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Physicians' Attitudes Toward Euthanasia and Assisted Suicide in Italy

Open ArchivePublished:September 17, 2018DOI:https://doi.org/10.1016/j.jpainsymman.2018.09.007
      Dear Editor
      Euthanasia and assisted suicide are matter of discussion all over the world.
      • De Lima L.
      • Woodruff R.
      • Pettus K.
      • et al.
      International association for hospice and palliative care position statement: euthanasia and physician-assisted suicide.
      In Italy, many cases raised by media recently provided the impetus for a new law regulating the living will. Of concern, it has been recently reported that there is a lack of knowledge among patients about the meaning of end-of-life issues.
      • Mercadante S.
      • Costanzi A.
      • Marchetti P.
      • Casuccio A.
      Attitudes among patients with advanced cancer toward euthanasia and living wills.
      Physician-assisted suicide and euthanasia have been increasingly debated in the public arena, and in some European countries, legislation exists to regulate these end-of-life issues.
      • Emanuel E.J.
      • Onwuteaka-Philipsen B.D.
      • Urwin J.W.
      • Cohen J.
      Attitudes and practices of euthanasia and physicians-assisted suicide in the United States, Canada, and Europe.
      Euthanasia and assisted suicide have been legal in The Netherlands and Belgium since 2002. Assisted suicide is permitted in Switzerland, although no specific legislation exists. When both practices exist, euthanasia occurs more frequently than assisted suicide. It also has been reported that legalization of assisted suicide only, but not euthanasia, seems to limit the number of hastened deaths and their increase over time.
      • Gamondi C.
      • Borasio G.D.
      • Limoni C.
      • Preston N.
      • Payne S.
      Legalisation of assisted suicide: a safeguard to euthanasia?.
      The ethics of these practices remain controversial.
      • Yang Y.T.
      Why physicians should oppose assisted suicide.
      In Italy, these procedures are illegal but highly debated. Media have frequently highlighted the news of patients who move to the near Switzerland to perform assisted suicide in special clinics.
      The increasing legalization of euthanasia and assisted suicide worldwide makes it important to understand the related attitudes and practices in each country.
      • Emanuel E.J.
      • Onwuteaka-Philipsen B.D.
      • Urwin J.W.
      • Cohen J.
      Attitudes and practices of euthanasia and physicians-assisted suicide in the United States, Canada, and Europe.
      Limited information is available about the attitudes of physicians who are involved in these decisions nor is their availability to perform euthanasia and assisted suicide known. Thus, a survey was planned among physicians belonging to a list of participants to Home Care-Italy events and to a visiting program at La Maddalena Cancer Center during the last three years to assess their attitudes toward euthanasia and assisted suicide and their availability to personally perform these practices.
      Four hundred forty-four physicians were contacted via e-mail to take part in the study and to fill in a questionnaire (Table 1). E-mails were resent four times. Anonymity was promised.
      Table 1Questionnaire and Responses
      In favor of euthanasian (%)
       Yes75 (36.2%)
       No130 (62.8%)
       Don't know2 (0.97%)
      In favor of assisted suicide
       Yes74 (35.9%)
       No130 (63.11%)
       Don't know2 (0.97%)
      Would you personally practice euthanasia?
       Yes58 (28.9%)
       No147 (71.7%)
      Would you personally practice assisted suicide?
       Yes63 (30.4%)
       No142 (68.6%)
       Don't know2 (0.97%)
      Descriptive statistics have been provided both for continuous and categorical variables. Statistical association between specialization, gender, setting, and the macroareas against the questionnaire's items was tested using point biserial correlations or the Fisher exact test, assuming a 5% Type I error. Furthermore, we carried out two component-wise analyses to detect the weight of each two components, given a statistically significant association. The correlation structure among items was calculated using the Spearman correlation coefficient. The null hypothesis that the correlation was zero has been tested, adjusting the level with Bonferroni's correction. A coherence items' analysis has been carried out using the Cronbach's alpha, stratifying for the religious belief. The analysis was performed using the statistical software STATA (Version 14).

      Results

      Two hundred seven participants responded to the questionnaire (46.6%). The mean age was 48 years (SD 10.4), and 96 (46.4%) were male. The other characteristics of physicians who agreed to participate are listed in Table 2. Physicians working in hospice or home care (31.9%) were more likely to be in favor of euthanasia (P < 0.0001, Fisher exact test). Specialization and years of experience in palliative care did not influence acceptability of euthanasia (P = 0.14 and P = 0.264, respectively, Fisher exact test). The younger physicians were more likely to be in favor of euthanasia (P = 0.003, point biserial correlations).
      Table 2Characteristics of Respondents
      Macroareasn (%)
       North71 (34.3%)
       Center65 (31.4%)
       South40 (19.3%)
       Islands27 (13.0%)
       Foreigner4 (1.9%)
      Background specialization
       Oncology73 (36.98%)
       Anesthesiology69 (34.8%)
       Radiotherapy8 (4.0%)
       Geriatrics7 (3.5%)
       Others or none41 (20.7%)
      Setting of work
       Hospice/home care87 (45.3%)
       Medical oncology unit47 (24.5%)
       Anesthesia and intensive care unit27 (14.1%)
       Outpatient pain clinic19 (9.9%)
       Others12 (6.2%)
      Experience
       1–5 yrs39 (18.8%)
       6–10 yrs20 (9.7%)
       11–15 yrs43 (20.8%)
       16–20 yrs37 (17.9%)
       >20 yrs68 (32.5%)
      Religions
       Practicing Catholic73 (35.4%)
       Nonpracticing Catholic81 (39.3%)
       Others religions5 (2.4%)
       Atheist47 (22.8%)
      Physicians living in the Northern macroarea (32%) were more likely to be in favor of euthanasia than physicians living in the central Italy (26.7%), islands (26.7%), and Southern macroarea (13.4%) (P = 0.001, Fisher exact test). Atheists were more likely to be in favor of euthanasia (44.6%) than nonpracticing Catholics or practicing Catholics (41.9% and 12.2%, respectively, P = 0.000, Fisher exact test). Nonpracticing Catholics (42.5%) were more likely to be in favor of assisted suicide than practicing Catholics (16.5%), and atheists (38.4%) (P < 0.001). Years of experience, gender, and geographic macroarea did not influence the choice of assisted suicide (P = 0.374, P = 0.587, and P = 0.770, respectively, Fisher exact test).
      The Cronbach test revealed a good, but not excellent, consistency among euthanasia, assisted suicide, and being willing to perform them personally (Cronbach's alpha 0.84). Atheists had a degree of consistency (Cronbach's alpha 0.77) less than practicing Catholics (Cronbach's alpha 0.80), and it was highest among nonpracticing Catholics (Cronbach's alpha 0.89).

      Comment

      In this survey, about 1/3 of the sample, particularly those living in the Northern macroarea, working in hospice or home care, were younger, and were Atheist, were in favor of euthanasia and assisted suicide, although they were not always available to personally perform these procedures. Of interest, although a higher consistency was expected among atheists, a better correlation was found among nonpracticing Catholics.
      Euthanasia and assisted suicide are increasingly being legalized and principally involve patients with cancer.
      • Emanuel E.J.
      • Onwuteaka-Philipsen B.D.
      • Urwin J.W.
      • Cohen J.
      Attitudes and practices of euthanasia and physicians-assisted suicide in the United States, Canada, and Europe.
      In a country like The Netherlands, physicians have more reservations about less common reasons such as psychiatric or psychological condition, dementia, or being tired of living. Some clinics perform these practices in patients whose regular physicians reject their request. In a study of the first year of activity in a clinic for assisted suicide in The Netherlands, physicians and nurses often confirmed the assessment of the previous physician but rejected about half of the requests, presumably because the legal criteria had not been met.
      • Snijdewind M.C.
      • Willems D.L.
      • Deliens L.
      • Onwuteaka-Philipsen B.D.
      • Chambaere K.A.
      Study of the first year of the end-of-life clinic for physician-assisted dying in The Netherlands.
      Of interest, the hypothesis that legal regulation of physician-assisted suicide can negatively affect the development of palliative care is not supported by the Belgium and Benelux experience. Indeed, regulation appeared to have promoted the expansion of palliative care.
      • Chambaere K.
      • Bernheim J.L.
      Does legal physician-assisted dying impede development of palliative care? The Belgian and Benelux experience.
      Although existing data do not indicate widespread abuse of these practices in North America and Europe,
      • Emanuel E.J.
      • Onwuteaka-Philipsen B.D.
      • Urwin J.W.
      • Cohen J.
      Attitudes and practices of euthanasia and physicians-assisted suicide in the United States, Canada, and Europe.
      a recent position paper of the International Association for Hospice and Palliative Care states that palliative care units should not be responsible for overseeing or administering these practices in countries where euthanasia and/or assisted suicide are legal, and any health professional who objects must be allowed to deny participating.
      • De Lima L.
      • Woodruff R.
      • Pettus K.
      • et al.
      International association for hospice and palliative care position statement: euthanasia and physician-assisted suicide.
      In a white paper of European Association for Palliative Care, a complete consensus seemed to be unachievable due to incompatible normative frameworks.
      • Radbruch L.
      • Leget C.
      • Bahr P.
      • et al.
      Euthanasia and physician-assisted suicide: a white paper from the European Association for Palliative Care.
      In a German study of the willingness of professionals to take action as regards euthanasia and assisted suicide, the rate of actual willingness to perform life-ending measures was low, as opposed to the general acceptance that was high.
      • Zenz J.
      • Tryba M.
      • Zenz M.
      Palliative care professionals' willingness to perform euthanasia or physician assisted suicide.
      A survey of Australian palliative care specialists showed a large opposition to the legalization of assisted suicide.
      • Sheahan L.
      Exploring the interface between 'physician-assisted death' and palliative care: cross-sectional data from Australasian palliative care specialists.
      A questionnaire-based survey suggested that the majority of Danish geriatricians are against euthanasia.
      • Ilvemark J.
      • Dahle B.
      • Matzen L.E.
      Questionnaire-based survey suggests that the majority of Danish geriatricians are against euthanasia.
      In a qualitative study with Dutch general practitioners, it was observed that tension can arise between physicians' views on death and dying, and the views and preferences of their patients.
      • Ten Cate K.
      • van Tol D.G.
      • van de Vathorst S.
      Considerations on requests for euthanasia or assisted suicide; a qualitative study with Dutch general practitioners.
      Finally, limited information is available on future generations of physicians. According to a medical student's perspective, euthanasia and assisted suicide are not in line with the core principles of medicine and that the focus should be rather on providing high-quality end-of-life and palliative care.
      • Rhee J.Y.
      • Callaghan K.A.
      • Allen P.
      • et al.
      A medical student perspective on physician-assisted suicide.
      In Germany, the majority of students surveyed wrongly assumed that assisted suicide was a punishable offense, although most of them considered assisted suicide ethically acceptable, compared to euthanasia.
      • Anneser J.
      • Jox R.J.
      • Thurn T.
      • Borasio G.D.
      Physician-assisted suicide, euthanasia and palliative sedation: attitudes and knowledge of medical students.
      Study limitations of this survey include the convenience sample and the incomplete list of physicians existing in Italy interviewed. Nevertheless, the sample could be representative of the palliative care world in Italy. There was also a little space for more detailed and descriptive answers due to no open-ended questions. Close-ended questions were aimed to get clear, straight answers to important issues.

      Conclusion

      Data reported in this survey, as in other studies in countries where euthanasia and assisted suicide are allowed, show the complexity and the variability of physicians' attitudes toward euthanasia and assisted suicide as well as the difficulties in the application of these practices. Further studies should analyze the conditions for which euthanasia and assisted suicide would be accepted, for example, terminal diseases or not, life expectancy, and so on.

      Disclosures and Acknowledgments

      There is no conflict of interest to declare. The authors thank all the participants of HOCAI group (home care–hospice–group for the study of palliative care).

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