Keywords

1 Introduction

The term Euthanasia derives from the Greek euthanatos, which can be translated as ‘a good death’. More specifically, it can be defined as a process aimed at causing the patient’s death, with a view to minimizing his or her suffering. Within this category a distinction is often drawn between active and passive euthanasia (Reichenberg 1987). The difference is that while the former requires a positive act on the part of a person performing euthanasia, the latter is based on withdrawing or withholding a life-sustaining treatment. It appears to be fair to argue that, in general, passive euthanasia enjoys more support than active euthanasia. Both types of euthanasia, however, are highly controversial issues. Opponents criticize them as highly immoral and contrary to the public interest. Euthanasia is also contrary to the views of numerous major religions. On the other hand, proponents of euthanasia tend to argue that the individual freedom should extend to the level at which one is able to decide whether or not he would like to have his life sustained, where no hope of recovery exists and considerable suffering is involved.

The problem becomes more important as progress in medical science makes it possible to keep terminally ill patients and people in persistent vegetative state alive for many years (Yun et al. 2011). Mass media present numerous instances of such a dramatic cases. This includes those of Eluana Englaro, Terry Schiavo, and Diane Pretty. The example of Diane Pretty in the UK involved a woman suffering from a terminal disease attempted to influence a change in the legislation concerning euthanasia in her country. Her appeals to the public, in which she proclaimed: ‘I want to have a quick death without suffering, at home surrounded with my family’ did not persuade lawmakers (MacDonald 2008). The British Courts refused to recognize a right to die. Many people share this opinion, believing that life is of supreme value, and that no one should be allowed to assist another in committing suicide. Those who oppose this view, on the other hand, emphasize that the value of life cannot be isolated from the issue of quality of life. No satisfactory solution of the matter in dispute has been reached to date. However, this problem should be examined and solved very quickly, because it is a source of suffering for patients or for their relatives and friends.

The moral, philosophical, and religious controversy over euthanasia is also reflected in legislation. There are only three countries in Europe that allow active euthanasia: Belgium, Luxemburg, and the Netherlands. They are followed by Switzerland and, more recently by Germany, which permit an assisted suicide. In other European countries such as the UK, France, Ireland, and Poland, active euthanasia constitutes a criminal offence, but passive euthanasia is permissible in some circumstances. It is also worth noting that in many of the countries the anti-euthanasia laws are not fully enforced and that despite its potential for punishment, prosecutions are not always brought up (Griffiths et al. 2008).

Many studies have been conducted to explore perspectives on euthanasia and its legalization. The main participants of the studies were medical students and medical practitioners, who observe life-threatening events suffered by patients (Cuttini et al. 2004; Beder et al. 2010). Different results have been achieved dependent on cultural factors, systems of values, knowledge, and the legal status of euthanasia (Cuttini et al. 2004; Iglesias et al. 2011). Generally, attitudes toward euthanasia are more positive in those countries where voluntary euthanasia is permitted, such as the Netherlands and Belgium. A survey conducted among Belgian medical personnel demonstrated that a broad spectrum of attitudes exists toward euthanasia among medical practitioners. The respondents were then divided into several sets. The first group included 23 % of all palliative care physicians and nurses who took part in a survey. The members of this group were convinced that euthanasia should be avoided as far as possible. However, they were unwilling to fully exclude voluntary euthanasia as a possibility in extreme circumstances. They also generally agreed that euthanasia was made superfluous by palliative sedation. Participants of a second group (35.2 %) were identified as ‘moderate advocates of euthanasia’. Those who were included in this group had significant doubts regarding the appropriateness of voluntary euthanasia in particular cases, such as in under aged and demented patients. However, in general they favored a broader application of voluntary euthanasia. The third and largest group (41.8 %) of all respondents exhibited the most liberal attitude toward voluntary euthanasia. They only barely wanted to fully exclude the possibility of euthanasia in the case of minors or demented persons. Most of them were against non-voluntary euthanasia, but a majority of the group held a positive view of a law regulating non-voluntary euthanasia (Broeckaert et al. 2010).

Extremely different attitudes toward euthanasia were revealed in Pakistan. Around 60 % of participants saw euthanasia as murder and over 70 % considered it to be unethical. The right to die based on the patient’s wish was respected by 16.2 % of medical students and 5.8 % of practitioners. The legalization of euthanasia in Pakistan was favored by 15.4 % of practitioners, compared with 10.4 % of students. The study also revealed that nearly half of the participants would not trust doctors if euthanasia became legal. Both students and doctors were strongly opposed to the performance of euthanasia in their country in the future (Hasan et al. 2012). Meade (1992) emphasized that physicians, nurses, and students of medical sciences have studied idealistic ethics of care, but in the workplace they make decisions that did not always reflect the theoretical ethics and once confronted with the issue in practice they do not always follow those ideals. Research indicates that more than half of Swedish oncologists declare they have heard their patients expressing a wish to pass away on their own. About one-third of them have provided the drugs or medicines in such doses that some of their patients’ deaths were hastened (Valversius et al. 2000). Interesting data concerning euthanasia can be found it a report prepared by Dutch scientists, which includes an evaluation of the procedure. In the Netherlands, physicians must report euthanasia and physician-assisted suicide to enable a review by one of five regional multidisciplinary review committees. In this way it is possible to collect data about the motives of patients who request active euthanasia. The research indicates that ‘physicians reported that the patient’s request was well-considered because the patient was clear-headed (65 %) and/or repeated the request several times (23 %). Unbearable suffering is often substantiated with physical symptoms (62 %), loss of ability (33 %), dependency (28 %), or deterioration (15 %). In 35 % of the cases, physicians report that there have been alternatives to relieve patients’ suffering, however the patient refuses to accept proposed form of treatment (Buiting et al. 2009).

Although most studies have focused on attitudes toward active euthanasia, some also explore beliefs about passive euthanasia. One issue raised by Broeckaert et al. (2010) in their research conducted in Belgium has been: ‘In my opinion, there is a huge ethical difference between, on the one hand, withholding life-prolonging treatment (e.g., artificial nutrition and hydration), and, on the other hand, active termination of life (non-voluntary euthanasia) and (voluntary) euthanasia’. Over 90 % of nurses and 80 % of physicians studied have agreed with this opinion. The problem of euthanasia has attracted a large amount of attention around the world. For this reason, study dedicated to this issue in Poland might also produce interesting results. The authors of the present article were particularly interested in whether there would be a uniformity between the doctrine of the Catholic church, which condemns euthanasia, and the personal views of respondents, in particular bearing in mind the fact that almost 90 % of Poles declare themselves as Catholics.

2 Methods

The Institutional Board for Human Research approved this survey study. The study consisted of two separate stages. In the first stage, the questionnaire called Attitude Toward Euthanasia was developed de novo by A. Glebocka and A. Gawor, the coauthors of this article. The development and verification of the questionnaire was carried out in a group of 108 randomly selected lay persons of different age and profession: 44 men and 64 women, mean age of 36 ± 12 years. The questionnaire consisted of 46 statements. Although the tool’s reliability was deemed satisfactory (Cronbach’s alpha = 0.83), it appeared appropriate to carry out a factor analysis (Varimax standardized) the pertinence index and to simplify the structure of the method. As a result, three components (factors) were distinguished, accounting for a total of 16.7 % variance. The first one, encompassing 12 statements, was called the informational support component; the second one consisted of 9 statements and was referred to liberal attitudes toward euthanasia; and the third one included 7 items designed to measure traditional and conservative attitudes. Examples of the items include statements such as: Factor I – (1) At every stage of treatment, patient’s relatives should have access to psychological support; (2) Relatives should be given the opportunity to say goodbye to the dying patient; Factor II – (1) Each individual has the right to decide whether he or she wishes to continue living or not; (2) Where medicine is helpless and there is no hope of recovery, the patient’s death should be facilitated; Factor III – (1) No one has the right to decide whether he or she wishes to continue living or not; (2) A patient’s life should be sustained at any cost and regardless of suffering to the patient involved.

In the second stage of the study, the questionnaire developed as above outlined was applied to 92 participants: 27 physicians and 34 nurses working in Intensive Care and Oncology Units and 31 people uninvolved with medical profession; mean age of 36 ± 10 years. Almost 17 % of the participants were caring for disabled relatives.

Data collected from the Attitude Toward Euthanasia Questionnaire in the form of raw scores were analyzed using a multivariate analysis of variance (MANOVA). Statistically significant differences were set at p < 0.05.

3 Results

Two different grouping factors were applied to the multivariate analysis of variance of the results of the Attitude Toward Euthanasia Questionnaire: (1) grouping factor based on participants’ profession (physicians vs. nurses vs. control group) – there were significant differences between the groups, Lambda Wilksa = 0.837, F (6.154) = 2.376 (p < 0.5); (2) grouping factor: looking after handicapped relatives (family caregivers vs. people having no experience with the terminally ill) – there were no significant main effects between the groups: Lambda Wilksa = 0.960, F(3.78) = 1.056 (p > 0.05).

The post hoc Scheffe’s test showed significant differences among the mean scores of the three factorial subclasses of the questionnaire: informational, liberal, and conservative, as outlined in the methods above, without regard to occupational affiliation. All three factor-groups, however, strongly agreed that informational and psychological support should be provided, to both patients and their relatives. Moreover, in each of the factor-group, liberal attitudes were stronger than the conservative ones. Interestingly, the research also demonstrated the least support for the conservative views among the physicians; this result was appreciable different from that in the control group (Table 55.1).

Table 55.1 Attitude towards euthanasia questionnaire
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Analysis of the mean results for particular items in the questionnaire indicated significant differences between the physicians and the control group (see Table 55.2). The research demonstrates that, when compared with the control group, the physicians are supportive of passive euthanasia. They are, however, much less in favor of active euthanasia. In so far as the active euthanasia is concerned as many as 65.38 % of physicians oppose it, while only 25 % members of the control group share such views. Active euthanasia is supported by 23 % of the physicians and 35.72 % of the control group participants. By contrast, when it comes to passive euthanasia, 7.7 % of physicians oppose it, and in the control group this number was 21.43 %. Support for this type of euthanasia amounts to 69.23 % for the physicians and 39.29 % of the control group.

Table 55.2 Attitude Toward Euthanasia Questionnaire: mean results for particular items – comparison between physicians and control group
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4 Discussion

The aim of the present study was to investigate whether the views of professional medical personnel can be distinguished from those of people from other backgrounds. It was assumed that such differences might occur for a variety of reasons, most importantly because professional medical personnel have specific education and training and due to the fact that they have day-to-day exposure to patients in a vegetative state. The research demonstrates that medical staff had a mildly positive attitude toward the liberal views, and that support for liberal views among the control group was at approximately the same level (Yun et al. 2011). Regarding conservative attitudes, all the groups had limited sympathy for such views. In particular, the physicians turned out to have the least conservative attitudes.

All of the groups favored providing passive euthanasia. This type of euthanasia was supported by the physicians in particular. Support for active euthanasia was more limited (Beder et al. 2010). Members of the control group approved of this type of euthanasia, but to a much lesser extent than the passive one. A noticeable difference between the two types of euthanasia occurred among the physicians. This group was more favorable towards passive euthanasia, but strongly opposed active euthanasia. The research also demonstrates strong and uniform support for the notion of providing terminally ill patients and their relatives with informational and psychological support.

The authors of this article are aware that the groups, however adequate for the present study, are not representative of the whole population of Poland. For that reason, a more general study on the views of the public would be welcomed. Moreover, it seems that investigating the causes for physicians’ rejection of active euthanasia demands further research. This issue seems to be especially interesting when one takes into account the fact that this group represented itself as the one that is least influenced by religion in their attitudes towards euthanasia. Finally, the authors believe it would be interesting to see if the age or the area of specialization of the physician has a significant influence on their views. The intended scope of the present research did not allow this to be explored, but it is the authors’ hope that the influence of such factors will be investigated in subsequent studies.