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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 55-59

Doctors' Perception of Assisted Death: The Effect of Career Stage


Department of Medicine, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission20-Aug-2020
Date of Decision02-Nov-2020
Date of Acceptance04-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Smitha Bhat
Department of Medicine, Father Muller Medical College, Kankanady, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BMRJ.BMRJ_11_20

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  Abstract 


Introduction: Doctors' role in care is changing to the extent that their responsibility now includes not only preserving life and its quality but extends to end of life care as well. Patients -are now asking for more autonomy in choosing the how and when of end of life care and processes. Doctors have different opinions regarding these methods of assisted death , and these opinions are determined by various personal and professional factors. Indian literature regarding the influence of career stage on doctors' approach to assisted death is scanty and our project aimed to assess this influence, as well as find the reasons for favouring or not favouing the various modalities of assisted death. Materials and Methods: In this study, a prevalidated, piloted questionnaire regarding the different types of assisted death was administered by the interviewer to professors, associate professors, assistant professors, senior residents and post graduate residents of a medical college. Results: Post graduate residents, senior residents and Assistant professors opined that Legalization of DNR, Physician assisted suicide and euthanasia might be acceptable under certain circumstances. Reasons for favouring assisted death included medical futility and patient suffering. Those who opposed assisted death did so on the grounds of medical ethics and humanity. Conclusion: Junior cadres tended to be more accepting of assisted death than their more senior colleagues.

Keywords: Assisted death, career stage, Euthanasia


How to cite this article:
Bhat S. Doctors' Perception of Assisted Death: The Effect of Career Stage. Biomed Res J 2020;7:55-9

How to cite this URL:
Bhat S. Doctors' Perception of Assisted Death: The Effect of Career Stage. Biomed Res J [serial online] 2020 [cited 2021 Oct 16];7:55-9. Available from: https://www.brjnmims.org/text.asp?2020/7/2/55/305767




  Introduction Top


Over the years, the physician's brief has been changed from merely curing disease and prolonging life, to one where they are expected to enhance the quality of existence, and in certain circumstances, provide symptom relief and comfort at the end of life. As medical technology prolongs, the process of dying, patients now request that they are given a certain degree of control over the how and when of death. Among doctors too, the idea of death is changing from that of an enemy that must be fought with, to an entity that is an inevitable part of life and must be accepted.

Globally, concepts and ideas that were previously vilified, such as withdrawal of life sustaining measures, physician-assisted suicide (PAS), and euthanasia have taken root, and indeed, are legal in some countries. In India at present, only withdrawal of life sustaining measures is legally acceptable.

There is an increasing amount of public and physician discourse on physician-assisted death.[1] Perhaps, this is a response to the prolonged process of dying, and futile processes to revive patients in technologically advanced intensive care units.[2] Terminally, ill patients are seeking a greater role in determining how and when they will die, and how much they would like to avail aggressive life sustaining measures.[3] While it is ethically and legally acceptable to refuse therapy at the end of life, the concept of seeking assistance to terminate life using a lethal medication is still controversial. Currently, there is a trend to increasing acceptance, and euthanasia is legal in some states of the United States and in the Netherlands and Switzerland.

Worldwide, doctors are the arbiters of care at end of life and more often than not, strongly influence what treatment options the patient receives at the end of life.[4] Therefore, it is essential to understand doctors' perceptions about assisted death.

A large number of physicians object to physician assisted death on the grounds that it undermines the sanctity of life, and also that it violates the physician's primary duty – the preservation of life.[5] Various studies have described physicians' attitude to assisted death, focusing on the religion and subspecialty of the physician.[6],[7],[8] There is scanty published literature from India about how career stage affects doctors' attitude to assisted death. Our study aimed to find whether career stage influences a doctor's attitude to assisted death.

Objective

The objective is to find whether an association exists between doctors' views on assisted death and career stage.


  Materials and Methods Top


The study was a cross-sectional interview-based study conducted on post graduate residents and faculty of cadres ranging from senior resident to professor of clinical departments in a medical college. Institutional Review Board approval was obtained for the study. Informed consent was taken from participants prior to the administration of questionnaire.

A questionnaire regarding attitude of student/doctor to various methods of assisted death was framed, piloted, and administered by an interviewer. On the questionnaire, participants were requested to specify their career stage, seniority as measured by age and number of years after graduation. Religious affiliation and the extent to which religion affected their decision-making were recorded.

Participants were asked to indicate their stance on the various methods of assisted death – withdrawal of life support, PAS, and euthanasia. They were asked to respond to open-ended questions to elucidate their attitude to various methods of assisted death. Reasons for choices were recorded. The open-ended questions were analyzed by content analysis.

Prior to the administration of the questionnaire, the definitions of Do Not Resuscitate (DNR), withdrawal of life support, euthanasia, and PAS were clarified to the subject. Data were tabulated and analyzed.


  Results Top


One hundred participants were invited for this study. They were 20 clinical postgraduates, 20 senior residents, 20 assistant professors, 20 associate professors, and 20 professors of clinical departments. Eighty-nine participants agreed to participate in the study. The average age of the participants was 38. Average number of years of experience after graduation was 12. Eighty-three percent of respondents considered themselves to be religious persons and said that religion played a role in their beliefs regarding end of life care. Respondent attitudes to DNR, PAS, and euthanasia are summarized in [Figure 1],[Figure 2],[Figure 3].
Figure 1: Attitude to euthanasia

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Figure 2: Attitude to physician assisted suicide

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Figure 3: Attitude to do not resuscitate

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  Discussion Top


This project aimed to study doctors' attitudes to assisted death, and the influence of career stage on their belief. Studies in many centers have explored the attitudes of various health care professionals and lay persons to assisted death in different forms. The effect of religion, nationality, and medical/surgical specialty has been elucidated. Nevertheless, important lacunae in information remain. Published literature regarding the effect of age and career stage on attitude to assisted death of doctors in India is scanty.

We clarified the following definitions to the participants before they used the questionnaire.

  1. Withdrawal of life support (passive euthanasia): Medical treatment is withdrawn when further treatment appears futile with the deliberate intention to hasten the death of a terminally ill patient


  2. Here, though symptom relief is provided, life saving measures such as assisted ventilation and inotropic support to maintain the blood pressure are discontinued.

  3. DNR Instruction telling medical staff not to attempt to resuscitate the patient if the patient has a cardiorespiratory arrest


  4. All medical treatment continues as before. Only in the event of a cardiorespiratory arrest is resuscitation withheld.

  5. PAS is the voluntary termination of one's own life by taking lethal medication with the assistance of a physician. The physician's role here is limited to prescribing the life taking medication
  6. Euthanasia-literally means “good death.” It is the painless killing of a patient suffering from an incurable and painful disease or in an irreversible coma. Here the health care professional or care giver is directly involved in administering the life limiting medication to the patient.


The majority of respondents in our study opposed PAS and euthanasia. The attitude of doctors in 4 medical colleges in Mangalore was studied, and slightly less than half of them agreed that when used correctly, PAS and euthanasia could ameliorate the financial and emotional burden of patients and their caregivers.[9] This was in contrast to a study done in the United Kingdom that showed that U. K. doctors opposed euthanasia.[10]

It is interesting to note that unlike medical professionals, the general public in countries like the United Kingdom is generally in agreement with the concept of euthanasia. They are aware that physician assisted death and euthanasia are legal in some nations, and many doctors have received requests for euthanasia.[11]

Career stage and age

Our study showed that stage of career significantly influenced attitude to euthanasia. Junior doctors, when compared to their seniors, were more likely to opine that withdrawal of care, PAS, and euthanasia were valid end of life options and must be offered to patients. In contrast to this, in a study done in Wales, junior doctors were more interventionist than their seniors, and tended to use aggressive life prolonging measures more, sometimes, regardless of their patients wishes, or an inability to express those wishes.[12] research from Finland also shows that younger doctors tend to oppose assisted death.[13] However, most research shows that older doctors are less likely than their juniors to favorably consider a request for assisted death.[14] This might be because older doctors have treated more terminally ill patients and are thus more aware of pain relief alternatives.[15] It could also be that younger doctors are more open to the relatively unconventional ideas of assisted death.[16] In addition, they be more intolerant to life with permanent disability, making them more likely to accede to a request for assisted death as an alternative to a painful and life limiting illness.[17]

Other factors which have been found to influence euthanasia include religiosity, subspecialty of medicine in which doctor is trained, and gender (with females tending to oppose euthanasia more than males).[18]

Scenario in India

It is difficult to discuss euthanasia in India without referring to the highly emotive Aruna Shanbhaug case. Ms. Shanbhaug was a nurse in a medical college hospital in the metropolis of Mumbai who was strangulated with a dog chain by a ward boy. She suffered irreversible brain damage due to hypoxia and lived in a persistent vegetative state for years, being cared for by the nursing staff of the hospital. A petitioner moved the court to stop her artificial nutrition and other care. This was opposed by the nursing staff. Doctors opined that the patient was in fact not brain dead and the petition to withdraw her care and artificial nutrition was rejected. However, the court on that occasion in 2011 passed the passive euthanasia law where it permitted withdrawal of artificial support of life from a patient not capable of making an informed decision.[19]

In spite of this landmark judgment, at present, apart from withdrawal of life support, none of the other methods of euthanasia are legal in India, though some doctors are working toward the legal acceptance of DNR.

Religion

In our study, 83% of the respondents considered themselves to be religious persons. They said that religion influenced their decision making about end of life issues. Not all studies show an influence of religion on attitude to PAS. However, the majority of research done till date shows that religiosity is inversely related with a positive attitude to assisted death.[20] Research has shown that doctors without formal religious affiliation were more likely to be sympathetic to the idea of euthanasia.[21] It is worth noting that religion plays a major role in the decision-making process of most Indians, even doctors, and the two main religions of India namely Hinduism and Islam proscribe suicide and euthanasia. According to Islam euthanasia is “haram,” and the right of the person to die voluntarily is not recognized. Muslims believe that all life is sacred, and human beings should not interfere in how long a person will live.[22] According to Hinduism, ending another person's life will invite Karmic retribution.[23]

Medical futility

Respondents in our study frequently referred to medical futility as the reason for supporting DNR, PAS or euthanasia [Table 1],[Table 2],[Table 3]. Medical futility is when a patient's condition is deemed by experts to be “untreatable, irreversible and unresolvable.”[24] Subjecting patients to treatment that is futile would impose a burden of pain, unhappiness and costs, both on the patients and his/her caregivers, and not yield concrete benefit.
Table 1: Legalization of Do Not Resuscitate

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Table 2: Legalization of Physician Assisted Suicide

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Table 3: Legalization of Euthanasia

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Factors influencing practice of euthanasia among doctors

While it can be argued that autonomy includes the right to die, it is also true that life is precious, and death must not be taken lightly. It may be worthwhile to explore reasons why the younger doctors were overwhelmingly in favor of physician assisted death, and to raise the question whether it is something in the training or curriculum that makes them think the way they do. Is it, for example, due to a lack of training in end of life care?

Medical Students do not receive formal training in the concept of “Medical Assistance in Dying.” In one study Canadian students supported the idea of medical assistance in dying and requested more training in the same.[25]

It was found that nonmedical students and 1 year medical students were in favor of always attempting resuscitation and life saving measures when compared to more senior students, however a surprisingly large number of year 1 students opined that it was acceptable to administer life terminating drugs to patients with a very poor prognosis.[26]

Emanuel et al. found that oncologists who had received adequate training in end of life care were less likely to have been involved in assisted death.[27] Physicians who have received training end of life care are less likely to accept requests for euthanasia, and more likely to oppose the legalizing of Physician assisted death.[27] The general perception is that palliative care and euthanasia serve opposite causes and are based on opposing ideologies. Palliative care seeks to remedy the pain and suffering which prompts many patients at end of life to seek PAS. It neither hastens nor delays death.[28] Education in palliative care at the undergraduate level is receiving more attention,[29] and this may improve end of life care, and conceivably diminish the demand for euthanasia.

It would be interesting to follow-up this cohort of junior doctors and find whether their attitudes to euthanasia change with time.


  Conclusion Top


In our study, we found that when compared to their senior colleagues, junior doctors had a strikingly higher acceptance of the concepts of various modalities of assisted death. Whether this is due to a lack of training in palliative care and pain relief remains to be explored.

Acknowledgement

Dr. Dipti Kamath.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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