euthanasia: american attitudes toward the physician`s role

Sm. Sri. Med. Vol. 40, No. 12, pp. 1671-1681, 1995
Copyright Q 1995 Elsevier Science Ltd
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EUTHANASIA:
AMERICAN ATTITUDES
PHYSICIAN’S ROLE
DAVID P. CADDELL’,
TOWARD THE
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 ideology 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.
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.
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 [ 1l] 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.
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 disconnecting 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.
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.
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.
ANOTHER DISTINCTION:ACTIVE EUTHANASIAVERSUS
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:
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).
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 Hippocratic tradition, doctors are forbidden to take part in
intentionally killing a patient. As is stated in the
Hippocratic Oath:
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.
THEORETICAL ORIENTATION
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
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-Christian 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, 81has 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
1673
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
Infanticideand euthanasiaare 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 Protestants 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
1674
David P. Caddell and Rae R. Newton
suicide and active euthanasia more acceptable than conservative
Protestants
or
Catholics.
H2: 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: 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.
H4: 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
Euthanasia: American attitudes toward the physician’s role
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).
1675
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
selfperception.
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 denomination. 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
David P. Caddell and Rae R. Newton
1676
Table 1. Agreement and disagreement with active euthanasia and
suicide
Independent variables
Agree active
Agree suicide
N
62.8
44.9
8384
62.4
59.6
51.7
65.9
68.7
39.7
40.3
43.1
50.5
52.9
1418
1433
1704
1416
904
13.2
66.4
54.1
63.1
81.4
82.8
59.1
44.8
33.2
42.7
80.2
78.3
548
1555
1770
2112
177
628
73.5
60.8
41.1
42.1
54.5
27.4
3648
641
3196
52.8
66.0
72.2
68.3
70.5
31.2
46.6
56.9
61.0
63.6
2430
4318
299
900
420
61.3
69.0
65.5
66.0
62.1
57.0
52.4
54.9
53.9
50.1
43.9
44.4
36.8
32.7
173
807
1070
2826
1224
989
Total sample
and estimates of the contributions of each discriminating variable was desired [43,44].
RESULTS
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
Extremely Conservative
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
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). Conservative 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
0.73
0.66
0.54
0.63
0.81
0.59
0.45
0.33
0.43
0.80
0.14
0.21
0.21
0.20
0.01
6.24
16.21
17.35
18.32
0.34
<O.OOl
<O.OOl
<O.OOl
<O.OOl
0.733
0.61
0.73
0.47
0.42
0.54
0.27
0.19
0.19
0.20
9.10
22.14
22.30
<0.0001
<O.OOOl
<O.OOOl
0.68
0.66
0.66
0.62
0.54
0.51
0.51
0.44
0.14
0.15
0.15
0.17
9.45
9.57
9.57
12.51
<O.OOOl
co.oOO1
<0.0001
< 0.0001
0.56
0.36
0.20
13.65
<O.OOOl
0.53
0.66
0.72
0.68
0.70
0.32
0.47
0.57
0.61
0.63
0.21
0.19
0.16
0.07
0.06
20.72
25.04
5.54
4.94
2.85
<0.0001
<0.0001
<O.OOOl
<O.OOOl
0.005
Religious afiliation
Liberal Protestants
Moderate Protestants
Conservative Protestants
Catholic
Jew
Religious self-perception
Somewhat strong
Not very strong
Strong
Political self-perception
Liberal and extremely Liberal
Slightly Liberal
Moderate
Slightly Conservative
Conservative and
extremely Conservative
Education
High school
High school graduate
Junior college
College degree
Graduate dearec
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-cO.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.
David P. Caddell and
1678
Rae R. Newton
Table 4. Discriminant function analysis results for active euthanasia and suicide
Agreement with suicide
Correlation
F
with function
Agreement with active euthanasia
Correlation
F
Sig. F
with function
Variable
Relative self-perception
No religious affiliation
Conservative Protestant
Education
Political self-perception
Jewish
Liberal Protestant
Moderate Protestant
Catholic
Other religious affiliation
Year
Canonical correlation
Eigenvalue
x’
-0.90
0.43
-0.27
0.24
-0.22
0.16
0.16
0.10
-0.02
0.01
0.14
628.00
146.30
56.51
45.09
37.89
20.97
20.42
7.21
0.48
0.07
16.18
<O.OOOl
<O.OOol
<O.OOOl
<O.OOOl
<O.OOOl
co.0001
<0.0001
0.0073
0.4860
0.7861
0.0001
0.31
0.11
732.33
(Pt0.0001)
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
-0.78
0.54
0.54
0.44
-0.22
0.23
0.18
-0.00
-0.07
0.04
0.17
875.80
423.50
423.50
277.90
72.53
75.28
47.24
0.03
7.91
2.30
41.75
Sig. F
<0.0001
<o.o001
<O.OOOl
<O.OOOl
0.2589
<O.oOOl
to.0001
0.8592
0.0048
0. I294
<O.OOOl
0.41
0.20
1320.11
(P<0.0001)
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
N
Predicted attitude
Unacceotable
Acceotable
Suicide
Unacceptable
2484
Acceptable
4185
Ungrouped cases
699
1015
40.9%
778
18.6%
162
23.2%
1469
59. I %
81.4%
537
76.8%
Percent correctly classified: 68.16
Actiw
uuthattsia
Unacceptable
2524
Acceptable
4586
Ungrouped
699
1029
40.8%
806
17.6%
189
27.0%
Percent correctlv classified: 67.64
1495
59.2%
3780
82.4%
510
73.0%
Euthanasia: American attitudes toward the physician’s role
model is useful in assisting us to predict respondent’s
attitudes.
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 importance of religion
The importance of religion in determining American 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].
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.
An important question for future research concerns
the impact of these religious trends on the outcome of
the euthanasia debate. In states where initiatives have
been placed on the ballot for a vote, conservative
religious and political groups have maintained a vocal
opposition. In each election, propositions to legalize
some form of active euthanasia have been defeated.
1619
Desirability of the physician’s role
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 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.
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.
Perhaps the clearest relationship is that between
education and the tendency to see a distinction
between the acceptability ofactive euthanasia and that
of suicide. As education increased, the tendency to see
a difference in the acceptability between the two clearly
diminished. This lends support to our hypothesis that
education increases an individual’s willingness to
David P. Caddell and Rae R. Newton
1680
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.
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