Physicians’ And Medical Students’ Attitude Towards Euthanasia In Sweden

WRITTEN REPORT Medicine Programme, Degree Thesis (30 hp)

PHYSICIANS’ AND MEDICAL STUDENTS’ ATTITUDE TOWARDS EUTHANASIA IN SWEDEN

Author: Alma Englund Main supervisor: Ulrik Kihlbom Supervisor: Karin Schölin Bywall

Date: 2021-04-15

Title: Physicians’ and Medical Students’ Attitude Towards Euthanasia in Sweden Author: Alma Englund

Abstract ... 2

Populärvetenskaplig sammanfattning (Swedish) ... 3

Background ... 4

Euthanasia ... 4

Euthanasia around the world ... 4

The debate about euthanasia in Sweden ... 7

Common arguments for and against euthanasia ... 8

Arguments for euthanasia ... 8

Arguments against euthanasia ... 8

Main purpose and problems ... 9

Methodologies ... 11

Recruitment and respondents ... 11

Survey instrument ... 12

Collecting data ... 12

Statistical analysis ... 14

Ethical considerations ... 14

Results ... 15

Question 1: Do Swedish physicians and medical students have different opinions regarding euthanasia in Sweden? ... 15

Question 2: Do physicians with different specialities have different opinions regarding euthanasia? .. 16

Question 3: Do physicians of different sex or age have different opinions regarding euthanasia? ... 17

Discussion ... 20

Result discussion and main results ... 20

Why were there differences? ... 21

Methodological discussion ... 21

Limitations ... 21

Strengths ... 23

Future research ... 23

Conclusions ... 23

Acknowledgements ... 24

References ... 25

Appendix A – The survey……….…...………28

Abstract

Background

Euthanasia is legal in six countries today; Sweden is not one of them. If a legalization should occur, it would affect the Swedish healthcare generally, and the daily work of some physicians

specifically, since physicians most likely would be the ones to perform euthanasia at patient’s requests. Hence, the opinions of Swedish physicians are highly interesting, and likely also

important for legislators. There is no recent large study about the opinions of Swedish physicians.

The aim of this study was therefore to try to make clear the opinions of Swedish physicians and medical students regarding euthanasia.

Methods

A survey was created and sent to physicians through two different medical associations, The Swedish Association of General Practice and Swedish Association for Palliative Care, and to medical students through Uppsala University. The answers were then compared and analysed.

Findings

Most of the responding physicians, 79%, said that they do not want euthanasia, while most of the medical students, 74%, said they do. In the group of responding physicians, specialists and residents in palliative care were more negative towards euthanasia compared to specialists and residents in general practice. Younger physicians and physicians with less experience tended to be more positive towards euthanasia.

Conclusions

A majority of responding physicians said they are against a legalization of euthanasia while a

majority of medical students said they are for. The results also indicate that specialists/residents in

palliative care are more negative towards euthanasia compared to specialists/residents in general

practice. Due to the small size of this study, the findings are not significant, and cannot be applied

on all Swedish physicians.

Populärvetenskaplig sammanfattning (Swedish)

Syftet med den här uppsatsen är att försöka klargöra svenska läkares och läkarstudenters åsikter angående eutanasi. Eutanasi innebär i den här studien att en läkare avsiktligt avslutar en svårt sjuk och beslutskapabel patients liv på dennes begäran. Eutanasi skiljer sig från läkarassisterat

självmord som innebär att en läkare på en svårt sjuk patients begäran tillhandahåller ett läkemedel med syfte att avsluta patientens liv, men där patienten själv måste inta läkemedlet.

För att ta reda på åsikterna utformades en enkät som skickades ut till läkare via två föreningar, Svensk förening för allmänmedicin och Svensk förening för palliativ medicin, samt till

läkarstudenter via Uppsala Universitet. Enkäten skickades totalt ut till cirka 2400 läkare i hela Sverige och 680 läkarstudenter i Uppsala. Totalt svarade 257 personer på enkäten.

Enkätsvaren delades upp efter kön, ålder, erfarenhet och typ av specialitet, för att undersöka om åsikterna skilde sig åt mellan dessa olika grupper. Det var stor skillnad på vad läkarna och studenterna ansåg. På frågan om eutanasi bör vara lagligt i Sverige svarade 79% av läkarna nej, medan 74% av studenterna svarade ja. Trots att 21% av läkarna sa att de ville att eutanasi skulle vara lagligt så sa samtidigt 36% av läkarna att de i vissa situationer skulle kunna tänka sig att efterfråga eutanasi för egen del, givet att det var lagligt. Av de läkare som svarade på enkäten var ST-läkare och specialister inom palliativ medicin mer negativt inställda mot eutanasi jämfört med andra läkare. Det var även tydligt att både yngre läkare och läkare med färre år av erfarenhet i vår undersökning var mer positivt inställda till eutanasi jämfört med äldre och de med mer än 20 års erfarenhet. Vid jämförelse av svar från män respektive kvinnor kunde inga större skillnader ses.

Då svarsfrekvensen var låg, går det inte att dra några slutsatser som kan appliceras på hela svenska

läkarkåren.

Background

Euthanasia

The word euthanasia originates from Greek. Eu- is a prefix which translates into good or well, while thanatos means death. Consequently, the meaning of euthanasia is a good death (1).

The definition of euthanasia, what is counted as euthanasia and what is not counted as euthanasia, is in this essay the same as in the Netherlands:

Euthanasia is performed by the attending physician administering a fatal dose of a suitable drug to the patient on his or her express request. The relevant Dutch legislation also covers

physician-assisted suicide (where the physician supplies the drug but the patient administers it).

Palliative sedation is not a form of euthanasia: the patient is simply rendered unconscious with pain reducing drugs and eventually dies from natural causes. (2)

Euthanasia around the world

Euthanasia is legal in six countries around the world: Colombia, the Netherlands, Belgium, Luxembourg, Canada and Australia (legal in one state out of six). New Zealand will become the seventh country to allow euthanasia (3). In some countries where euthanasia is not legal, a change of attitude towards euthanasia among physicians has occurred. A survey performed among Finnish physicians showed that they have grown more positive towards euthanasia over the last decade (4).

In Great Britain, the Royal College of Physicians has gone from a firm stand against assisted dying to a neutral one, to more reflect the views of its members (5).

To give the reader an idea of what euthanasia looks like in different countries, there is an overview of the countries where euthanasia is legal below. The countries are sorted by which year euthanasia became legal. In all of these countries, the person requesting euthanasia has to suffer unbearably and request euthanasia of their own free will. For most countries, the patient has to be 18 years or older. If other criteria are demanded, or if other patients can request euthanasia, it is mentioned in the text.

1997 – Colombia. In 1997, the high court decided that ending someone’s life was not a crime if the

individual suffered from a terminal illness where no treatment existed, and they had requested

euthanasia. However, while ruling it was not a crime, the government did not explicitly make

euthanasia legal. While a handful of physicians in Colombia have performed euthanasia regularly

since 1997, other physicians have refrained and has been asking for proper legislation, meaning that

when euthanasia is not properly regulated, it can easily be abused (6). Nearly 20 years later, in April

2015, euthanasia was officially legalized and guidelines for health care professionals were provided.

Since 2018 it is also legal for minors above the age of seven to request euthanasia. If the child is above 14, no parental agreement is necessary (7).

2002 – the Netherlands. The individual requesting euthanasia must be under unbearable suffering, mental or physical, and without prospect of improvement. The physician performing the euthanasia must be confident that the request is well-considered and that it has been made voluntarily. The physician must inform the patient of his or her situation and prognosis, and together with the patient come to the conclusion that there is no other reasonable alternative but euthanasia. The physician must also consult another, independent physician, who must see the patient in person and make a written assessment of whether or not the patient fulfils all the criteria (8). Children above 12 years of age can also request euthanasia. If the child is between 12 and 16 years old, the parents or

guardians must consent. If the minor is between 16 or 17 years old the parents or guardians must be consulted, but the decision is ultimately made by the minor. Recently, discussions in the parliament have taken place and it is likely that in the near future, the law will also include children between the age of 1 and 12 (9). For the last couple of years, around 6000 patients per year have had their life ended by euthanasia. This represents about 4% of deaths in the Netherlands. In 2019, 64% of euthanized patients suffered from cancer. The least common condition among euthanized patients were psychiatric conditions, which 1% suffered from (10).

2002 – Belgium. In 2002, the parliament legalized euthanasia. The patient requesting euthanasia has to suffer unbearably, but the suffering can be either physical or psychological. The patient needs to make the request repeatedly and in writing. If the patient is not capable of writing the request, he or she can appoint someone to write the request for him/her. At least a month must pass between the written request and the euthanasia, with exceptions being made if the patient is terminally ill. Many in Belgium, both from the public and from the parliament, felt that this new law discriminated against minors, so in 2014, the law was expanded to include children as well, without any age restrictions. For these patients, the criteria differ from that of adult patients. Underage patients must suffer physically from a condition that cannot be cured, and be expected to die within “the

foreseeable future”. Their guardians must also consent to their request and a psychiatrist or

psychologist must meet with the patient to determine that they have “capacity of discernment” (11).

Belgium remains to this day the only country in the world to allow minors of any age to request

euthanasia. The total number of people euthanized in 2019, including both adults and minors, were

2655. This represents 2.4 % of deaths in Belgium that year (12). Very few minors use the law. In

2016 and 2017, one 9-year-old, one 11-year-old and one 17-year-old requested and were given euthanasia (11). No minors were euthanized in 2018 (13).

2009 – Luxembourg. As in Belgium, the suffering can be either physical or psychological (14).

From 2009 to May 2019, 71 people chose to end their lives by euthanasia or physician-assisted suicide, the majority of which (69 people) chose euthanasia. Furthermore, during these 10 years, over 3000 people have signed a legal document, stating their wish for euthanasia should they ever be in a state where they could not make that decision, for example if they would become comatose (15).

2016 – Canada. In June 2016 the parliament passed a bill which allows Canadian residents to request assisted dying either by euthanasia or by physician-assisted suicide. The law is called Medical Assistance in Dying (MAID). Patients must be mentally stable and suffer from a “grievous and irremediable condition” (16). The condition must not be fatal. In 2019, a total of 5631 people chose to end their life via some form of assisted dying, representing 2.0% of deaths in Canada that year. Of the 5631 patients, all except seven chose euthanasia. Most patients who received MAID in Canada 2019 suffered from cancer, 67.2%. Other common reasons for receiving MAID in 2019 were: respiratory diseases - 10.8%, neurological diseases - 10.4%, and cardiovascular diseases - 10.1% (17).

2019 – Australia. Since June 2019 euthanasia and physician-assisted suicide is legal in the state of Victoria. The law is called Voluntary Assisted Dying (VAD). The patient requesting VAD needs to suffer from a terminal condition and have less then 6 months left to live. Exceptions from the 6- month rule can be made for patients who suffer from neurodegenerative diseases such as multiple sclerosis (MS) or amyotrophic lateral sclerosis (ALS), but only for an additional 6 months. The patient has to be a resident of Victoria and having been so for at least a year when making the first request. Furthermore, the patient has to make the request three times, one of which have to be in writing and observed by two witnesses (18). In the first six months after the new law took place, 52 patients had requested and received VAD. Out of these patients, 9 were euthanized while the rest died by physician-assisted suicide (19). The state of Western Australia has approved a law that will permit their residents to apply for assisted dying from mid-2021. This does not include euthanasia (20).

2021 – New Zealand. The residents of New Zealand got to vote about euthanasia in a referendum

along with the general elections on the 17 ^th of October 2020. They were asked: “Do you support the

End of Life Choice 2019 coming into force?”. 65.1% of New Zealanders voted yes (21). The parliament passed the Act to legalize euthanasia in November 2020, and from November 2021, residents will be able to apply for euthanasia (3).

The debate about euthanasia in Sweden

Since its start in 1985, The Swedish National Council on Medical Ethics (SMER) has, on two different occasions, called upon the government to investigate how to increase patients’ rights to influence the end of their lives. The first time SMER did this was in 1996, when the government was led by the social democratic party. The second time was in 2008, when a conservative party led the government. Both of these governments neglected SMER’s request (22). However, single members of parliament have on several occasions presented a motion to investigate the possibility to legalize some kind of assisted dying, but such motions have always been denied (23–32). When the political parties of Sweden (Socialdemokraterna, Moderaterna, Sverigedemokraterna,

Liberalerna, Centerpartiet, Kristdemokraterna, Vänsterpartiet, Miljöpartiet) were asked their opinion in the summer of 2020, only two parties out of eight (Miljöpartiet, Liberalerna) were in favour of a governmental investigation of whether a legalization of assisted dying should occur or not. The rest of the parties were against assisted dying and did not want an investigation (33). On the other hand, the Swedish public seems, overall, to be supportive of assisted dying in some form.

In 2010, 66% of the Swedish public supported assisted dying according to a survey made by SIFO (34). In 2017, the number had changed to 61% according to a survey made by Novus (35). In 2019, another survey was made, which showed that 70% of the Swedish public supported assisted dying, according to Swedish news programme TV4Nyheterna (36). Additionally, between the years 2000 and 2019, 34 people from Sweden have gone to Switzerland to die, acquiring the services of the Swiss non-profit, suicide assisting organization Dignitas (37).

In surveys where Swedish physicians have been asked to give their view, their opinion on the

matter is more divided than the opinion of the public. In a survey from 2008, one third of 1200

physicians stated that they would prescribe lethal drugs to a patient during the right circumstances

(38). Another study showed that 34% of physicians were positive towards physician-assisted

suicide, while 39% were negative (39). It is not mentioned, however, what specific questions were

asked, or what the criteria were for someone to be able to request assisted dying.

Common arguments for and against euthanasia

The following arguments for and against euthanasia are often seen in the debate about euthanasia and physician-assisted dying. This essay does not take a stand in whether these arguments are valid or not.

Arguments for euthanasia

Autonomy. The most common argument for euthanasia is that every person has a right to control their life and make choices regarding to their wishes. When it is a human right to choose how to live your life it should include the right to choose when and how you die (22).

Palliative care is not always enough to relieve suffering. Even though Sweden offers palliative care for all who needs it, sometimes the treatments and medications offered are inadequate. Some patients go through severe pain and anxiety in the last period of their life, suffering greatly, because palliative care is not always sufficient. Some people argue that all patients deserve to be able to end their life on their own terms, without suffering, before reaching a stage that cannot be managed properly. People want to die with dignity and without suffering (22).

The access to euthanasia relieves fear and stress. Many people who are diagnosed with a terminal disease live in fear that there will come a time in their life when they have to live every day in pain, with anxiety or simply depend on other people to help them perform the simplest tasks of daily life.

Not all patients are willing to live their life like this during their last period alive, stressing how important it is to die with dignity. If euthanasia was legal, these patients would be able to live their life without fear of what they might have to endure in the future (40).

The Swedish public want euthanasia to be legal. When a majority of the Swedish public believe euthanasia should be legal, and Sweden is a democracy, the government should listen to the public and legalize euthanasia (22).

Arguments against euthanasia

The slippery slope. If legalization of euthanasia should occur, there would be a risk that legislation

would change every now and then, allowing more and more people to request euthanasia. For

example, people with psychiatric conditions, minors or people who feel that they have lived a

complete life, could be euthanized. Another view of the slippery slope is the fear that society would

start to look differently on people with disabilities and elderly people, who could be perceived as

not contributing to society (22).

The risk of ending a life to soon. Some countries have a criterion that states that in order to receive euthanasia the patient has to have a maximum of six months left to live. There is an obvious risk that a physician can get their estimation wrong, and a patient become euthanized when he or she actually has longer than six months left to live. Furthermore, there is a risk that patients are euthanized and that some years later, a cure or a medication that would have had a significant improvement on their life would be discovered (22).

Physicians should not end lives. A phrase often repeated by physicians and others is: “The task of medicine is to cure sometimes, to relieve often, and to comfort always.” Many physicians firmly believe that they are supposed to save lives, not end them (22).

Pressure to request euthanasia. Patients who are severely ill can get the feeling that they are a burden to their loved ones or to society, and thereby feel a pressure to request euthanasia even though they have a will to live (22).

Decreased trust in healthcare. Some people believe that a legalization of euthanasia would make the public trust healthcare less, because the primarily purpose of healthcare is to save people’s lives, not to end them (22).

Main purpose and problems

If a legalization of euthanasia should occur in Sweden, it would affect the overall healthcare, and presumably also affect the everyday work of some physicians. Physicians would likely to be the ones to perform euthanasia, and also the ones to evaluate whether their patients are eligible for it, should they ask. Furthermore, it is likely that the government would listen to the opinions of

physicians, if an investigation should occur. With this in mind, it seemed important to find out what Swedish physicians thought of euthanasia. No deeper survey had recently been performed where Swedish physicians had been asked about their opinions on euthanasia or physician-assisted suicide.

It seemed there was a possibility that another, more detailed, survey could add further knowledge to

what was known about the opinions of Swedish physicians regarding euthanasia. Since the Swedish

Society of Medicine was performing a survey about physicians’ opinions about physician-assisted

suicide at the same time, the focus of this essay is euthanasia. The purpose of this essay was to

investigate the opinions of Swedish physicians and medical students regarding euthanasia in

Sweden. Three different research questions were formed in order to meet this purpose:

Question 1: Do Swedish physicians and medical students have different opinions regarding euthanasia in Sweden?

Question 2: Do physicians with different specialities have different opinions regarding euthanasia?

Question 3: Do physicians of different sex or age have different opinions regarding

euthanasia?

Methodologies

Recruitment and respondents

Five different specialities were chosen due to their frequent work with patients who are at the end of their lives or due to the fact that they work with the same patients for a longer period of time, hence getting to know their patients far better than most other physicians. The chosen specialities were:

clinical oncology, geriatric medicine, anaesthesia/intensive care, general practice and specialists with an additional speciality in palliative care. To be able to distribute the survey to physicians within these fields, the following associations were contacted: The Swedish Association of General Practice (Svensk förening för allmänmedicin), Swedish Association for Palliative Care (Svensk förening för palliativ medicin), Swedish society of oncology (Svensk onkologisk förening), Swedish Geriatric Society (Svensk geriatrisk förening) and Swedish association for Anaesthesia and

Intensive Care (Svensk förening för anestesi och intensivvård). Only the first two of these five associations were willing to send the survey to its members. The Swedish Association of General Practice was willing to send the survey as a part of their digital newsletter. Swedish Association for Palliative Care does not send newsletters to their members regularly, but agreed to send the survey to their members in a specific e-mail. To be able to investigate if there was a difference in opinion between practicing physicians and medical students, the survey was also sent to medical students of term 5 – 11 at Uppsala University. The students of the first four terms were deselected because of their lack of clinical experience.

The criteria for inclusion and exclusion were as follows:

Inclusion criteria:

• Physicians who are members of The Swedish Association of General Practice and subscribe to their newsletter or

• Physicians who are members of Swedish Association for Palliative Care and have their e- mail-address registered or

• Medical students of Uppsala University attending term 5 – 11.

Exclusion criteria:

• Physicians belonging to the chosen specialities (general practice and palliative care) but who are not members of one of the two chosen associations.

• Physicians who belong to other specialities and are not registered to newsletters from one of the organizations above.

• Medical students of terms 1 – 4 at Uppsala University.

• Medical students attending other universities.

Survey instrument

A specific survey was made for this project, the questions were not validated. The survey was made in a survey application of Uppsala University, Kurt. The survey in its entirety can be seen in

appendix 1. It started with information about the project and the definition of euthanasia. After this, respondents were asked to give their informed consent to participate in the survey. They were informed that their answers would be anonymous. The survey consisted of 18 questions, where the respondents first were asked to answer questions about themselves, and then questions about their opinion regarding euthanasia in Sweden. The premises for euthanasia in the survey were the same as for adults in the Netherlands, the physicians must meet all the requirements in the box below (8).

The survey included questions about if they thought that euthanasia should be legal in Sweden, if they wanted the government to perform an investigation and if they themselves would perform euthanasia, should it be legal. The survey also included a question about whether they thought they themselves could ever request euthanasia, should they find themselves eligible for it. After some of the questions, the next question asked the respondent to rank how sure they felt about the answer they just gave, from a scale of 1 to 10 (1 being not sure at all, 10 being completely sure).

The physician performing euthanasia must:

• Be confident that the patient is suffering unbearably without prospect of improvement

• Be confident the request is well-considered and has been made voluntarily

• Have informed the patient about his/her situation and prognosis

• Have consulted another, independent physician, who has seen the patient in person and written an assessment of whether or not the patient fulfils all the criteria

• Together with the patient come to the conclusion that there is no other reasonable alternative

• Have exercised due medical care and attention while terminating the patient’s life

Collecting data

The newsletter of Swedish Association of General Practice reaches about 2400 members, while Swedish Association for Palliative Care reaches about 453 members. The total number of

physicians reached via this survey would consequently be about 2850 physicians. Additionally, 680

medical students who attended term 5 – 11 in the autumn of 2020 at Uppsala University, were all

sent an invitation to answer the survey. Due to the survey being sent out via mail from the organizations and via Uppsala University, the participants in this project were selected in a non- random way. Since the survey was distributed in different ways, it was also distributed on different days. Members of the Swedish Association for Palliative Care were the first to receive the survey, they got it on the 3 ^rd of December 2020. The survey was sent out to medical students on the 14 ^th of December 2020. Lastly, members of the Swedish Association of General Practice got the survey on the 18 ^th of December 2020. On the 12 ^th of January 2021, the survey was closed and the data

downloaded for analysis.

When the survey was sent to the members of the Swedish Association for Palliative Care, 30 of the e-mails failed, so in total, 423 members received the mail. Of the 2014 newsletters that were sent by the Swedish association for General Practice to its members, 1888 were delivered, and 898 opened.

This meant that 1321 physicians had the chance to see and answer the survey. In total, 155

physicians answered, of which 141 gave their informed consent. As for the students, 680 students got the survey. 149 students answered, of which 116 gave informed consent. The 257 respondents who gave informed consent are described in Table 1. Of the 141 physicians who answered, the vast majority were specialists with many years of experience. A small number of responding physicians were not yet specialists, so the decision was made to present the answers from all physicians – regardless of experience – together, so as not to compromise anyone’s integrity. Answers were received from all regions of Sweden, with the most answers from Region Stockholm (33 answers), Västra Götalandsregionen (19 answers) and Region Skåne (17 answers). From the other regions, between 1 and 7 physicians per region answered, with a median value of 4.

Table 1. Description of respondents.

Residents or specialists in general practice (N)

Residents or specialists in palliative care (N)

Residents or specialists in other fields*

(N)

Women (N)

Men (N)

Total Number (N)

Physicians 62 42 37 84 57 141

Medical

students 67 49 116

All

respondents 151 106 257

*Most common other fields were clinical oncology, internal medicine and intensive care and anaesthesia.

Some of them worked in palliative care but were specialists/residents in other areas. Included in this group

was also physicians who had not yet started a residency.

Statistical analysis

Descriptive data have been used in this study to describe the study population. The data was presented as numbers and percentages. Contingency tables in the statistic programme SPSS were used to compare the data received from the survey. Chi-squared analyses were used in order to investigate if the differences in the results were statistically significant. Chi-squared analyses are used in order to receive a p-value, which reveals how large the risk is that the data is a result of a coincidence. A p-value of 0.05 or lower was considered statistically significant.

Question 1: Do Swedish physicians and medical students have different opinions regarding euthanasia in Sweden?

To answer this research question contingency tables were used along with chi-squared analysis to receive a p-value and sum value to calculate a median value.

Question 2: Do physicians with different specialities have different opinions regarding euthanasia?

To answer this research question contingency tables were used along with chi-squared analysis.

Question 3: Do physicians of different sex or age have different opinions regarding euthanasia?

To answer this research question contingency tables were used.

Ethical considerations

All medical research should be designed and performed with regards to the Declaration of Helsinki (41). The risks that the respondents could be exposed to had to be smaller than the benefits that the research would produce. The respondents were not exposed to physical harm in this study, all discomfort that they could experience was psychological. While reading the survey and answering the questions it was possible that the respondents would feel discomfort. The subject included topics such as death and severe disease. Thinking about matters like these can cause feelings such as sadness, anger or frustration. The discomfort some respondents possibly experienced could be outbalanced by a moment of thought and reflection that this survey could evoke.

In line with the Declaration of Helsinki, the respondents had to give their informed consent.

Furthermore, the integrity of the participants was protected by the anonymity.

This project was approved by the Swedish Ethical Review Authority (2020-05203).

Results

Question 1: Do Swedish physicians and medical students have different opinions regarding euthanasia in Sweden?

The answers to survey question 8, 9, 10 and 11 was used to respond to this research question. The survey questions read: 8: “Do you think euthanasia should be legal in Sweden?”, 9: “How sure do you feel about the answer you just gave?”, 10: “Do you think the government should perform an investigation to determine if euthanasia should be legal in Sweden?” and 11: “How sure do you feel about the answer you just gave?”. The answers to survey question 8 can be seen in Figure 1: 21.3%

of responding physicians and 74.1% of responding medical students said they want euthanasia in Sweden. The difference between these answers had a p-value of 0.000. The answers to survey question 10 can be seen in Figure 2: 36.2% of responding physicians and 87.1% of responding medical students said they want the government to perform an investigation regarding euthanasia in Sweden. Survey question 9 and 11 was answered with a number from 1 to 10, 1 being not sure at all, and 10 being completely sure. The students were less sure about their answer compared to the physicians. While answering to survey question 9, students had a median value of 6.61 while physicians had a median value of 8.74. This difference had a P-value of 0.000. When asking how sure they felt about the answer they gave on survey question 10 (Do you think the government should perform an investigation to determine if euthanasia should be legal in Sweden?), students had a median value of 8.47, and physicians had a median value of 8.57. With a P-value of 0.813, this was not statistically significant.

Figure 1. Answers to the question: “Do you think euthanasia should be legal in Sweden?”.

Figure 2. Answers to the question: “Do you think the government should perform an investigation to determine if euthanasia should be legal in Sweden?”.

Answers to other survey questions were also used to try to answer this research question. From these answers it was shown that 35.5% of responding physicians could see themselves requesting euthanasia in some situations, should it be legal. Moreover, 31.9% of them could see themselves giving euthanasia to a patient who has requested it, should it be legal. When being asked who is best suited to perform euthanasia, 66.3% of students answered that specialists in palliative care were best suited. 90.3% of physicians chose the alternative “Others, who?” where they could write freely.

The most important argument against euthanasia was the risk that someone could feel pressured to request euthanasia according to 44% of responding medical students and 36% of responding physicians. Regarding the most important argument for euthanasia, 40% of students said that autonomy was the most important argument, while the physicians were a bit more torn, 29%

answering autonomy and 30% answering the importance of living life without worry and anxiety over the risk to die in pain.

Question 2: Do physicians with different specialities have different opinions regarding euthanasia?

The answers to survey question 8 and 10 was used to respond to this research question. The survey questions read: “Do you think euthanasia should be legal in Sweden?” and “Do you think the government should perform an investigation to determine if euthanasia should be legal in Sweden?”. The answers to survey question 8 divided by speciality can be seen in Figure 3:

residents/specialist in palliative care were the most negative towards euthanasia with 11.9% of them

saying that they want euthanasia in Sweden. Answers to survey question 10 divided by speciality

can be seen in Figure 4: between 33.3% and 41.9% of responding residents/specialists said they

want the government to perform an investigation. In total, 135 specialists or residents answered the

study. Of them, 62 were specialists or residents in general practice, 42 were specialists or residents

in palliative care and 31 were specialists or residents in another field. Most of the other fields were clinical oncology, intensive care and anaesthesia or internal medicine. The P-value of the difference between these three categories was 0.156.

Figure 3. Answers to the question: “Do you think euthanasia should be legal in Sweden?”, divided by speciality.

Figure 4. Answers to the question: “Do you think the government should perform an investigation to determine if euthanasia should be legal in Sweden?”, divided by speciality.

Question 3: Do physicians of different sex or age have different opinions regarding euthanasia?

The answers to survey question 8 and was used to respond to this research question. The survey

question read: “Do you think euthanasia should be legal in Sweden?”. The answers were sorted by

which decade the physicians were born, which can be seen in Table 2 and Figure 5, and also by how

many years of experience they had after their graduation, see Table 3 and Figure 6. Answers from

medical students are not included in these tables and figures. The answers were also sorted by sex,

the results from this can be seen in Table 4, which do include answers from medical students.

Table 2. Physician’s answers to the question “Do you think euthanasia should be legal in Sweden?”. Two physicians did not answer which year they were born.

Year of birth* Yes (N) Yes (%) No

(N) No (%) Total number

of physicians (N)

1980 – 1999 7 53.8 6 46.2 13

1970 – 1979 7 23.3 23 76.7 30

1960 – 1969 9 20.5 35 79.5 44

1950 – 1959 4 10.8 33 89.2 37

1930 – 1949 3 20.0 12 80.0 15

All 30 109 139

*The number of responding physicians born 1930 – 1939 and 1990 – 1999 was very small. To protect their integrity, their opinions have been presented together with 1940 – 1949 and 1980 – 1989, respectively.

Table 3. Answers to the question: “Do you think euthanasia should be legal in Sweden?”, divided by years of experience after graduation.

Years of experience after

graduation

Yes (N) Yes

(%) No

(N) No

(%) Total number of physicians (N)

0-10 4 40.0 6 60.0 10

11-20 12 30.8 27 69.2 39

21-30 6 15.0 34 85.0 40

31-40 4 14.3 24 85.7 28

40+ 4 16.7 20 83.3 24

Figure 5. Answers to the question “Do you think euthanasia should be legal in Sweden?”, divided by the physicians’ year of birth. Since the number of responding physicians born 1930 – 1939 and 1990 – 1999 was very small, their answers are presented in the same pie chart as 1940 – 1949 and 1980 – 1989, to protect their integrity.

Figure 6. Answers to the question: “Do you think euthanasia should be legal in Sweden?”, divided by years of experience after graduation.

Table 4. Answers divided by sex.

Do you want euthanasia to be legal in Sweden?

Do you want the government to perform an investigation?

Yes No Yes No

Female physicians 18 (21.4%) 66 (78.6%) 28 (33.3%) 56 (66.7%) Male physicians 12 (21.1%) 45 (78.9%) 24 (42.1%) 33 (57.9%) Female students 48 (71.6%) 19 (28.4%) 57 (85.1%) 10 (14.9%)

Male students 38 (77.6%) 11 (22.4%) 44 (89.8%) 5 (10.2%)

Discussion

Result discussion and main results

The main result from this survey is that the answers clearly indicate that medical students were more positive towards euthanasia compared to physicians. The answers also indicated that even though the majority of physicians did not want euthanasia, some of them could see situations where euthanasia could be preferred above continued living. Furthermore, a number of physicians seemed willing to comply with legalization, should euthanasia become legal in Sweden.

As an answer to who they believe should perform euthanasia, many physicians expressed the belief that it is highly important that physicians who would perform euthanasia has been given extra education for this purpose, in the form of a specific course or a new residency/speciality. Many also emphasized the importance of free will, only physicians who want to work with euthanasia should be the ones to perform it. A few physicians also expressed that they did not think physicians should perform euthanasia at all, but that this rather should be a task for relatives, lawyers or a completely new profession.

Läkartidningen (A magazine published by The Swedish Medical Association) published a study in 1996 where they asked physicians from five different fields about their views on euthanasia in Sweden. The results from their survey varied between different specialities (42), similar to the results from this study. Among the responding physicians in this study, specialists/residents in palliative care were more negative towards euthanasia compared to specialists/residents in general practice, but also compared to physicians working in other fields. This is in line with results from other studies where physicians in palliative care also have been seen to be more negative towards euthanasia compared to other physicians (39). Do physicians in palliative care believe that most patients get a dignified end, and so there is no need for euthanasia? Is it possible that they are concerned that if a legalization would occur, many would consider the physicians in palliative care the best ones to provide the euthanasia, since they already work so closely with terminal patients?

Or could it be that when others are speaking about legalizing euthanasia in Sweden, physicians in

palliative care sees this as a failure of their work? Regardless of the reasons, a large majority of the

responding physicians in palliative care said they do not want euthanasia in Sweden. Interestingly,

although only 11% of responding physicians in palliative care wanted euthanasia, about a third of

them wanted the government to perform an investigation about whether or not euthanasia should be

legal, which was the same amount as the residents/specialists in general practice, see Figure 4.

Why were there differences?

The results from this study indicate that physicians and medical students hold opposite opinions.

74% of responding medical students said they wanted euthanasia in Sweden, compared to 21% of responding physicians. This study also indicated that older physicians and physicians with more years of experience tend to be more negative towards euthanasia compared to younger physicians.

This goes against a previous survey, where it was seen that younger physicians in fact were more negative towards euthanasia compared to older physicians (22). One hypothesis is that people’s opinions gradually change to be more similar to the opinion of people around them. In that sense, it is possible that students who oppose euthanasia become influenced by other students around them who are positive towards euthanasia. In the same way, it is possible that physicians who are positive towards euthanasia, gets influenced by physicians around them who are negative towards

euthanasia, causing them to change opinion. Another hypothesis is that it is a generational issue, and that students and physicians born in the 80s or 90s are more positive towards euthanasia compared to physicians born in earlier decades.

Regardless of the reason behind the differences, one possibility is that some or many of the students will continue to be positive towards euthanasia, causing the Swedish medical field to become more positive towards euthanasia in the future. This could have the effect that The Swedish Medical Association would follow in the footsteps of the Royal College of Physicians in Great Britain and change their stance on euthanasia to a neutral one to reflect the views of its members. Moreover, if a majority of both the Swedish public and the Swedish medical field hold the opinion that euthanasia should be legal in Sweden, the government might feel the pressure to do what SMER asked them to do 13 years ago, namely to investigate how to increase patients’ rights to influence the end of their lives. Another possibility is that some, or many, of the students who are positive towards euthanasia today will change their minds as they get older and/or surrounded by colleagues who are negative towards euthanasia, so that the future opinion of the medical field will remain more or less the same.

Methodological discussion Limitations

A major limitation in this essay was that only two, quite small, organizations agreed to help

distribute the survey. The Swedish Medical Association (Sveriges Läkarförbund), the trade union

for physicians in Sweden, with over 55 000 members (43) and the Swedish Society of Medicine

(Svenska Läkaresällskapet), an independent organization with 10 500 members (44) were both

contacted but declined participation. Having one of these organizations to help spread the survey to its members would ensure that the survey would reach a very large number of physicians, and also physicians from many different specialities. This would have made the conclusions of the study valid for a large part of Swedish physicians. The small number of answers that was received from this study meant that it was impossible to draw any large conclusions from this study.

Another limitation was that the survey was sent out digitally. It is possible that the survey would have received more answers had it been sent by physical mail. Additionally, when the survey was sent from the Swedish Association of General Practice to its members it was included in a

newsletter. Some receivers may not have noticed the invitation to answer the study. Regarding the survey sent to members of the Swedish association of palliative care, it is not known how many receivers saw or opened the e-mail. Since it is impossible to know how many physicians actually saw the survey, it was not possible calculate an accurate response rate. The response rate for students was more reasonable to calculate, since they got their survey in an official e-mail from the university. The response rate for the students was 17.1%.

Furthermore, the surveys were sent out on different dates but closed at the same time, meaning that the three different categories of respondents had different amounts of time to answer the survey. It was suspected however that this did not affect the response rate in a large scale, since most

respondents answer a survey in the first week (45).

Regarding the medical students, the survey was only distributed to students attending Uppsala University. It is possible that medical students from other universities hold different opinions, so the answers received by medical students in this survey does not necessarily reflect the views of all medical students in Sweden.

Other limitations include:

No power-calculation was performed before the start of the study.

Selection bias – non-random selection of possible respondents within the members of the organizations, only members engaged in newsletters.

Detection bias – non-validated study specific questions.

Possible systematic error – people tend to be more eager to express their view if they have negative feelings about a subject. It is possible that the results to this study would have been different, with more respondents being positive towards euthanasia, if the selection of respondents would have been randomised.

Strengths

A strength in this study was that this was the first study (as known by the author) to compare the opinions of physicians with the opinions of medical students. By including medical students in a study such as this, it was possible to try to predict the opinions of future physicians.

Future research

A larger study is needed. Preferably a study where all different fields in medicine are represented by large numbers. It would also be interesting to follow the medical students to see if their opinions change over time, or if they continue to be positive towards euthanasia.

Conclusions

This essay had the purpose to investigate Swedish physicians’ opinions regarding euthanasia in Sweden. Of the responding physicians, 78.7% said they did not want euthanasia to be legal, but at the same time, 35.5% of them said they could request it for themselves if it was legal. Physicians in palliative care were more negative compared to other physicians, 88.1% of them said they do not want euthanasia. Medical students were on the other hand positive towards euthanasia, 74.1% of them said that they want euthanasia to be legal in Sweden. Future research could show if younger generations stay positive towards euthanasia or if they change their opinion.

Because of the small size of this study, no conclusions can be made regarding the opinions of all

physicians or medical students in Sweden. More studies are needed.

Acknowledgements

Thank you

To my main supervisor Ulrik Kihlbom, for guidance and support throughout this entire experience.

To my supervisor Karin Schölin Bywall, for support and help with surveys and statistics.

To my mother and proofreader, Agneta Pihlgren, whose sharp eye rarely misses a misspelling.

Without her this essay would contain a whole lot more mistakes.

To my significant other, Hampus Bergström, for endless support and for never tiring of helping

me with all things computer related.

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Appendix A – The survey

Enkät

1. Samtycke att delta i enkäten

Jag har fått informationen om studien och har haft möjlighet att ställa frågor.

Jag får behålla den skriftliga informationen.

☐ Jag samtycker till att delta i studien ’svenska läkares inställning till eutanasi’.

☐ Jag samtycker till att uppgifter om mig behandlas på det sätt som beskrivs i forskningspersonsinformationen.

Om du väljer att fylla i och skicka in denna enkät så godkänner du att dina svar kan användas för en studentuppsats och eventuell framtida publikation. Om du inte vill delta i enkäten kan du stänga ner sidan, om du vill komma med en synpunkt om varför du ej vill delta i enkäten så går det bra att maila Alma Englund, mailadress finns längst ner. Detta är givetvis helt frivilligt.

Denna enkät behandlar ämnet Eutanasi. Eutanasi innebär här att en läkare avsiktligt avslutar en svårt sjuk och beslutskapabel patients liv på dennes begäran. Detta skiljer sig från

läkarassisterat självmord som innebär att en läkare på en svårt sjuk patients begäran

tillhandahåller ett läkemedel med syfte att avsluta patientens liv, men patienten måste själv inta läkemedlet.

Följande premisser gäller för eutanasi i denna enkät:

Läkaren som utför eutanasi ska

• ha en välgrundad övertygelse om att patientens önskan är frivillig och genomtänkt.

• vara övertygad om att patienten har ett outhärdligt lidande utan utsikter till lindrande.

• ha informerat patienten om situation och prognos.

• tillsammans med patienten nått slutsatsen att det inte finns något rimligt alternativ för att lindra lidande.

• ha konsulterat minst en oberoende läkare som personligen har besökt patienten och som har utfärdat ett skriftligt omdöme om att kriterierna är uppfyllda.

• kunna garantera att eutanasi utförs i enlighet med God vård.

En patient som efterfrågar eutanasi

• måste vara över 18 år och bedömas vara beslutskapabel.

2. Vilket år är du född?

3. Juridiskt kön

• Kvinna

• Man

4. Sysselsättning

• Läkarstudent

• Underläkare innan legitimation/AT-läkare

• Underläkare efter AT

• ST-läkare

• Specialist

5. Om du är specialist eller ST-läkare, inom vilket område jobbar du?

• Specialist/ST-läkare i allmänmedicin

• Specialist/ST-läkare med tilläggsspecialitet palliativ medicin

• Annat, vad?

6. Hur många år har du jobbat efter att du tog läkarexamen? (hoppa över om du är student)

• 0–5 år

• 6–10 år

• 11–15 år

• 16–20 år

• 21–25 år

• 26 – 30 år

• 31 – 35 år

• 36–40 år

• 40+ år

7. I vilken region arbetar du? (hoppa över om du är student)

• Region Blekinge

• Region Dalarna

• Region Gotland

• Region Gävleborg

• Region Halland

• Region Jämtland Härjedalen

• Region Jönköpings län

• Region Kalmar län

• Region Kronoberg

• Region Norrbotten

• Region Skåne

• Region Stockholm

• Region Sörmland

• Region Uppsala

• Region Värmland

• Region Västerbotten

• Region Västernorrland

• Region Västmanland

• Region Örebro län

• Region Östergötland

• Västra Götalandsregionen

Frågor om vad du anser om eutanasi:

8. Anser du att Sveriges lagstiftning bör ändras så att eutanasi blir lagligt?

• Ja

• Nej

9. Hur säker är du på det svar du gav ovan?

10 = helt säker 1 = väldigt osäker SKALA

10. Anser du att regeringen bör tillsätta en utredning för att ta ställning till om eutanasi bör vara lagligt i Sverige?

• Ja

• Nej

11. Hur säker är du på det svar du gav ovan?

10 = helt säker 1 = väldigt osäker SKALA

12. Om eutanasi skulle vara lagligt i Sverige, vilka anser du bäst lämpade att bistå en patient med detta? (går välja flera alternativ)

• Samtliga legitimerade läkare

• Samtliga läkare med specialistkompetens

• Specialister i allmänmedicin

• Specialister i geriatrik

• Specialister i onkologi

• Specialister i anestesi och intensivvård

• Specialist med tilläggsspecialitet palliativ medicin

• Annat, vilka?

patient med detta vid dennes förfrågan?

• Ja

• Nej

14. Hur säker är du på det svar du gav ovan?

10 = helt säker 1 = väldigt osäker SKALA

15. Givet att eutanasi är lagligt, finns det någon situation där du själv skulle kunna komma att efterfråga det?

• Ja

• Nej

16. Hur säker är du på det svar du gav ovan?

10 = helt säker 1 = väldigt osäker SKALA

17. Om eutanasi skulle bli lagligt, hur tror du att det skulle påverka allmänhetens förtroende för vården?

• Allmänheten skulle få högre förtroende för vården

• Allmänheten skulle få lägre förtroende för vården

• Allmänhetens förtroende för vården skulle vara oförändrat

• Vet ej

18. Vilket anser du är det viktigaste argumentet för legalisering av eutanasi?

• Autonomi – alla har rätt att bestämma över sitt eget liv och sin egen död.

• Alla har rätt att leva och dö under värdiga former.

• Vetskapen om att det går att få hjälp att avsluta sitt liv gör att man slipper oro och ångest över risken att behöva dö under plågsamma.

• Annat, vad?

19. Vilket anser du är det viktigaste argumentet mot legalisering av eutanasi?

• Läkare ska bota, lindra och trösta, ej döda.

• ”Det sluttande planet” – om vi börjar med att legalisera eutanasi så kan det ske en glidning i lagstiftningen, t.ex. att vi snart godkänner eutanasi av minderåriga.

• Personer kan känna sig pressade att begära eutanasi för att ej känna sig som en börda för anhöriga/samhället.

• Risken att godkänna eutanasi hos någon som kanske skulle haft längre tid kvar att leva än man beräknat, eller har en sjukdom där man kan hitta botemedel om några år.

• Annat, vad?

Vid frågor om enkäten går det bra att kontakta oss.

Alma Englund

Läkarstudent, termin 10 Uppsala Universitet

Mail: Alma.Englund.1901@student.uu.se Ansvarig forskare:

Ulrik Kihlbom

Docent i Medicinsk Etik

Centrum för forsknings- & bioetik Uppsala Universitet

Mail: ulrik.kihlbom@crb.uu.se