359-281-6

1277592427

15049

6133331657

133943334427

201

63-281-172-866-757.4

71-473-1

76-3614166-064-082-6

56-581-382-770-274-655-171-8

(There are a few cases missing in each category where the age, sex, religion or number of years ofmedical practice were not shown.)

ResultsAll respondents were asked if they ever receivedrequests to hasten the death of a patient either bywithdrawing treatment or by taking active steps, andwhether these requests came from the patient or thepatient's family. No definition of the term 'activesteps' was given in the questionnaire as it wasconsidered the meaning was implicit in thejuxtaposition of the term with the phrase 'withdrawalof treatment', and that no confusion shouldtherefore exist between passive and active euthanasiain this context.

Forty-seven per cent of medical practitioners hadreceived a request from a patient to hasten death bywithdrawing treatment, and the same proportionhad received a request from a patient's family.Thirty-three per cent had received a request from apatient to hasten death by taking active steps and 22per cent had received a request from a patient'sfamily. Age and gender were associated withdifferences in request rates, with males and personsaged 29 years and under, more likely than others tohave received requests. 'Persistent and irrelievable

pain', 'terminal illness' and 'incurable condition',were the most frequently cited reasons for suchrequests.The majority would or did discuss requests with

another medical practitioner (71 per cent), nursingstaff (63 per cent), or relatives of the patient (79 percent), while lesser proportions were prepared to orconsulted with a religious adviser (27 per cent), abioethics adviser (23 per cent) or someone else (18per cent).

Eighty-nine per cent of respondents believed thata request to hasten death could be consideredrational. Only ten per cent considered it was not,while one per cent felt it could be considered rationalunder some circumstances. An open-ended questioninvited further explanation, and the four mainreasons were given for affirmative responses - where:(a) the patient suffered intractable pain andsuffering, (40 per cent of respondents); (b) thepatient was near death or death was inevitable, (35per cent of respondents); (c) the patient experienceda quality of life which was extremely poor (30 percent of respondents), and (d) this was a matter of

- Yes


Christine A Stevens, Riaz Hassan 43

individual freedom of choice (17 per cent ofrespondents).To ascertain attitudes towards passive and active

euthanasia, respondents were asked if it was everright to bring about the death of a patient bywithdrawing treatment, or by taking active steps.These questions did not define 'right' and respon-dents were free to interpret the meaning in a legal,moral or ethical sense. For withdrawal of treatment,65 per cent said yes, 27 per cent said 'yes, but only ifrequested by the patient', while 8 per cent said it wasnot. For active euthanasia, 18 per cent answered yes,26 per cent said it was 'right', but only if requestedby the patient, and 55 per cent said it was not.

All respondents were asked whether, in discussingthe options ofmedical treatment available to a patient,they had ever suggested withholding or withdrawal oftreatment as possible choices (see Table 1). Therewere statistically significant differences in responserates for withholding treatment according to age (7)and number of years of medical practice (8).

In response to the question: 'Have you ever takenactive steps which have brought about the death of apatient' which was asked of all respondents, 19 percent said yes (56 individuals), 73 per cent said no, 6per cent did not wish to answer, and 2 per cent wereunsure. There were no significant differences in

response rates according to age, sex or religiousaffiliation (see Table 2).

While there was a strong association betweentaking active steps which had brought about apatient's death and the receipt of a request, 49 percent of those who had done so, had never received arequest from a patient, and 54 per cent had neverreceived a request from the family of a patient.Not surprisingly, there was a strong association

between taking active steps, and belief that suchaction was 'right'. Of all medical practitioners whohad done so 50 per cent considered active steps to be'right', and 32 per cent felt it was 'right' whenrequested by the patient. However, 18 per cent whohad undertaken active euthanasia did not think suchaction was ever 'right', while ten per cent who hadnot, said active euthanasia was 'right', and a further21 per cent of this group said active euthanasia was'right' if requested by the patient.

Persons who had practised active euthanasia (56respondents) were asked if they felt they had donethe 'right' thing. Eighty-five per cent said yes, 13 percent considered they had not, while one per centwere unsure. An open-ended question requested anexplanation, and the reasons given most frequentlywere: (i) this action had relieved pain, suffering anddistress experienced by the patient (42 per cent of

Table 2Ever taken active steps which have brought about the death of a patient by age,

sex and religionActive steps ever taken

Yes No Not knownA Age

20-29 years 15-8 73.7 10-530-39 years 13.7 77.9 8-540-49 years 18-8 70-6 10-650-59 years 30-8 59-0 10-660+ years 17-5 77-2 5.3

B SexMale 22-5 68-9 8-6Female 5-6 84-7 9-7

C ReligionC of E 20-9 65-1 14-0Other Prot 20-7 74-1 5-1Catholic 4-0 88-0 8-0Other 16-0 84-0None 23.7 68-4 7.9

Total 18.8 72-5 8-7Total A= 295

B= 294C= 295

(Data shown in percentages)



respondents); (ii) the patient was near death (31 percent of respondents); (iii) the situation was hopeless(31 per cent of respondents); (iv) the patient had noprospect of a meaningful or independent existence(15 per cent of respondents), and (v) acted on orders(3 per cent of respondents).

People who had not practised active euthanasiawere asked if they had rejected a request because itwould have been illegal. Only 16 per cent (40persons) responded in the affirmative, while 38 percent (91 individuals) said the question of legality wasnot a factor in their decision-making. Forty-five percent of respondents had received no request.To ascertain the level of awareness of current

legislation in South Australia pertinent to the man-agement of death and dying, all respondents wereasked firstly, whether they were aware ofThe NaturalDeath Act, 1983 (9), and secondly, how many timesin the last five years they had been presented withdeclarations made under this act. Seventy-two percent were aware of the legislation, but only 24 percent had been presented with declarations.

As the current legal position of medicalpractitioners who withdraw or withhold medicaltreatment is not clear (10), all respondents wereasked if they thought 'guidelines should beestablished so that the legal position of medical

practitioners regarding withholding and withdrawalof treatment could be clarified'. Sixty-eight per centsaid yes, 18 per cent said no, and 13 per cent wereunsure. The only significant differences on this issuewere between males and females, 21 per cent of theformer of whom were opposed to the idea ofguidelines compared with only 8 per cent of females,while 23 per cent of females were undecidedcompared with ten per cent of males. An open-ended question requested suggestions on what theseguidelines could be, and Table 3 lists those whichwere raised most frequently.

Attitudes towards legalisation of active euthanasiawere canvassed in the question: 'Do you think itshould be legally permissible for medical prac-titioners to take active steps to bring about apatient's death under some circumstances?'. Only 45per cent of medical practitioners were in favour oflegalisation of active euthanasia, while 39 per centwere opposed. An open-ended question asked thosewho answered yes to indicate the circumstances,which are listed in Table 4.

ConclusionThe growing tension between the dual roles ofsustaining life and relieving suffering has resulted in

Table 3Suggested guidelines for withdrawal/withholding oftreatment

Medical Practitioners

Number % Resp % CasesGuidelinesOnly on patient request 25 6-5 15-2On patient and/or family request 19 4-9 11 6Decision to be made by two or more doctors 28 7-2 17 1Decision to be made by doctor, patient and family 12 3 1 7-3Decision to be made by medical panel 9 253 5-5Decision to be made by multi-disciplinary panel 10 2-6 6- 1Document all decisions 14 3-6 8-5Ensure there is legal indemnity for doctor 14 3-6 8-5Psychiatric assessment of patient 11 2-8 6-7Patient and family to be fully informed 19 4 9 11 6When patient is terminally ill 36 9 3 22-0When patient has incurable disease 14 3-6 8-5When patient has intractable pain and suffering 23 5-9 14-0When patient is brain dead 6 1 6 3-7Consider quality of life of patient 14 3-6 8-5Exceptional cases to be defined 9 253 5-5In situations where medical treatment is valueless 14 3-6 8-5State the treatment to be withheld 7 1-8 4-3Withdraw active treatment only 3 0-8 1-8

N=387 N= 164(Table includes main guidelines only) (Resp Responses; Cases= Respondents)


Christine A Stevens, Riaz Hassan 45

an expanding debate on what constitutes right,correct or proper medical care, especially for theterminally or severely ill. The study confirmed a lackof unanimity of opinion among medical practitionersconcerning the moral, ethical and legal status ofdecisions to withhold or withdraw medicaltreatment, where the effect of these actions would beto hasten the death of a patient.The legal ambiguity of the current situation

means that patients are often subject to the ethicaland moral codes of individual doctors whendecisions are made, and variations are demon-strated, not only in attitudes, but in practice betweenindividual medical practitioners in this sample. Thesurvey revealed majority support in this sample forguidelines to be established to clarify the legalposition of medical practitioners regarding with-holding and withdrawal of medical treatment.

Increasingly, questions have been raisedconcerning the question if, and/or when it is properin a medical, ethical or moral sense actively toterminate the lives of patients. Not surprisingly, thesurvey revealed considerable differences of opinionon this issue, but the evidence indicates that whatmany regard as reasonable or proper medicalpractice is in conflict with the law.The findings also indicate that higher proportions

of respondents used internalised ethical and moralvalues to guide their decision-making than theproportion who depended on externally imposedlegal sanctions to circumscribe their actions. Theseand previous findings suggest, firstly, that altera-tion or clarification of the law would not neces-sarily change the practices of individual medical

practitioners, and secondly, that questions of legalityare currently not the principal considerations usedwhen making decisions to withhold or withdrawtreatment or to terminate the lives of patients.The research found that there was some

preparedness by medical practitioners to overlookthe law and take active steps to hasten the death oftheir patients, and that the majority of those who hadwere confident they had done the right thing in thecircumstances. This suggests that a minority withinthe medical profession perceive the law as too rigidto allow for the problems posed by individualsituations, and that legality, morality and ethicalbehaviour are not necessarily regarded assynonymous. However, the disjunction betweenmedical practice and the law, and individualjustifications for it given by those involved, do not bythemselves constitute sufficient reasons for makingofficial changes to current codes of practice relatingto active euthanasia.

Medical practitioners were divided on thequestion of the legalisation of active euthanasia, withconsiderable and almost equal minorities opposedto, or in favour of changes in the law. Among thosewho favoured the legalisation of active euthanasiathere was some agreement that terminal illnessand intractable pain and suffering constitutedcircumstances in which active euthanasia could orshould be legal. However, there were minorityopinions that poor quality of life, mental disabilityand physical handicap should also be validcircumstances for active euthanasia. The diversity ofopinion on these issues invites caution to ensure thatin framing guidelines or legislation, current abuses

Table 4Suggested circumstances under which it should be legally possible for medical

practitioners to take active steps to bring about a patient's deathMedical Practitioners

Number % Resp % CasesCircumstancesTerminal illness 61 21-5 51-3Incurable illness 38 13.4 31-9Intractable pain and suffering 57 20-1 47.9Physical handicap 10 3-5 8-4Mental disability 19 6-7 16-0Poor quality of life 24 8-5 20-2Patient request 34 12-0 28-6Patient and family request 21 7-4 17-6Decision of one doctor 2 0-7 1-7Decision of two or more doctors 10 3-5 8-4Committee decision 5 1 8 4-2Decision of health team 3 1 1 2-5

N=284 N=119(Table includes main circumstances only) (Resp=Responses; Cases=Respondents)



which result from the enthusiastic and aggressivepursuit of the aim of preserving life do not becometransmuted into abuses due to lack of adequateprotection of life.

AcknowledgementThis research was funded by the CriminologyResearch Council.

ChristineA Stevens, Dip Soc Stud, BA (Hons), PhD, isat present a Consultant in Social Issues Research. At thetime of this research she was a Research Fellow inSociology at the Flinders University of South Australia.Riaz Hassan, BA, MA, PhD is Professor ofSociology atthe Flinders University of South Australia.

References(1) Wanzer S H et al. The physician's responsibility

towards hopelessly ill patients: a second look. NewEnglandjournal of medicine 1989; 320, 1: 844-849.

(2) Gillon R. Euthanasia, withholding life-prolongingtreatment, and moral differences between killing and

letting die. Journal of medical ethics 1988; 14:115-117.

(3) Parker M. Moral intuition, good deaths and ordinarymedical practitioners. J7ournal of medical ethics 1990;16: 28-34.

(4) Davies J. Raping and making love are differentconcepts: so are killing and voluntary euthanasia.Jrournal of medical ethics 1988; 14: 148-149.

(5) Loewy E H. Involving patients in Do Not Resuscitate(DNR) decisions: an old issue raising its ugly head.Journal of medical ethics 1991; 17: 156-160.

(6) Complete findings of the research are reported inStevens C A, Hassan R. Management of death, dyingand euthanasia: attitudes and practices of medicalpractitioners and nurses in South Australia. Reportprepared for the Criminology Research Council, 1992.

(7) Age, X2=25 7, DF=4, P=< 05(8) Number of years of medical practice, X2 =24-8,

DF=5, P=< 05(9) Patients over the age of 18 years may make an

advance declaration (commonly referred to as a livingwill) that extraordinary means need not be taken ifthey are terminally ill and death is imminent.

(10) Pollard B J. Withdrawing life-sustaining treatmentfrom severely brain-damaged persons. The medicaljournal ofAustralia 1991; 154: 559-561.

News and notes

2nd World Congress of BioethicsThe International Association of Bioethics's SecondWorld Congress of Bioethics will be held in BuenosAires, Argentina on October 24-26 1994.For further information contact: Silvina Mathen,

Secretaria, Escuela Latinoamerican de Bioetica,

Fundacion Dr Jose Mainetti, Calle 508e/1 6y17 (1897)MB Gonnet, Buenos Aires, Argentina.

Telephone: (021) 71 1160 or 64 71 2616/3119; fax:54/21/71 2222; Email: Postmast @funmai.org.ar.

News and notesScientific (Mis)Conduct and Social (Ir)ResponsibilityThe Poynter Center for the Study of Ethics andAmerican Institutions at Indiana University will hold aone-day conference on the relationship betweenscientific misconduct and broader issues of socialresponsibility on May 27, 1994.There is no conference fee, but pre-registration is

required by April 15, 1994.More information on the conference may be

obtained by contacting Dr Kenneth D Pimple at thePoynter Centre, 410 North Park Avenue, Bloomington,Indiana 47405, phone 812-855-0261, [email protected].


Australia.practitioners in South and practices of medicaland euthanasia: attitudes Management of death, dying

C A Stevens and R Hassan

doi: 10.1136/jme.20.1.411994 20: 41-46 J Med Ethics

http://jme.bmj.com/content/20/1/41found at: Updated information and services can be

serviceEmail alerting

right corner of the online article. cite this article. Sign up in the box at the top Receive free email alerts when new articles

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:


j med ethics 1994 stevens 41 6

Documents