A literature search was performed using a range of online databases, of which two relevant papers were chosen, reviewed and compared. The subject matter concerned attitudes towards euthanasia and physician-assisted suicide (PAS), the authors of the papers sent questionnaires out to a number of currently practicing doctors and analysed the results using data analysis methods. The results were then delivered in a series of tables and graphs.
This literature review is based upon people's attitudes towards Euthanasia, which comes from the Greek meaning ‘good death' and in English means the killing of one person by another to relieve the suffering of that person and Physician Assisted Suicide (PAS), which is described as; a medical professional aiding a person who is incapable of the act themselves to commit suicide, (NHS, 2010). For this literature review, a literature search was performed using the Cochrane library, Science Direct, EBSCOhost and Sage using the key words:
- Assisted suicide
- United Kingdom
- Right to Die
- Assisted Dying
Most of these words (with the exception of Assisted Suicide and Assisted Dying) were used in each of the search engines individually and also used to form sentences, however, the only electronic databases that gave this search the information it required was Sage. This provided a substantial amount of journals, a lot of the others used were subscription based or a fee was required, but from the free to use information two of the most relevant to the subject I wished to perform the review on were chosen. The two papers were chosen from surveys and studies performed in the United Kingdom, because it was decided to research what the thoughts and feelings of medical professionals were in a place where this practice was presently illegal. Use in the literature search, but this was difficult to come by. The titles of the three journals are: ‘Legalisation of Euthanasia or Physician Assisted Suicide: Survey of Doctors' Attitudes', and Opinions of the Legalised of Physician Assisted Suicide. Despite not inputting the word ‘physician' into the search engine, a lot of the searches came up with types of journals which mention this anyway.
This review will critically evaluate the information in the journals and will be compared with each other, discussing the disadvantages of the surveys and the advantages. The review will also include the various research methods used in the research.
The Literature Review
The first paper reviewed is in English by Clive Seale, PhD, from the Centre for Health Sciences, Barts and The London School of Medicine and Dentistry, London and is called ‘The legalisation of Euthanasia or Physician-Assisted Suicide: Survey of Doctors' Attitudes'. The protocol was to determine what doctors' opinions about the legalisation of medically assisted dying (which includes the terms, euthanasia and physician-assisted suicide (PAS)) were and this was done in comparison with the opinions of the general public of the UK. The methodology was to send out structured questionnaires with a series of questions using qualitative methods and then analyse the results in a quantitative manner. In 2007, Binley's database (http://www.binleys.com) was used to send questionnaires to 8857 currently working medical practitioners all over the UK, this was broken down into 2829 (7%) GPs, 443 (43%) neurologists, 836 (21% of these were doctors) specialists in the care of the elderly, 462 (54% of these were also doctors) specialists in palliative medicine and 4287 workers in other hospital based specialities. This is quite a large sample to use and covers a wide range of specialities. It is not clear in what month in 2007 these questionnaires were sent out but follow-up letters were sent to non-respondents between November 2007 and April 2008 to enquire as to why they did not respond, in which 66 doctors in all responded with the most common reason being lack of time to complete the survey. Overall the response rate was 42.1% with specialists in palliative medicine being the most responsive with 67.3% of people returning their questionnaire, along with specialists in the care of the elderly (48.1%) neurologists (42.9%) other hospital specialties (40.1%) and GPs (39.3%). Despite the large sample of people, 42.1% of replies are quite disappointing, although it is a very emotive subject.
The questions consisted of personal questions such as age, gender, grade, ethnic origin, and speciality of the respondent and, on average, the number of deaths attended. They were all asked four questions about their attitude towards euthanasia and assisted suicide, in order to obtain the questionnaire in full the author of the survey invited people to contact him. An email was sent: Appendix (a) and a reply was received the next day: Appendix (b). Previous surveys regarding this subject were performed in the Netherlands, Oregon (USA) and Belgium majority support from the medical profession has been important in passing permissive legislation in these countries.
The keywords used in this study were assisted dying; euthanasia; physician-assisted suicide; right to die and terminal care. The distribution of questionnaires meant that the methodology used was right as it was discreet and reached a lot of people in a short amount of time, the only danger with this method was that the medical professionals did not have to respond which was shown in the return response of 42.1% there was no financial or other incentive as this would go against all ethical considerations. Ethical approval for this study was granted by the South East Research Ethics Committee. The results showed that those who were specialists in palliative medicine were more opposed to euthanasia or PAS being legalised than the other specialities, although this could be down to the higher response rate in this area. Those that expressed their religious beliefs were more opposed to the legalisation also. The study showed that the most widely held view was that British doctors do not support legalising assisted dying in either euthanasia or PAS; this differs from the British Social Attitudes (BSA) survey which has tracked changes in public opinion since 1984, and is the most consistent source of data (http://www.britsocat.com).
The second paper reviewed is ‘Survey of doctors' opinions of the legalisation of physician assisted suicide' by William Lee, Annabel Price, Lauren Rayner and Matthew Hotopf from the Institute of Psychiatry. King's College, London. The protocol is similar to the first paper in that they were looking at practitioners' opinions on euthanasia and PAS. The article begins by saying that there is wide support among the general public for assisted dying but not so much for those who care for the dying. The methodology was to send out a postal survey of a 1000 senior consultants and medical practitioners were selected randomly from the commercially available ‘Informa Healthcare Medical Directory (2005/2006), retired doctors were excluded from the survey. Questionnaire were sent firstly in February 2007, 12 weeks later, in May, non-respondents were contacted and then six weeks later they were telephoned, it was discovered that that some of the possible contributors had moved, died or retired. This information was adjusted to take this into account. The authors completed separate univariable (a single variable) and multivariable (containing more than one variable) predicting the outcomes using polytomous methods which would allow two outcomes to be predicted together.
The response rate to the survey was 50% once the exclusions were accounted for, which is higher than the first paper and still gave a lot of date to work with. Included in the survey the authors included a brief outline of the Assisted Dying for the Terminally Ill Bill (2006) 32% of the doctors who responded had read some of the Bill. Gender, speciality and years in post had no effect on opposition or support for a new law. An interesting point noted is that the views of doctors who do not care for the dying tally with the general publics view, so there is some correlation there with 66% of those who never cared for the dying supporting a change in the law. The outcome of interest for the authors was to what level practitioners agreed with the statement: “The law should not be changed to allow assisted suicide”.
A second outcome of interest was the level of agreement with the statement “I would be prepared to prescribe a fatal drug to a terminally ill patient who was suffering unbearably, were that course of action to become legal”. (Hotopf, et. al. 2007:3). The findings of this questionnaire can be found in Appendix (c). Both of these questions were determined using five-point Likert-type scales, used commonly in questionnaires, following this were converted into three-point scales comprising of ‘agree', ‘neither agree nor disagree' and ‘disagree' with a change in law. The survey shows that senior doctors are split abut their views regarding a change in the law; fewer are in favour than the general public in the United Kingdom. These findings have been noted in the US, as well as Canada, Finland and the Netherlands as well as the UK. Ethical permission was gained from the Institute of Psychiatry, King's College London Research Ethics Committee.
Comparisons and Conclusions
There are many comparisons between the two papers, for example, both sent out questionnaires to their target group, who were specialists in certain fields. However, the first paper surveyed over double the amount of people the second paper did but got less replies. Both studies were done in the same year but it is difficult to tell who started theirs first as the date for first paper is unknown other than it was performed in 2007. The second survey is far more in depth that the first one, and it suggests that qualitative research is needed to understand doctors' views better whereas the first paper did not state which the preferred method was. The second paper suggests that doctors who oppose a change in the law comes from an ‘over-optimistic' credence in their ability to relieve the suffering of the dying. (Hotopf, et.al. 2007). It is possible to argue against this though and the knowledge and experience of patients who are dying influences views about PAS. Both compare the attitudes between the general public and the specialist doctors and note a big difference between them. On the whole both papers conducted a thorough and precise survey but there is room for further research and investigation.
Hotopf, L, Lee, W, Price, A, and Rayner, L. (2009) ‘Survey of Doctors' Opinions of the Legalisation of Physician-Assisted Suicide', Bio-Med Central, [Online], Available from: http://www.biomedcentral.com/content/pdf/1472-6939-10-2.pdf [Accessed: 22nd April 2010].
NHS (2010) Euthanasia and assisted suicide [Online], London. Available from: http://www.nhs.uk/Conditions/Euthanasiaandassistedsuicide/Pages/Definition.aspx [Accessed 22nd April 2010].
Seale, C. (2009) ‘Legalisation of Euthanasia or Physician-Assisted Suicide: Survey of Doctors' Attitudes', Palliative Medicine, [Online], Available from: http://pmj.sagepub.com/cgi/content/abstract/23/3/205 [Accessed 22nd April 2010].
Papers used in Literature Search:
Hotopf, L, Lee, W, Price, A, and Rayner, L. ‘Survey of Doctors' Opinions of the
Legalisation of Physician-Assisted Suicide'.
Seale, C ‘Legalisation of euthanasia or physician-assisted suicide: survey of doctors' attitudes'.
A Research Proposal
Euthanasia and Assisted Suicide in the United Kingdom.
2. Research Questions
Should Euthanasia and Assisted Suicide be made legal? What are the arguments for and against policy change in the United Kingdom? Which section of society is most supportive of a change in the law? Which section is most opposed and why?
3. Aims of Project
This research aims to investigate, using secondary data, whether a change in the law is needed to clarify the position of euthanasia and assisted suicide in the United Kingdom, and whether this should be made legal just for those who are terminally ill or for those whose quality of life is considered poor with no improvement by the individual concerned. There is a lot of information regarding what members of the medical profession think, but it was found in the literature search that there was not a lot of information on what the general public thought, just by an initial search using the search engines below. The project also aims to find out why people have strong positive feelings towards euthanasia and physician-assisted suicide (PAS) and why those who have strong opposition towards it do, including the religious and ethical issues. This project will aim to address all these questions and give a defined answer to them using secondary data and primary research to carry out a systematic review of the data collected.
As the laws and legislation on euthanasia and assisted suicide have been very sketchy in the United Kingdom until recently, it seems that there is a need for some clarification in the law that leaves people in no doubt as to where they stand regarding this issue. While there are several countries where only physician-assisted suicide for the terminally ill is legal, these are in Oregon (USA) the Netherlands and Belgium; there is still some opposition from doctors and focus groups in these countries and you also need to be a resident of that country to be considered for this procedure. In Switzerland, however, there is a clinic called Dignitas which, under Swiss law, is permitted to assist with suicide for altruistic reasons only and people can travel from all over the world to use this service, but there are strict guidelines and the police are informed in the case of every death (The Guardian, 2010). The work and procedures of Dignitas will be researched as part of the project. The other aims of this project are to compare feelings in the countries that have decriminalised euthanasia and PAS and those that haven't.
4. Initial Literature Review
An initial literature review has been undertaken using the following databases:
The Cochrane Library and
The following search words were used:
Right to die Assisted Suicide Opinions
Attitudes Euthanasia United Kingdom
Assisted Dying Public
A more thorough search will take place as part of the project when the research begins in July 2010, where more keywords will be used.
‘Survey of doctors' opinions of the legalisation of physician assisted suicide' by Hotopf, M, Lee, W, Price, Annabel and Rayner, L. and ‘Legalisation of euthanasia or physician-assisted suicide' by Searle, C were the papers used for the literature review (in part A) and were just a small sample of the information available from the databases mentioned above. These databases will be searched in more depth and other methods of research will be used, such as books and journals to back up the information. Both authors sent out a postal structured questionnaire with a follow-up to non-respondents a few months later. Whilst both of the papers used in the literature review asked the views of doctors and consultants in various specialties (Seale, 2007) and (Hotopf et.al. 2007) neither set of authors surveyed the general public and instead used statistics from the British Social Attitudes (BSA) survey to compare the information. The papers used in the literature review, so far, have used qualitative data to collect their information, as this is seen as the best way to record and take note of the comments and to collect the data. Both of the papers used in the literature review produced an interesting outcome, it showed that more senior doctors are opposed to a step towards legislation than in support of the assisted dying as a whole and doctors that were caring for the dying were more opposed than those that didn't. Also the religious views of the doctors' surveyed came out strongly opposed to the possibility of legislation being passed for clarification of the law regarding euthanasia and PAS. According to Seale (2007), despite many doctors in the UK being opposed to euthanasia and PAS, the British Medical Association (BMJ) dropped their opposition to assisted dying and took a neutral stance in 2005. The Guardian (2006) states that in 2002 the Netherlands were the first country to legalise euthanasia along with Belgium and is legal from the age of twelve years. The US state of Oregon passed a law which allows doctors to prescribe legal drugs but not administer them under the Death with Dignity Act (1998). The surveys in the literature review were performed three years ago, with euthanasia, in particular, in the news a lot recently and the need for clarification in some situations, it is possibly the right time for another survey. This project would research into this possibility and look for more recent papers on the subject. In the United Kingdom, a member of the House of Lords, Lord Joffe produced a Bill that would give doctors the right to prescribe drugs to a person who was terminally ill and in severe pain. These could be used to end their life, and there was a passionate debate regarding the ethics and practical considerations about the proposal, but this Bill was blocked by the House of Lords (House of Lords, 2005). The Assisted Dying for the Terminally Ill Bill (2005) will be looked at in more depth and analysed and any updates on this Bill will be looked at.
A mostly qualitative methodology will be adopted for secondary data collection, as it aims to ‘understand the individual's view without making any judgements during the data collection' (Bowling, 2009:380). Empirical data collection will also be used as a part of the research for the project.
To begin with there will extensive research which will start at least eight months before the project needs to be completed, this will involve searching databases, books and journals using numerous keywords for appropriate material which can be used towards the project. Surveys and other research methods will be searched for to begin with in order to obtain a relevant starting point for data collection. Journals and books will then be used for back up information and to explain the certain aspects of euthanasia and assisted suicide. When the data is collected it will be analysed thoroughly, compared and critically evaluated. It will then be sorted into a logical order and written up with results, findings and fact presented in a systematic way along with the inclusion of graphs, tables and charts if appropriate.
6. Ethical and Practical Constraints
University guidelines will and have been adhered to and ethical issues have been considered and will be considered throughout the project. As this project is for secondary research the search will only include papers that have already been ethically approved and will also be peer reviewed. Being able to find enough information on the relevant subject could hinder progress as the project will have to rely on work others have done. Starting the research early enough to thoroughly analyse the information would ease the problems of rushing the research, and maybe not reaching the right conclusion. In order to conduct the right research it would also be important to consider the definition of euthanasia, as the different variants of euthanasia create different ethical and moral dilemmas in relation to the legalisation of euthanasia. It is also worth taking into consideration that there is only one researcher working on this project and so progress may possibly be slower than a project with several researchers.
Timetable for Dissertation Preparation
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