Although most physicians recognize a duty to provide compassionate end-of-life care, they often feel ill prepared to do so. Of particular controversy is physician-assisted suicide. Physician-assisted suicide is commonly defined as the practice of providing a competent patient with a prescription for medication for the patient to use with the primary intention of ending his or her own life. In a recent survey of approximately 2,000 U.S. physicians, 3.3% reported that they had written at least one prescription to hasten death.1 Eleven percent reported they would write a prescription to hasten death if requested to do so under the current legal system. If legalized, 36% of the physicians would be willing to write a prescription to hasten death.1
Consistent with the diversity of physicians' opinions about the practice of assisted suicide, attitudes toward its legalization are also divided. When physicians in Michigan were asked to choose between legalizing or banning assisted suicide, 56% favored legalizing it, while 37% voted for a specific ban.2
Several studies have examined the demographic correlates of physicians' attitudes towards assisted suicide. Although age and sex were unrelated to opinions about assisted suicide,3 race was related. Furthermore, physicians' and patients' preferences for particular approaches to end-of-life care followed similar racial patterns. White physicians were more likely than African American physicians to endorse assisted suicide in terminal care scenarios.3 Catholic and devoutly religious physicians were also less likely than others to endorse it.4,5
Physicians' specialties may also help explain these differences of opinion. Oncologists were more likely to oppose assisted suicide.6,7 Similarly, support was higher among psychiatrists than among emergency medicine physicians.4,8,9 Only one study investigated the rationales for physicians' views on assisted suicide. One third of physicians in this study felt that it was immoral, 34% felt that it violated professional ethics, and 30% felt that it conflicted with their own religious beliefs.10
Since the legalization of physician-assisted suicide is an area where opinion is sharply divided, research is needed to understand the basis of physicians' beliefs about it. This study was designed to examine the extent and correlates of physicians' endorsements of the legalization of assisted suicide with regard to their specialties, sex, and opinions about certain other contemporary issues in the U.S. health care system.
Method
Graduates of Jefferson Medical College from the classes of 1987-1992 (N = 1,271) who were practicing medicine in the United States comprised the study population. Based on a search of relevant literature and two pilot studies,11 a survey was developed that consisted of 33 items to be answered on a five-point Likert scale (strongly agree = 5, to strongly disagree = 1). The survey addressed five aspects of changes in the U.S. health care system influencing medical education, quality of care, patient referral, cost of care, ethical issues, and sociopolitical matters11 (copies of the survey are available from the authors). The item reading Physician-assisted suicide should be legalized was used as the dependent variable in the present study.
The questionnaires were mailed in May 1998, followed by three reminders mailed to non-respondents at three-week intervals. Useable forms were returned by 835 physicians (66% response rate), of whom 830 responded to the item on the legalization of physician-assisted suicide. The respondents included 578 (69%) men and 257 (31%) women, with a mean age of 35.8 years. The specialties of respondents were distributed as follows: family practice, 116 (14%), general internal medicine, 85 (10%), pediatrics, 38 (5%), emergency medicine, 49 (6%), obstetrics-gynecology, 34 (4%), surgery and surgical subspecialties, 47 (6%), psychiatry, 28 (3%), hospital-based specialties (anesthesiology, pathology, and radiology), 97 (12%), medical subspecialties, 86 (10%), and other specialties and subspecialties, 255 (30%). Statistical analysis included bivariate and multivariate correlation, t test, chi-square, and z test for proportions.
Results
No significant difference was found between respondents and non-respondents with respect to gender (31% versus 33% women, respectively), age (35.8 versus 35.9 years), full-time salaried faculty appointment (14% versus 12%), and primary care practice (which was defined as family medicine, general internal medicine, and general pediatrics) (29% versus 34%).
Similarly, no difference was found for academic performance measures such as scores on the United States Medical Licensing Examinations, Steps 1-3, and clinical competence ratings provided by residency program supervisors at the end of the first postgraduate training year in three competence areas of data-gathering and processing skills, interpersonal skills and attitudes, and socioeconomic aspects of patient care.1,12
Respondents' Endorsement of Legalization of Physician-assisted Suicide. Of the 830 respondents, 284 (34%) endorsed legalization-73 (9%) strongly agreed, and 211 (25%) agreed; and 340 (41%) opposed it-189 (23%) disagreed, 151 (18%) strongly disagreed, and 206 (25%) expressed no opinion. The response patterns were similar for physicians who graduated in the six different cohorts.
Correlates of Endorsement of Legalization of Assisted Suicide. The endorsement rates for legalization of physician-assisted suicide were examined by the following variables:
* Demographics. Endorsement of legalization was unrelated to age and gender. Although the small number of African-American and Hispanic physicians in the sample was insufficient for meaningful statistical analysis. Asian physicians (n = 48) were significantly more likely (63%) than were whites (n = 557) to endorse (43%) legalization (z-test for proportions = 2.85, p <.01).
* Specialty. Orthopedic surgeons endorsed assisted suicide at the highest rate, which was 52%, followed by psychiatrists (41%), and physicians in the hospital-based specialties (40%). The lowest rates were for medical subspecialists (25%), general internists (28%), emergency medicine physicians (31%), family physicians (33%), and general pediatricians (34%). These differences in attitudes toward legalization among specialties were statistically significant (x2(20) = 33.7, p <.05).
* Postgraduate ratings of clinical competence. The physicians who endorsed legalization had been rated significantly lower by their residency program directors in the postgraduate clinical competence areas of interpersonal skills and attitudes (F(1,452) = 6.25, p <.01), and socioeconomic aspects of patient care (F(1,452) = 6.94, p <.01). No significant difference was noted in the area of data gathering and processing skills.
* Other significant predictors of endorsement of legalization. Bivariate correlations between responses to the item on legalization and those for other 32 items in the survey were examined. Nine items had statistically significant correlations with endorsement of legalization. A stepwise multiple regression algorithm was used, in which numerical weights assigned to responses to the item on legalization were considered as the dependent variable (criterion measure) and numerical weights assigned to the nine items of the survey that had significant correlations with responses on the physician-assisted suicide item were the independent variables (predictors). Only seven items contributed significantly (p <.05) to the multiple regression model, which is summarized in Table 1. Five contributed positively in that endorsement of legalization of physician-assisted suicide was associated with agreement with those items. Two contributed negatively, meaning that endorsement of legalization was associated with disagreement with those items.
As reported in Table 1, those who endorsed legalization were more likely to agree that physicians should unionize (r =.17, p <.01), that the present paradigm of medical education does not take into account the psychosocial factors related to illness (r =.15, p <.01), that government should take responsibility to regulate health care policies (r =.12, p <.01), that learning to work in a changing health care environment should become an essential part of medical education (r =.11, p <.01), and that physicians who work with managed care organizations order fewer tests than their counterparts in private practice (r =.11, p <.01).
Conversely, the physicians who endorsed legalization were more likely to disagree that the future of health care should be based on the needs of society rather than on physicians' satisfaction (r =.11, p <.01) and that physicians in HMOs as compared with those in other settings have similar dedication to their patients (r =.08, p <.05). The multivariate correlation was.30, p <.01 (see Table 1).
It is noteworthy that the responses to the item on legalization were not correlated with several other items, including the consideration of cost as an important factor in patient care decisions, physicians' support for the efforts of government to ration care, and the role that organized medicine should take with respect to social issues that can influence the well-being of society.
Discussion, Conclusions, and Implications
The findings of the present study support prior research showing that physicians hold widely disparate views regarding the legalization of physician-assisted suicide. More physicians in our study were opposed to legalization (41%) than supported it (34%), and a significant fraction of these physicians (25%) had not formed an opinion. The proportion of physicians in our study favoring legalization was similar to those in other survey work in this area.2 Almost all respondents endorsed medical school preparation for, and subsequent provision of, compassionate care at the end of life (92%), suggesting that the differences of opinion related only to the controversial area of assisted suicide and not to caring for the dying patient in general.
Our study found that physicians in the people-oriented specialties most associated with direct and ongoing patient contact that included treatment of dying patients (general medicine, family medicine, and medical subspecialties) were less likely to endorse legalization than were technology-oriented physicians, including hospital-based specialists and orthopedic surgeons. Experience with the first year of legalized physician-assisted suicide in Oregon acknowledges the great emotional toll on physicians directly involved in its implementation.14 The emotional burden and the acknowledged complexities in caring for dying patients may make physicians involved in this process more reluctant to endorse legalization. An interesting corollary suggested by our findings is that physicians endorsing legalization were less comfortable with their medical school training in the psychosocial aspects of care and were rated poorer in the areas of interpersonal skills and attitudes and in socioeconomic aspects of patient care in the first year of residency.
It is not known to what degree opinions about legalization are subject to modification by educational experiences during medical school. A recent study that examined medical students' views on physician-assisted suicide found that fourth-year medical students in Oregon were less likely than were fourth-year medical students in other areas of the country to be willing to provide a patient with a lethal prescription.15 The authors suggested that a change in willingness to comply with legalized physician-assisted suicide might have occurred as a result of experience with such requests from dying patients.
Unlike many areas of medical education where knowledge is largely dependent on didactic teaching, care of the dying and attitudes towards assisted suicide are likely to be influenced primarily by personal experiences as well as the moral, ethical, and political tenets that adults bring to medical training. In addition to exploring more closely the relationship between these personal beliefs and attitudes, an important priority for research is to determine whether attitudes towards care of the dying and physician-assisted suicide could be modified by education. Evaluation of the impact of educational experiences such as structured exposure to palliative care or rotations in a hospice service for medical students and residents would help to answer these questions. As the U.S. health care system moves from theory to practice regarding physician-assisted suicide, more research is needed to explore further the impact of legalization on physicians and their patients.
The advantages of this survey include the large sample size, gender composition, and specialty and geographic distribution of the participants that represent a broad spectrum of the population of physicians. Despite these advantages, one limitation of our study is that it ascertained physicians' views of the legalization of assisted suicide rather than their views of its practice. However, the two concepts seem logically related. The primary purpose of the survey was to gather views of multiple issues in the current health care system, including attitudes toward legalization of assisted suicide. Another limitation is that the results of this study of young physicians who graduated from a single private medical school in the Northeast may not be fully generalizable to all U.S. physicians. However, the distribution of reactions is similar to that reported in the literature.2
As physicians hold an influential position in the public debate on the legalization and practice of physician-assisted suicide, it is important to further understand the bases for their strong and disparate views. Further research in this area should elucidate the political, moral, and ethical frameworks that physicians bring to this topic. Specifically, it is essential to understand the degree to which physicians' views on the legalization of physician-assisted suicide are subject to modification by medical education in general,16 and by experiences with dying patients in particular.
References
1. Meier DE, Emmons CA, Wallenstein S, et al. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med. 1998;338:1193-201.
2. Bachman JG, Alcser KH, Doukas DJ, et al. Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia. N Engl J Med. 1996;334:303-9.
3. Mebane EW, Oman RF, Kroonen LT, Goldstein MK. The influence of physician race, age and gender on physician attitudes toward advanced care directives and preferences for end-of-life decision-making. J Am Geriat Soc. 1999;47:579-91.
4. Schmidt TA, Zechnich AD, Tilden VP, et al. Oregon emergency physicians' experiences with, attitudes toward, and concerns about PAS. Acad Emerg Med. 1996;3:938-45.
5. Siaw LK, Tan SY. How Hawaii's doctors feel about physician-assisted suicide and euthanasia: an overview. Hawaii Med J. 1996;55:296-8.
6. Abramson N, Stokes J, Weinreb NJ, Clark WS. Euthanasia and doctor-assisted suicide: responses by oncologists and non-oncologists. South Med J. 1998;91:637-42.
7. Cohen JS, Fihn SD, Boyko, EJ, Jonsen AR, Wood RW. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med. 1994;331:89-94.
8. Ganzini L, Fenn DS, Lee MA, Heintz RT, Bloom JD. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry. 1996;153:1469-75.
9. Roberts LW, Roberts BB, Warner TD, et al. Internal medicine, psychiatry, and emergency medicine residents' views of assisted death practices. Arch Intern Med. 1997;157:1603-9.
10. Lee MA, Nelson HD, Tilden VP, Ganzine L, Schmidt TA, Tolle SW. Legalizing assisted suicide-views of physicians in Oregon. N Engl J Med. 1996;331:310-5.
11. Hojat M, Veloski JJ, Louis DZ, et al. Perceptions of medical school seniors of the current changes in the U.S. health care system. Eval Health Prof. 1999;22:169-83.
12. Hojat M, Veloski JJ, Borenstein BD. Components of clinical competence ratings: an empirical approach. Educ Psychol Meas. 1986;46:761-9.
13. Hojat M, Borenstein BD, Veloski JJ. Cognitive and noncognitive factors in predicting the clinical performance of medical school graduates. J Med Educ. 1988;63:323-5.
14. Chin AE, Hedberg K, Higginson GK, Fleming DW. Legalized physician-assisted suicide in Oregon-the first year's experience. N Engl J Med. 1999;340:577-83.
15. Mangus RS, Dipiero A, Hawkins CE. Medical students' attitudes toward physician-assisted suicide. JAMA. 1999;282:2080-1.
16. Barzansky B, Veloski JJ, Miller R, Jonas HS. Education in end-of-life care during medical school and residency training. Acad Med. 1999;74(10 suppl):S102-S104.
Section Description
Research in Medical Education: Proceedings of the Thirty-ninth Annual Conference. October 30 - November 1, 2000. Chair: Beth Dawson. Editor: M. Brownell Anderson. Foreword by Beth Dawson, PhD.