Attitudes among Swedish medical students towards assisted dying

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Degree project, 30 ECTS December 30 2020

Attitudes among Swedish medical students

towards assisted dying

Version 2

Author: Benjamin Hegarty, MB

School of Medical Sciences Örebro University Örebro Sweden

Supervisor: Rolf Ahlzén, MD, PhD

Camtö, USÖ, Örebro Region of Värmland, Karlstad Sweden Word count

Abstract: 249 Manuscript: 4231

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Abstract

Introduction

Over the last decades a positive shift in attitudes towards legalisation of assisted dying (AD) (AD including euthanasia (EUT) and physician-assisted suicide (PAS)) have occurred in western Europe. Physicians are generally more negative than the general public toward legalisation. Medical students’ attitudes, as future practitioners, are important to assess when addressing this ethically complex issue.

Aim

The aim was to explore the attitudes among medical students at Örebro university, Sweden regarding assisted dying and their stance on the legalisation of assisted dying and to evaluate if religious beliefs, current term of study, gender, and a shift of legal framing would affect medical students´ attitudes.

Methods

A cross-sectional online-based anonymous survey containing eight different patient scenarios was distributed to all medical students enlisted at Örebro university Sweden (n=657).

Association between demographics and positive attitudes towards AD was tested using logistic regression, and McNemar for difference of proportion in attitudes between various scenario framings.

Results

Thirty five percent (n=229) of the medical students responded with completed questionnaires. Sixty percent of the respondents believed PAS for terminally ill patients should be legalized in Sweden. Shifting of legal framing resulted in statistically significant differences of position in all eight scenarios (p<0.05). Strong religious beliefs were associated with decreased

likelihood for positive attitudes towards AD in scenario 1-6 (p<0.05).

Conclusions

Most respondents in this study believed PAS should be legalised. Held attitudes toward AD were affected by religious beliefs and legal framework. Additional studies to further explore medical students´ attitudes are deemed necessary.

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Abbreviations

AD – Assisted dying EUT – Euthanasia

IVO - The Health and Social Care Inspectorate MS – Medical students

PAS – Physician assisted suicide

SLS – The Swedish Society of Medicine

Smer - The Swedish National Council on Medical Ethics WMA – World Medical Association

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Introduction

The Swedish term “dödshjälp” (directly translated as “death help”) is used as a term for euthanasia (EUT) and physician assisted suicide (PAS)[1]. In this paper assisted dying (AD) will be used as an umbrella term for EUT and PAS[2], using the definition provided by The Swedish National Council on Medical Ethics (Smer): “A procedure performed after an

explicit request by a patient, where the intention is that the procedure will lead to the patient´s death.”[3] AD does not in this paper include the termination or withdrawal of medical

treatment or life support. Neither does AD include end-of-life treatment where a foreseeable but not sought effect of the treatment is the hastening of the patients´ death. EUT is when the decisive act of AD that instantly and deliberately leads to death is carried out by a physician (by administration of a lethal dose of drugs), and PAS is when the decisive act of AD that leads to death is carried out by the patient (where a lethal dose of drugs is prescribed to the patient, with the knowledge that the patient will use it to end his/her life).

Definitions of AD, EUT and PAS differ in countries and cultural contexts, and other terminology is also used, causing confusion when discussing assisted dying practises[2]. “Assisted dying” is also used as a term for physician-assisted suicide /physician-assisted death[4], often referring to the “Oregon model” which is advocated by organisations campaigning for the legalisation of different forms of assisted dying[5]. Suicide as a term describing practices of AD is by some of those advocating AD deemed inappropriate as it is not an act sought under the same context as suicide is considered to be[6], but by some of those opposing legalization suicide is the correct term, and using other terms would be to embellish the gravity of the matter[7]. The predominant term in research for when a

physician, at the patients´ explicit request, prescribes drugs knowing that the patient intends to use them to end its life, is PAS[8], and will be used in this paper. EUT is legal in seven different jurisdictions: Belgium, Canada, Colombia, Luxemburg, Netherlands, Victoria (Australia) and Western Australia. PAS can be legally practiced in ten US jurisdictions, as well as Switzerland [2].

Attitudes toward AD have shifted over the last decades, becoming more positive in the western parts of Europe[8]. This applies to the general population as well as among

physicians and medical students (MS)[9–11]. Physicians are more negative towards assisted dying than the general public[12,13]. Results in surveys about AD can be affected by how

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questions are phrased, different response alternatives, and what information is given in the survey[14,15]. In Oregon, there was seen a drop by 10-12 % in support of the dying with dignity act in the opinion polls, when the phrase “dying with dignity” was replaced with “euthanasia” or “suicide”[16]. Previous studies regarding attitudes among MS towards AD have shown different results, with great difference depending on the country in which the study took place. Most studies covered either EUT or PAS, or different end of life-related attitudes. They differ in design and method[11,17–26].

Support for EUT increased from 16% to 49 % among MS in Austria from year 2001 to 2009, with arguments for patient autonomy increasing in strength[11]. In several studies religious beliefs have been seen to affect the attitudes toward AD [18,19,21,23,27,28]. There are variable results for the influence of gender on held attitudes. [29,30]. Attitudes shifted towards becoming more negative in later terms of medical education in some studies [31], and attending different universities was seen to affect held attitudes in others[18,21,32]. The death of a relative, or experience of giving care professionally to a dying patient, indicated strengthening of the position already taken on AD, but not shifting it toward a certain standpoint[33]. When AD was framed as legal there was a shift in the attitudes among MS who initially were negative[19].

A study in 2006 explored the attitudes toward EUT among Swedish MS, showing a majority (52%) with negative attitudes towards euthanasia, although only 18 % were not willing to consider euthanasia as an option for themselves in the future[20]. Euthanasia is illegal in Sweden[34]. Assisting a suicide is not a crime in Sweden, but it is regarded that PAS is a breach of the ethics of the medical profession, and not admissible under Swedish laws regulating health care[3]. A retired Swedish physician enabled a man suffering from Amyotrophic lateral sclerosis (ALS) to undergo PAS in July 2020[35]. The physician is under investigation from The Health and Social Care Inspectorate (IVO) and risks having his medical license withdrawn[36]. With almost every legal model of AD involving physicians, a legalisation of assisted dying in Sweden will potentially affect the premises of future working life for MS, and thus their attitudes towards the subject is worth further exploration.

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Aim

The aim was to explore the attitudes among medical students at Örebro university, Sweden regarding assisted dying and their stance on the legalisation of assisted dying and to evaluate if religious beliefs, current term of study, gender, and a shift of legal framing would affect medical students´ attitudes.

To do so the following research questions were formulated:

- What are the attitudes among medical students towards legalisation of assisted dying, and would held attitudes towards assisted dying shift if it were considered legal? - Do religious beliefs, gender, and current term of study affect medical students’

attitudes towards assisted dying, and does differences in the patient’s situation, such as the presence/absence of a terminal disease, or unbearable suffering affect held attitudes?

Material and Methods

A cross-sectional survey (APPENDIX A) was conducted among MS attending Örebro university (Campus USÖ) in Sweden. It was an online anonymous survey, containing no individual identifiers, using the survey platform SurveyMonkey (surveymonkey.com). All enlisted students during autumn term 2020 (n=657) received information about the possibility to participate through the university´s digital platform as well as in the closed Facebook-group for medical students attending the university, with a link to the survey. Data was collected during October 2020.

The survey

A literature search was made prior to developing the questionnaire. No studies on attitudes toward both PAS and EUT among medical students in Sweden were found to base data collection instrument on. From findings in the literature search a questionnaire was

developed, containing 30 questions. It was pilot tested to assess face validity by a physician working in ethics, as well as by four physicians (previous students from Örebro university).

The survey was divided into six sections. The first part provided information about

participation in the study, which ensured anonymity for participants, and that agreement to partake in the study was given by responding. It was also clarified that once answering the survey, there was no way to withdraw the data, as it was collected anonymously. Section two

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held information about definitions used in the survey and a short information about the current legal status of AD in Sweden (as of 2020). Section three contained demographic questions (gender, current term: 1-3, 4-7, 8-11) as well as two questions about religious beliefs and the importance of such beliefs in everyday life.

Section four to six had short patient scenarios regarding AD (Table 2). All scenarios were framed in the Swedish health care context, with current laws (2020) applying. The patient was a fully competent adult with Swedish citizenship. The same scenarios were re-used for PAS and EUT respectively, only differing in what form of AD that was requested from the patient, making a total of eight scenarios in the survey. Every scenario was framed as a patient giving a request to a physician for AD (PAS or EUT), and the responders had to choose whether they agreed to granting the patient´s request or not. Every scenario also included a question asking if the respondent would agree to grant the patients´ request in a framing where AD was legal. The multiple-choice questions had the response alternatives: yes, no, don´t know. Section four and five had scenarios of a patient with a terminal disease, section six was based on scenarios without terminal illness. Each section had a scenario with a patient with severe suffering even with treatment (palliative treatment in section four and five), and another with a patient with little/no suffering.

The survey also included questions about: willingness to participate in assisted dying as a physician if it was legalized, if the respondent was willing to consider assisted dying for themselves if they had a terminal disease (had two yes response alternatives, “yes” and “yes, but only if in great suffering”), and if medical staff should have the right not to partake in assisted dying if it would be legalized (using the question framing used in previous studies[37,38]). Direct questions about whether respondents believe that assisted dying should be legalized in Sweden (with/without terminal sickness, for both PAS/EUT separately) were also included.

Statistical analysis

Fully answered questionnaires, defined as missing one or zero answers, were exported into an excel data file. Proof reading of data entries to the exported Excel document were done to ensure correctly exported data. Further data analysis was conducted using SPSS (v. 26). Descriptive statistics were conducted, with categorical variables presented as percentages. To

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analyse if a legal framing of AD would affect MS´ held attitudes, the two questions in each scenario (current legal framework/if AD was legal) were analysed using NcNemar test, to test for statistical significance in difference of proportion of positive answers. Answer categories were re-coded into two categories (“yes” into “positive”, and “no” and “don’t know” into “not positive”). NcNemar test was also used to compare difference of proportion of positive answers between various scenarios, and questions regarding participation in AD.

Logistic regression analysis was conducted on the different scenarios to assess if association could be seen between MS´ held attitudes under current Swedish regulations (2020) and potential variables of interest (gender, current term, religious beliefs importance in everyday life). The independent variable “religious beliefs importance in everyday life” was recoded from five into three categories; (Very important, important, less important, not important, no religious beliefs, into: “Strong”, “Mild” and “Non-believer”) to facilitate data analysis and interpretation. For dependent variables (scenario 1-8, question framed with current legal situation), the responses “no” and “don’t know” were coded to a “not positive” category, and “yes” was coded as “positive”.

Ethical considerations

The survey was designed to retrieve data anonymously. With anonymous data, none of the criteria needed for application for ethical approval of the study to local ethical board was required. All data was presented on group level. The university of Örebros´ appointed ethics faculty member read the finalized version of the questionnaire and approved it before distribution.

Results

Respondents

Response rate was 45.1% (296/657), with 34.9% (n=229) being completed questionnaires. Only completed questionnaires were analysed. The participating students gender distribution was 63.3% female, 36.7 % male, with the enlisted population distribution being 62.1% female, 37.9% male. One student´s gender was unidentified. Demographics are shown in Table 1. No statistically significant difference between gender distribution and number of terms studied were found (χ2-test, not presented here).

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Attitudes

Of the 229 fully completed questionnaires, 60.2% of the respondents believed PAS for terminally ill patients should be legalised in Sweden, while 18.8% believed it should not be legalised, and 21% were unsure. Regarding legalising EUT for terminally ill patients´, 43.2 % agreed, with 31.4% disagreeing, while 25.3% were unsure. When asked about patients

without terminal illness, 21.0% of the respondents believed PAS should be legalized, and 15.4% for EUT, while 62.3% (PAS) respectively 70.2% (EUT) disagreed, leaving16.7% (PAS) and 14.4% (EUT) unsure.

The proportions of positive respondents differed when questions shifted between addressing PAS or EUT, with increasing negative attitudes for EUT when compared to PAS. Differences were also seen when the patients’ health status differed. The number of respondents who would agree to the doctor granting the patients request and administer PAS, when the patient was terminally ill and under great suffering was 39.5%, whereas 29.3% agreed when the patient requested euthanasia under the same circumstances. Further differences are presented in Table 2.

Of the responders, 61.1% could consider taking active part (prescribing the lethal drug dose) in PAS in the future when becoming licensed physicians. For EUT, 44.5% could consider taking active part (administrating the lethal dose), while 31.9% said no, and 23.6% were unsure. When asked whether the respondents could consider requesting PAS for themselves, if suffering from a terminal illness, 22.3% could consider requesting PAS without the

precondition of great suffering, while an additional 45.0% could only consider requesting Table 1 – Distribution of sociodemographic among responding medical students with completed questionnaires

Current attending term in medical school 1-3 4-7 8-11 Response rate % (Respondents/Enlisted) * 34.3 (70/204) 33.2 (77/ 232) 36.7 (81/221) Gender % (Respondents/ Enlisted) Male 34.3 (24/84) 33.8 (26/88) 42.0 (34/77)

Female 65.7 (46/120) 66.2 (51/144) 58.0 (47/144) World view % (n)

Atheist/Agnostic/Non-believer

67.1 (47) 68.8 (53) 64.2 (52)

Religious/Believer 21.4 (15) 27.3 (21) 25.9 (21) Other 11.4 (8) 3.9 (3) 9.9 (8) Importance of religious beliefs in

everyday life % (n)

Strong 17.1 (12) 19.5 (15) 19.8 (16) Mild 27.1 (19) 27.3 (21) 28.4 (23) No religious beliefs 55.7 (39) 53.2 (41) 50.6 (41)

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PAS if suffering severely, while 19.2% could not consider requesting PAS, with 13.5% remaining unsure. For EUT the corresponding rates were yes 18.3%, yes, but only if severely suffering 41.1%, no 25.8%, don’t know 14.8%.

Answering whether hospital staff should have the right to refrain from partaking in AD, if it would become a legal right that falls upon Swedish health care to provide; regarding PAS, 41.1% agreed. 48.5% disagreed, while 10.4% were unsure. For EUT, 49.8% agreed, 41.0% disagreed, while 9.2% were unsure.

Legality

When the framing of the scenario shifted between current legal regulations and a framing where AD was legal (question included in all eight scenarios), a statistically significant difference in proportion was found across all scenarios. Results are presented in Table 3. Differences in attitudes held by MS´s toward AD in the eight scenario framings used, which varied in patient factors; terminal illness, suffering and requesting of PAS/EUT, were tested using McNemar test for proportion. Using the framing of current legal framework (AD not

Table 2 – Distribution of medical students’ responses to the question “do you believe that the physician should grant the patients´ request for assisted dying (under current legal framework)” in scenarios 1-8

Scenario framing of patient* Agreeing to that the physician should be granting patients´ request of assisted dying

Yes % (n) No % (n) Don’t know % (n) Scenario 1 PAS Terminal illness Suffering, have palliative treatment 39.4 (90) 48.3 (110) 13.3 (28)

Scenario 2 PAS Terminal illness Not suffering, have palliative treatment 19.7 (45) 71.2 (163) 9.1 (21)

Scenario 3 EUT Terminal illness Suffering, have palliative treatment 29.3 (67) 56.8 (130) 13.9 (32)

Scenario 4 EUT Terminal illness Not suffering, have palliative treatment 13.5 (31) 76.0 (174) 10.5 (24)

Scenario 5 PAS No terminal illness Suffering, does have the treatment currently available

24.6 (56) 61.0 (139) 14.4 (33)

Scenario 6 EUT No terminal illness Suffering, does have the treatment currently available

16.7 (38) 68.9 (157) 14.4 (33)

Scenario 7 PAS No terminal illness Not suffering 4.0 (9) 89.5 (204) 6.5 (15)

Scenario 8 EUT No terminal illness Not suffering 2.6 (6) 92.5 (210) 4.9 (11)

*all scenarios include an adult patient, who asks their physician for assisted dying (PAS/EUT), under current Swedish legal medical framework (assisted dying not legal).

PAS – Physician Assisted Suicide EUT – Euthanasia

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legal), statistically significant difference could be seen between the different factors varying in the eight scenarios and MS held attitudes (Appendix B, Table 1A).

Logistic regression

Binominal logistic regression was conducted to assess whether independent variables gender, current term, and importance of religious beliefs had any association with positive attitudes toward AD. Scenario 1-3 displayed statistical significance for the model (Table 4). The variable gender had no statistically significant effect on held attitudes in this model. The variable “current term” met statistical significance in scenario two (p<0.05) for “current term 4-7”, but in no other scenario statistical significance was seen. The variable “importance of religious beliefs” displayed statistical significance in category “strong believer”, that was associated with lower odds to have a positive attitude about AD (OR ranging from 0.167-0.219 (p<0.05)). For scenario 4-8 no statistically significant association between variables of interest and attitudes was found for the model. Further analyses were conducted on these scenarios by analysing for each independent variable separately using X2-test. Religious beliefs showed statistical significance (p<0.05) in scenario 4-6, but not in scenario seven or eight, while gender and current term showed no statistical significance in scenarios 4-8. A Table 3 –Difference of proportion between positive/not positive answers among responding medical students in scenarios 1-8, when shifting legal framings (one where assisted dying is not legal, and one where it is legal)

Scenario framing a

Assisted dying framed as:

Difference % (n) p-values* Attitude Not Legal % (n) Legal % (n) Scenario 1 _Positive _{39.5 (90)} _{66.7 (152)} ±27.2 (62) <0.001 Not positive 60.5 (138) 33.3 (76) Scenario 2 Positive 19.7 (45) 34.5 (79) ±14.8 (34) <0.001 Not positive 80.3 (184) 65.5 (150) Scenario 3 _Positive _{29.3 (67)} _{50.7 (116)} ±21.4 (49) <0.001 Not positive 70.7 (162) 49.3 (113) Scenario 4 Positive 13.5 (31) 26.6 (61) ±13.1 (30) <0.001 Not positive 86.5 (198) 73.4 (168) Scenario 5 _Positive _{24.6 (56)} _43.0(98) ±18.4 (42) <0.001 Not positive 75.4 (172) 57.0 (130) Scenario 6 Positive 16.7 (38) 35.1 (80) ±18.4 (42) <0.001 Not positive 83.3 (190) 64.9 (148) Scenario 7 _Positive _{3.9 (9)} _{9.2 (21)} ±5.3 (12) 0.008 Not positive 96.1 (219) 90.8 (207) Scenario 8 Positive 2.6 (6) 7.0(16) ±4.4 (10) 0.013 Not positive 97.4 (221) 93.0 (211)

a _{For scenario framing details see Table 2}

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dichotomous category for believer/nonbeliever was tested in the logistic regression for scenario 4-8, as the positive responses in the initial sub-categories struggled to fit the model of analysing (too small sub groups), with the new categories (believer/non-believer) still not showing statistical significance when analysed in the logistic regression (data not shown).

Discussions and conclusions

No formal analysis of representability of respondents versus study population was possible due to data being retrieved anonymously but respondents did not differ in gender distribution from the study population. The response rate was lower than hoped for but in line with other online-based surveys among students [17,25,30,37,39,40]. A shorter questionnaire could arguably have increased response rates, but at the loss of important data. A shorter

questionnaire does not guarantee increased response rates among MS and physicians[41]. Of Table 4 –Medical students´ likelihood for positive attitudes towards assisted dying in the scenario framing where assisted dying is not legal, based on sociodemographic variables religious beliefs, current term of study in medical school and gender.

Scenario a _Variables _p-values* _Odds

Ratio

95% C.I for EXP(B) Lower Upper Scenario 1 Non-believer ** - 1 Strong believer <0.001 0.167 0.061 0.456 Mild believer 0.414 1.292 0.698 2.391 Current term 1-3 0.434 1.315 0.662 2.612 Current term 4-7 0.642 1.174 0.597 2.309 Current term 8-11** - 1 Male b _0.642 _1.148 _0.641 _2.055 Constant 0.137 0.643 Scenario 2 Non-believer ** 0.018 1 Strong believer 0.025 0.181 0.041 0.805 Mild believer 0.200 1.593 0.781 3.248 Current term 1-3 0.287 1.619 0.667 3.932 Current term 4-7 0.045 2.362 1.020 5.472 Current term 8-11** - 1 Male b _0.356 _1.389 _0.692 _2.790 Constant <0.001 0.142 Scenario 3 Non-believer ** - 1 Strong believer 0.007 0.219 0.073 0.659 Mild believer 0.355 1.352 0.714 2.562 Current term 1-3 0.598 1.215 0.588 2.510 Current term 4-7 0.838 1.078 0.526 2.208 Current term 8-11** - 1 Male b _0.387 _1.310 _0.711 _2.413 Constant 0.002 0.38

a_{For scenario framing details see Table 2. Only scenarios where the model reached statistical significance are}

presented.

b _{Female are the reference group}

* Binominal logistic regression ** Reference categories

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those who did not complete the survey, the two major drop-out points were after responding to the demographic questions (question 1-4), and secondly when the scenario framing shifted from PAS to EUT. More than 50% of the respondents not completing the questionnaire had a faith/religious conviction (question 4), giving these respondents a disproportional distribution in comparison to the analysed group. One possible explanation for this could be that the questions in the survey bring discomfort to those who hold religious beliefs, who more often hold negative attitudes toward AD[19,42,43], and thus did not complete the survey. This could potentially be a selection bias that gives a false high rate of positive answers in the study. When comparing responses from those dropping out after completing the first section of questions about AD (section 4) with fully completed questionnaires, there are only minor differences in distribution between responses (< 2%). A lesser third point for drop out was when the scenario framing shifted to not terminally ill patients (last page of survey), also not showing relevant differences. These later drop out points might be due to experiencing the survey as too lengthy to complete. Monetary incentives was one possible way to increase responses[44], although not having considerable effect among MS previously[30,41], and ethically questionable if not limited to smaller amounts.

Attitudes in Western Europe towards AD have shifted to become more positive[8,42,45], although comparing outcome of studies with varying survey wording and different contexts makes it difficult to draw generalizable conclusions[8,14,15]. In an earlier study among MS in Sweden, one third expressed positive opinions towards the legalization of EUT, while most were negative[20]. Adding the findings in this study with earlier findings, this indicates a shift towards more positive attitudes regarding EUT among Swedish MS, although any conclusions must be drawn with great caution due to the large drop-out. Sweden ranks highest globally in secular-rational values and values of self-expression according to World Values survey, values that have shifted greatly in the last 30 years[46], further strengthening the evidence for a change of attitudes. This study displayed statistical significance for “strong believers” having a greatly decreased likelihood for positive attitudes toward AD, or

reversely, that non-believers had an increased likelihood for positive attitudes toward AD. In a study evaluating predictors for seeking physician assisted death (PAD) as a patient, it was found that low spirituality (measured on the Functional Assessment of Chronic Illness Therapy-Spiritual Well Being Scale) was the strongest predictor[47]. Other positive predictors for pursuit of PAD included depression, hopelessness, and “dismissive attachment(attachment to others characterized by independence and self-reliance)”[47].

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These predictors might be of interest to study further for association of positive attitudes among MS´ towards AD, although there is vast difference between the context of a MS and a terminally ill patient.

A limitation of this study is that it only assessed a small number of variables that could affect held attitudes, and thus may well have missed other important factors. To ensure anonymity for participants many possible factors were excluded, that in future studies could be of interest to further investigate, including but not limited to: Age, religious affiliation, previous education, experience in working with terminally ill, or private experience of someone close with terminal illness, and ethnicity/cultural background. Future studies could further examine the held attitudes of MS through qualitative methods to deepen the understanding of what motivates held attitudes. Also, of interest would be a larger study including more MS in different universities in Sweden, possibly including other Nordic countries as well, to explore possible cultural differences between different universities and countries. Another limitation of the study is the dichotomous grouping of responses into “positive” and “not positive” while conducting statistical analysis. The reasoning for not only having “yes” and “no” answers and include “don’t know” answers in the survey and re-order responses to new groups while analysing, was to not force responses from undecided participants, as well as to increase likelihood of MS completing the survey[14]. A third limitation is the fact that the survey was conducted in Swedish, with possible incorrect translations, lost meaning or nuances of phrases while writing this paper in English. A strength of the study is that the finding of religious beliefs affecting held attitudes is in line with previous studies on attitudes toward AD, which is seen among MS, the general public as well as among

physicians[8,18,19,42].

There was a big difference in number of positive responses when shifting between current medical framework and a legal framing. Legality’s ability to shift a negative response to a positive was seen in a study among Mexican MS[19]. While this could be explained as a willingness to abide by the law and respect patient autonomy in a legal framework, it is somewhat contradicted by the surprisingly high number of respondents positive towards AD even when not legal. Most respondents were negative toward AD under more controversial framing, legal or not. The autonomy of the patient is a central argument for proponents of AD[3,48,49]. This study did not include any questions directly asking responders about their

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granting the patients request for AD (e.g. autonomy). The responses indicate that the patients´ autonomy is regarded in the scenario context with reservations, or maybe limitations to its importance depending on framing, with suffering outweighing terminal illness as a single factor for being positive to granting the patients´ request. In all comparable scenarios fewer respondents agreed when the patient requested EUT than PAS. This difference in attitudes toward PAS/EUT have been seen in previous studies among MS and physicians[10,50,51]. In bioethics there is a debate if there is an ethical argument to make for a clear moral distinction between PAS/EUT[52]. As both practices will lead to a hastened death for the patient, maybe the favouring of PAS among respondents lies with the decisive act which leads to death, and that it is carried out by the patient in PAS, hence regarding PAS as a less complex ethical issue. An indication of this was that more MS believed that health care personnel should have the right to conscientious objection for EUT than for PAS.

A striking difference seen in this study compared to earlier studies is the number of respondents believing conscientious objection for health care personnel regarding EUT should not be an option (41%). Previous studies concluded that MS in the United Kingdom were more in favour of the right for physicians to object to any procedure with which they might have a moral, cultural or religious disagreement to, than MS in Norway (45% vs 21%)[37,38]. Although not favouring conscientious objection as a general principle for physicians, 89% the Norwegian MS believed it should be possible to object to perform euthanasia[38]. Norway does have a legal option for conscientious objection for physician and midwifes regarding abortion, something Sweden does not, maybe to some extent

explaining the vast difference. Another possible explanation is that the difference might be an expression of high levels of conformity and collectivism in Sweden around some matters, with less room for tolerance regarding issues within these matters where different ethical conclusions are drawn. Maybe this study, despite the insecurity regarding the drop out of respondents, may be interpreted as another indication of the strong “trend” for increased support of AD in western Europe, which has been seen for several decades? With levels of religiosity in society seemingly inversely correlating to levels of support for AD among the public, and religious belief being a strong factor in affecting held attitudes towards AD on a personal level[8], future support for AD seem at least partly dependent on which impact religiosity will have on Western Europe moving forward. In the occurrence of a future legalisation in Sweden of AD, the previous medical student, now a licensed physician, might not have a legal option to object in partaking in AD, as conscientious objection for abortion

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has been rejected when tried legally. This although postulated in the Abortion Bill by the Social Affairs Committee that healthcare personnel should be excluded from abortion on the base of conscientious objection, and that it therefore is not necessary to have a legal

regulation of the matter[53,54]. Among physicians there is no unity regarding AD but seen in most studies a majority is against legalisation, although differing greatly between

countries[8]. With increasing support among MS, will this shift in the future towards a majority supporting legalisation among physicians, and could this further increase the division seen among physicians? World Medical Association (WMA)have taken a stance against legalisation of AD[55], while The Swedish Society of Medicine (SLS) remains neutral[56]. If the shift in attitude toward AD remains, or continues to increase, increased pressure could come from within the profession of physicians as more MS graduate, toward a legalisation of some form of AD, most probably PAS. Something to consider is the

possibility of MS changing their stance on AD when they are specialized physicians and have another role and other responsibilities. Thus, it is not clear that an increased shift toward more positive attitudes among physicians will occur over time.

In conclusion, a majority of responding medical students´ in this study believe that physician assisted suicide should become legalised for terminally ill patients´ in Sweden. Respondents attitudes were affected by religious beliefs, and legality was able to shift previously negative responses to positive ones, even in more controversial framings, indicating the prescriptive effect of legality. Different patient’ health aspects also affected the willingness to grant the patients´ request for assisted dying. A large portion of responding MS did not support conscientious objection for health care personnel regarding assisted dying. With the high percentage of respondents willing to grant assisted dying to the patient even when not legal, it seems improbable that support for assisted dying among physicians will decrease anytime soon.

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44. VanGeest JB, Johnson TP, Welch VL. Methodologies for improving response rates in surveys of physicians: a systematic review. Eval Health Prof 2007;30:303–21.

45. Cohen J, Marcoux I, Bilsen J, Deboosere P, van der Wal G, Deliens L. European public acceptance of euthanasia: socio-demographic and cultural factors associated with the acceptance of euthanasia in 33 European countries. Soc Sci Med 1982 2006;63:743–56. 46. AB I kommunikation. World Values Survey Cultural Map [Internet]. [cited 2020 Dec

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48. Dugdale LS, Lerner BH, Callahan D. Pros and Cons of Physician Aid in Dying. Yale J Biol Med 2019;92:747–50.

49. Fontalis A, Prousali E, Kulkarni K. Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate? J R Soc Med

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APPENDIX A - SURVEY – In Swedish

DÖDSHJÄLP - Attityder blandläkarstudenter

1. Välkommen

I denna enkät har du möjlighet att besvara ett antal frågor kring dödshjälp. Data som inhämtas och redovisas är anonym. All data redovisas anonymt på gruppnivå. Syftet med enkäten är att kartlägga vad läkarstudenter i Sverige har för

inställning till dödshjälp. Resultatet kommer att redovisas som en del i en magisteruppsats, samt kan komma att publiceras.

Du kan läsa mer om hanteringen av insamlad data hos surveymonkey via följande länk: https://sv.surveymonkey.com/mp/legal/privacy-policy/

Vid frågor kring datahantering till ägaren av enkätundersökningen kan du kontakta denne via följande mailadress: benhev161@studentmail.oru.se

Det är inte möjligt att få din data borttagen efter att du slutfört undersökningen då ingen persondata insamlas och dina svar inte kommer att kunna skiljas från andras. Genom att besvara och skicka in enkäten ger du ditt medgivande till att din data får användas i dessa syften.

2. INFORMATION & DEFINITIONER

På följande sidor kommer du att få svara på frågor gällande din inställning till dödshjälp utifrån några patientscenarion. Alla scenarion utgår från svensk sjukvård idag; patienten är vuxen och svensk medborgare, med rådande lagstiftning. Samma frågor kommer att ställas två gånger, den ena gången gällande läkarassisterat självmord och den andra gången gällande eutanasi. Nedan definieras vad som menas med olika begrepp i enkäten:

- DÖDSHJÄLP: Definieras i denna enkät som "åtgärder som syftar till att avsluta en patients liv på dennes begäran."

o Eutanasi: Dödshjälp där någon ANNAN än patienten utför den avgörande handlingen som leder till patientens död.

o Läkarassisterat självmord: Dödshjälp där patienten SJÄLV utför den avgörande handlingen som leder till patientens död.

- Terminal sjukdom: Mindre än sex månaders förväntad överlevnad

Med dödshjälp menas INTE avslutande av livsuppehållande behandling. Inte heller menas med dödshjälp palliativa insatser där en förutsebar men ej sökt effekt av insatsen är ett påskyndande av döden.

Juridiska situationen gällande dödshjälp i Sverige idag:

Eutanasi är brottsligt i Sverige idag. Det är inte olagligt som privatperson att assistera någon vid självmord, alltså att möjliggöra för någon annan att begå självmord (exempelvis genom att föra in läkemedel i munnen på en person som sedan själv kan svälja dessa).

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utreda och behandla sjukdomar och skador” (2 kap 1 §). Tolkningar av lagen gör gällande att olika former av dödshjälp inte ryms under denna definition idag och inte utgör en vårdåtgärd. Smer (Statens medicinetiska råd) skriver att läkare lyder under patientsäkerhetslagen, där en vanlig tolkning av lagen är att läkarassisterat självmord inte är förenlig med kravet om vetenskap och beprövad erfarenhet. I förarbetena till hälso- och sjukvårdslagen uttrycks att patientens

självbestämmande kring åtgärderna i vården inte sträcker sig till att innefatta dödshjälp. Utövande av läkarassisterat självmord kan idag leda till förlust av legitimation och eventuellt åtal för tjänstefel. Detta har inte prövats juridiskt ännu.

3.Demografiska frågor

Q1. Är du?

 Man  Kvinna

Q2. Vilken termin går du för närvarande på?

 Termin 1-3  Termin 4-7  Termin 8-11

Q3. Hur skulle du beskriva dig?

 Religiös/Troende

 Ateist, agnostiker, icke-troende  Annat

Q4. Välj det alternativ som bäst stämmer in på dig:

 Min tro/religiösa övertygelse är väldigt viktig för mig i min vardag  Min tro/religiösa övertygelse är viktig för mig i min vardag

 Min tro/religiösa övertygelse är mindre viktig för mig i min vardag  Min tro/religiösa övertygelse är inte viktig för mig i min vardag  Jag har ingen tro/religiös övertygelse.

4. LÄKARASSISTERAT SJÄLVMORD

Läkarassisterat självmord: ”när en läkare på begäran av patienten förskriver en dödlig dos läkemedel som patienten sedan administrerar sig själv i syfte att avsluta sitt liv.”

Scenario 1

En beslutsförmögen patient med terminal sjukdom lider mycket svårt

av sin sjukdom trots palliativa insatser. Patienten ber sin läkare om

hjälp att avsluta sitt liv genom läkarassisterat självmord.

Q5. Anser du att läkaren bör tillmötesgå patientens önskan?

 Ja  Nej

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 Vet ej

Q6. Anser du att läkaren bör tillmötesgå patientens önskan om läkarassisterat självmord är lagligt i detta scenario?

 Ja  Nej  Vet ej Scenario 2

En beslutsförmögen patient med terminal sjukdom har god effekt av

sina palliativa insatser och beskriver sig som relativt välmående.

Patienten ber sin läkare om hjälp att avsluta sitt liv genom

läkarassisterat självmord.

 Ja  Nej  Vet ej

Q9. Om läkarassisterat självmord legaliseras för patienter med terminal sjukdom, kan du tänka dig, i din framtida roll som legitimerad läkare, att ta en aktiv del

(förskriva läkemedlet) i detta?

Q10. Om läkarassisterat självmord blir en lagstiftad rättighet för patienter som åläggs hälso- och sjukvård att utföra, bör vårdpersonal ha rätt att avstå från att utföra denna uppgift utifrån moraliska, kulturella eller religiösa motsättningar?

Q11. Skulle du själv i roll som patient kunna efterfråga läkarassisterat självmord för egen del vid terminal sjukdom?

 Ja

 Ja, men enbart vid svårt lidande.  Nej

 Vet ej.

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legaliseras i Sverige?

5. EUTANASI

Här följer frågor om eutanasi: ”Dödshjälp genom administrering av en dödlig dos läkemedel utförd av någon annan än patienten med syfte att avsluta patientens liv.”

Scenario 3

En beslutsförmögen patient med terminal sjukdom lider mycket svårt

av sin sjukdom trots palliativa insatser. Patienten ber sin läkare om

hjälp att avsluta sitt liv genom eutanasi.

Q13. Anser du att läkaren bör tillmötesgå patientens önskan om eutanasi är lagligt i detta scenario?

Scenario 4

En beslutsförmögen patient med terminal sjukdom har god effekt av

sina palliativa insatser och beskriver sig som relativt välmående.

Patienten ber sin läkare om hjälp att avsluta sitt liv genom eutanasi.

Q16. Om eutanasi legaliseras för patienter med terminal sjukdom, kan du tänka dig, i din framtida roll som legitimerad läkare, att ta en aktiv del (administrera

läkemedlet) i detta?

 Ja  Nej

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 Vet ej

Q17. Om möjlighet till eutanasi blir en lagstiftad rättighet för patienter som åläggs hälso- och sjukvård att utföra, bör vårdpersonal ha rätt att avstå från att utföra denna uppgift utifrån moraliska, kulturella eller religiösa motsättningar?

Q18. Skulle du själv i roll som patient kunna efterfråga eutanasi för egen del vid terminal sjukdom?

 Ja

 Ja, men enbart vid svårt lidande.  Nej

 Vet ej.

Q19. Anser du att eutanasi för patienter med terminal sjukdom bör legaliseras i Sverige?

6. Dödshjälp utan terminal sjukdom

DÖDSHJÄLP: "åtgärder som syftar till att avsluta en patients liv på dennes begäran."

Scenario 5

En beslutsförmögen patient lider mycket svårt av sjukdom, men är

inte terminalt sjuk. Patienten blir inte bättre och man har uttömt

befintliga behandlingsalternativ. Patienten ber sin läkare om hjälp att

avsluta sitt liv genom läkarassisterat självmord.

Scenario 6

En beslutsförmögen patient lider mycket svårt av sjukdom, men är

inte terminalt sjuk. Patienten blir inte bättre och man har uttömt

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befintliga behandlingsalternativ. Patienten ber sin läkare om hjälp att

avsluta sitt liv genom eutanasi.

Q23. Anser du att läkaren bör tillmötesgå patientens önskan om det är lagligt med eutanasi i detta scenario?

Scenario 7

En beslutsförmögen patient som inte har någon psykisk sjukdom,

eller lider svårt av någon somatisk sjukdom, ber sin läkare om hjälp

att avsluta sitt liv genom läkarassisterat självmord.

Scenario 8

En beslutsförmögen patient som inte har någon psykisk sjukdom,

eller lider svårt av någon somatisk sjukdom, ber sin läkare om hjälp

att avsluta sitt liv genom eutanasi.

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legaliseras i Sverige?

Q30. Anser du att eutanasi för patienter utan terminal sjukdom bör legaliseras i Sverige?

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APPENDIX B

Table 1A – Comparison of differences in scenario framings of the patients´ current health status, to assess statistically significant shifts of proportion

Scenario framing aspects of the patient** Scenario 1: Terminally ill Suffering PAS Scenario 2 Terminally ill Not suffering PAS Scenario 3 Terminally ill Suffering EUT Scenario 4 Terminally ill Not suffering EUT Scenario 5 Not terminally ill Suffering PAS Scenario 6 Not terminally ill Suffering EUT Scenario 7 Not terminally ill Not suffering PAS Scenario 8 Not terminally ill Not suffering EUT Scenario 1: Terminally ill Suffering, PAS Suffering * PAS/EUT * PAS/EUT Suffering * Term. illness * Term. illness PAS/EUT * Term. illness Suffering * Term. illness Suffering PAS/EUT * Scenario 2: Terminally ill Not suffering PAS Suffering PAS/EUT * PAS/EUT p = 0.001 Term. illness Suffering p = 0.063 Term. illness Suffering PAS/EUT p = 0.265 Term. illness * Term. illness PAS/EUT * Scenario 3: Terminally ill Suffering EUT Suffering * Term. illness PAS/EUT p = 0.112 Term. illness * Term. illness Suffering PAS/EUT * Term. illness Suffering * Scenario 4: Terminally ill Not suffering, EUT Term. illness Suffering PAS/EUT * Term. illness Suffering p = 0.248 Term. illness PAS/EUT * Term. illness * Scenario 5: Not terminally ill Suffering PAS PAS/EUT * Suffering * Suffering PAS/EUT * Scenario 6: Not terminally ill Suffering EUT Suffering PAS/EUT * Suffering * Scenario 7: Not terminally ill Not suffering PAS

EUT/PAS p = 0.375

Scenario 8: Not terminally ill Not suffering EUT

* p < 0.001, McNemar test

** All scenarios are framed with an adult patient, that makes a request to its physician about assisted dying, under current Swedish legal framework (assisted dying not legal).

PAS: Physician assisted suicide EUT: Euthanasia

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COVER LETTER (218 ord)

Journal of Medical Ethics Editorial Office December 29, 2020 BMA House Tavistock Square London, WC1H 9JR UK John McMillan Editor-in-Chief

Dear Editor of Journal of Medical Ethics,

Kindly, consider the enclosed manuscript entitled “Attitudes among medical students in Sweden towards assisted dying” for publication in your journal.

In a cross-sectional online survey among Swedish medical students, held attitudes toward assisted dying is examined in eight scenario framings (including both euthanasia and physician-assisted suicide). Also studied is if the factors gender, current term, shifting of legal framework and religious beliefs affect held attitudes. Our data indicates that most medical students support legislation permitting physician-assisted suicide. Strong religious beliefs being is shown as the main factor for decreased likelihood of positive attitudes toward assisted dying. Shift of legal framing gave significant difference in proportions of answers in all scenarios, something we think will be of importance for future studies regarding attitudes toward assisted dying.

This manuscript is our own original work, which is not previously published and is not being considered for publication elsewhere. No conflict of interest has been declared by the authors, and final version of the manuscript have been approved by all authors. This study was

approved of representative of local ethical committee before being conducted. Sincereley,

Benjamin Hegarty, MB School of Medical Sciences Örebro University

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Populärvetenskaplig sammanfattning (244 ord)

Dödshjälp i olika former har kommit att legaliseras i ett flertal länder, men är fortfarande olagligt i absoluta merparten av världens länder, Sverige inräknat. Dödshjälp innebär att en patient får hjälp att avsluta sitt liv efter att den uttryckligen har efterfrågat detta. Dödshjälp finns i två former, eutanasi och läkarassisterat självmord. Eutanasi innebär att den avgörande handlingen som leder till döden genomförs av vårdpersonal, medan läkarassisterat självmord innebär att en dödlig dos läkemedel förskrivs som sedan patienten själv tar för att avsluta sitt liv.

Syftet med denna studie var att kartlägga inställningen till dödshjälp bland läkarstudenter, samt att studera om olika faktorer så som kön, aktuell termin, en lagstiftning som tillåter dödshjälp samt religiös övertygelse påverkade studenternas inställning. Detta gjordes genom en anonym webbaserad enkät, där alla inskrivna studenter på läkarprogrammet erbjöds att delta. Från denna enkät genomfördes analyser för att undersöka i vilken omfattning studenterna var för/emot dödshjälp, samt om det fanns några samband mellan de olika faktorerna och vilka ståndpunkter deltagarna intog.

Vi såg att 60% av deltagarna var för legalisering av läkarassisterat självmord. Stark religiös övertygelse var den faktor som sammankopplades med lägst sannolikhet att ha en positiv inställning till dödshjälp. När dödshjälp var ett lagligt alternativ ökade antalet positiva svar. Studien visade att läkarstudenter följt utvecklingen i Västeuropa med ökande positiv inställning till dödshjälp. En betydande del av de som påbörjade enkäten valde att inte slutföra denna, vilket till viss mån begränsar möjligheten för vilka slutsatser man drar av studien.

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Etisk reflektion (249 ord)

Då denna studie gällde ämnet dödshjälp, som av många kan anses känsligt, blev den huvudsakliga principen när enkäten utvecklades att säkra anonymitet för deltagare. Därför begränsades antalet demografiska frågor för att säkerställa att ingen enskild respondent skulle kunna identifieras. Av samma skäl valdes inga öppna frågor i enkäten. Sociodemografiska frågor gällande religiösa övertygelser inkluderades i studien, då detta i tidigare studier varit en viktig faktor för vilka attityder man har gentemot dödshjälp.

Då många har en tydlig åsikt gällande dödshjälp finns det viss risk för selektionsbias i denna studie. Dels genom att de som är positivt eller negativt inställda kanske är mer måna om att delta. En annan risk är att ämnet dödshjälp orsakar obehag för dem som är negativt inställda, vilket leder till att färre av dessa deltar. Då datainsamlingen sker anonymt finns inget sätt att jämföra svarsgruppen mot hela studiepopulationen genom en formell bortfallsanalys, vilket kan göra att studiens generaliserbarhet försämras.

Allmänheten är mer positiv än läkare till legalisering av dödshjälp. Denna skillnad belyser viktiga frågor kring patientcentrerad vård, men också trovärdigheten av resultaten i

opinionsundersökningar.

Det finns en risk att studenterna som deltar i studien upplever obehag, på ett känslomässigt och existentiellt plan. Läkarstudenter möter under hela utbildningen svåra etiska frågor och dilemman, och erhåller resurser för att hantera dessa inom ramen för sin utbildning. Till stöd för studenter finns även campushälsa i form av möjlig kuratorskontakt, samtalsstöd, och universitetskyrka. Obehag som deltagare i studien kan uppleva får vägas mot den eventuella forskningsnyttan studien kan generera.