Assisted suicide and euthanasia from the perspective of professionals and academics in a university hospital

Abstract

The objective of this study was to identify the attitude of professionals and academics in a university hospital regarding assisted suicide and euthanasia. The study was conducted using a questionnaire and included 354 participants. In cases of patients with terminal illnesses, 68.1% of participants supported the legalization of assisted suicide and 73.2% supported the legalization of euthanasia. The support for legalization of assisted suicide or euthanasia was 46.9% in cases of patients with progressive neurodegenerative diseases and 30.8% in cases of tetraplegia. In cases of terminal illnesses, if those were legalized, 45% of participants would commit assisted suicide, 57% would request euthanasia, 36.5% would aid in assisted suicide and 39.9% would aid in euthanasia. In conclusion, the great support for legalization of euthanasia and assisted suicide among the participants emphasizes the need to broaden the discussion on the subject in the population.

Suicide assisted; Euthanasia; Right to die; Attitude to death; Bioethics

Resumo

Objetivou-se identificar a atitude de profissionais e acadêmicos de enfermagem, fisioterapia, medicina e psicologia de um hospital universitário perante suicídio assistido e eutanásia. O estudo foi desenvolvido por meio de questionário de autopreenchimento e contou com 354 participantes, entre os quais, 68,1% concordaram com a legalização do suicídio assistido e 73,2% com a legalização da eutanásia para pacientes com doenças terminais. A concordância com a legalização do suicídio assistido ou da eutanásia foi de 46,9% em casos de pacientes com doenças neurodegenerativas progressivas e de 30,8% em casos de tetraplegia. Em casos de doenças terminais, se legalizados, 45% dos participantes cometeriam suicídio assistido, 57% solicitariam eutanásia, 36,5% auxiliariam suicídio assistido e 39,9% auxiliariam eutanásia. Conclui-se que a ampla aceitação da legalização da eutanásia e do suicídio assistido entre os participantes enfatiza a necessidade de se ampliar a discussão sobre o tema entre a população.

Suicídio assistido; Eutanásia; Direito a morrer; Atitude frente à morte; Bioética

Resumen

Se tuvo como objetivo identificar la actitud de profesionales y estudiantes de enfermería, fisioterapia, medicina y psicología de un hospital universitario ante el suicidio asistido y la eutanasia. El estudio fue desarrollado por medio de un cuestionario de auto-llenado y contó con 354 participantes, entre los cuales el 68,1% concordó con la legalización del suicidio asistido y el 73,2% con la legalización de la eutanasia para pacientes con enfermedades terminales. La concordancia con la legalización del suicidio asistido o de la eutanasia fue del 46,9% en casos de pacientes con enfermedades neurodegenerativas progresivas y del 30,8% en casos de tetraplejia. En los casos de enfermedades terminales, si se legalizara, el 45% de los participantes practicaría suicidio asistido, el 57% solicitaría eutanasia, el 36,5% colaboraría en el suicidio asistido y el 39,9% colaboraría en la eutanasia. Se concluye que la amplia aceptación de la legalización de la eutanasia y del suicidio asistido entre los participantes enfatiza la necesidad de ampliar la discusión sobre el tema entre la población.

Suicidio asistido; Eutanasia; Derecho a morir; Actitud frente a la muerte; Bioética

Assisted suicide and euthanasia are practices performed to shorten the lives of patients who are in unbearable suffering and with no prospect of improvement. In assisted suicide, the patient intentionally, with the help of third parties, ends his life, taking or self-administering lethal drugs; in active euthanasia, a third person, at the patient’s request, administers a lethal agent with the intention of shortening life and ending suffering ¹.

There are countries that authorize and regulate practices to speed up the death process. In the Netherlands, Luxembourg and Canada, both assisted suicide and euthanasia are legalized for patients in irreversible medical condition, suffering from constant, unbearable suffering and can not be relieved ². In Colombia and Belgium, euthanasia is also legalized for patients suffering from unbearable physical or mental suffering ³.

In the United States, the states of Oregon, Washington, Montana, Vermont, and California permit assisted suicide for patients with a prognosis of at most six months of life ². In Switzerland, assisted suicide is practiced by non-profit organizations, as there are no laws that prohibit this practice; however, its performance is not acceptable with the motivation of alleviating family financial expenditures or releasing the hospital bed to another patient who is in need of treatment ¹.

There is no mention of euthanasia in the Brazilian Penal Code, but in this case the concept of privileged homicide motivated by relevant social value or violent emotion, based on § 1 of art. 121, called pious homicide; when there is intent to harm, the conduct falls under § 2, for intentionally anticipating death. Assisted suicide is included in Article 122, which deals with the inducement, instigation or aid to someone’s suicide ⁴.

The Code of Medical Ethics ⁵ of 2010 does not specifically cite assisted suicide or euthanasia in its text. However, art. 41 prohibits the physician from shortening the life of the patient, even at the request of the very patient or of their legal representative, and in his sole paragraph, the code condemns dysthanasia and defends orthatanasia, palliative care and patient autonomy.

Regardless of the legal status of the conduct, it is a controversial issue. Euthanasia and assisted suicide find their basis in the bioethical principle of autonomy, according to which the patient has the right to decide when and where to die, and these acts can also decrease their suffering during the process of death ⁶. However, there are moral and religious impediments, which argue that it is not ethically correct to help someone die ⁷.

There is also the “slippery slope” argument which says that legalizing assisted suicide or euthanasia would make it difficult or impossible to protect vulnerable patients, such as the elderly and disabled, from errors and abuse ⁷. Meanwhile, stringent safety criteria such as those used in countries where such practices are legalized may provide adequate protection against misconducts ⁷.

In addition, there is the thought that physicians would be violating the principles of their profession, since according to the oath of Hippocrates, they are prohibited from participating in the intentional death of a patient ⁸. However, the primary obligations of physicians are both to alleviate suffering and to respect the autonomy of their patients, and physicians would be acting according to the highest values of their profession when they heed the request of a patient who wishes to end an unbearable suffering, abbreviating his process of dying ⁷.

Due to the fact that the studies on the subject are scarce in the Brazilian literature, mainly referring to the opinion of health professionals, this research aimed to identify the attitude of professionals and students of a university hospital in the face of assisted suicide and euthanasia.

Methods

This is descriptive and crosscut study, with a quantitative approach. The sample was formed by professionals and students from the health area of the Hospital Universitário Santa Terezinha (“Santa Terezinha University Hospital” - HUST), in the city of Joaçaba, Santa Catarina, Brazil. The inclusion criterion included professionals and health students who were working or practicing at the HUST during the period of data collection. Individuals who did not meet these criteria, or who chose not to participate in the study by explicit refusal, or who did not sign the free informed consent form (FICF), or who did not respond to the whole questionnaire were excluded from the sample.

The research consisted of 354 participants and was performed in all sectors of the hospital in July and August 2016: oncology, ICU, emergency, medical clinic, surgical clinic, surgical ward, imaging, maternity and pediatrics. As a research instrument, a self-fulfillment questionnaire was used, composed of five sociodemographic questions and 14 questions structured according to the Likert scale, which measures attitudes in opinion surveys. The questionnaire is presented as an annex to this article.

Participants were approached at the health facility during working hours, and care was taken that no hospital service or care was interrupted or delayed. At the opportunity, the FICF was presented to professionals and students and, after agreement and completion by the participant, the questionnaire was returned directly to the researcher, to a pedagogical space clerk or deposited in ballot boxes that were in the nursing posts of the different sectors of the hospital.

The data collected were transcribed to Microsoft Excel and submitted to descriptive statistical analysis, used to describe and summarize the data set. Subsequently, they were analyzed statistically, according to the variables measured and the type of distribution presented by the data set. For this, Pearson’s chi-square test and Fisher’s exact test were used.

Participants were divided into three major groups: Group 1, graduates, composed of higher-level professionals (nurses, pharmacists, physicians and psychologists); Group 2, technicians, composed of professionals of trade school level (technicians in nursing and in radiology); Group 3, students, composed of undergraduate students (in nursing, physiotherapy, medicine and psychology).

To guarantee statistical reliability, some analyses used only professional groups with more than 50 participants, namely: physicians, nurses, medical students and nursing technicians. The differences between groups were considered significant when p≤0.05. For each of the questions, the absolute frequencies for the responses between the aforementioned clusters were compared. In order to understand among which groups the statistical difference resided, complementary and independent analyzes were performed, always comparing the answers for each of the groups with all other possible groups. For such complementary analyses, the significant differences (p <0.05) are represented by symbols in the tables (*, # and $). All analyses were done with the use of the Statistica 7.0 and/or Excel softwares.

Results

The estimated population of health professionals and students performing internships at the HUST during the data collection period included 80 physicians, 65 nurses, 10 physiotherapists, 5 pharmacists, 3 nutritionists, 2 psychologists, 1 social worker, 140 nursing technicians, 20 radiology technicians, 65 medical students, 15 nursing students, 30 physiotherapy students and 2 psychology students, a total of 438 individuals.

Of this total of possible participants, 411 were approached and 362 (88.1%) answered the questionnaires. Eight participants whose questionnaires were incomplete or who had not signed the FICF were excluded. The final sample consisted of 354 participants divided into three major groups: Group 1 comprised of 140 (39.5%) graduated professionals, considering 64 (18.1%) physicians, 55 (15.5%) nurses, 10 (2 8%) physiotherapists, 5 (1.4%) pharmacists, 3 (0.8%) nutritionists, 2 (0.6%) psychologists and 1 (0.3%) social workers; Group 2 comprised 116 (32.8%) technical professionals, with 113 (31.9%) nursing technicians and 3 (0.8%) radiology technicians; Group 3 comprised 98 (27.7%) students, with 60 (16.9%) medical students, 27 (7.6%) physiotherapy students, 9 (2.5%) nursing students and 2 (0.6%) psychology students.

As for sex, 265 (74.9%) were female and 89 (25.1%) were male. In relation to age, 174 (49.2%) were between 18 and 29 years of age, 94 (26.6%) between 30 and 39 years, 55 (15.5%) between 40 and 49 years, 22 %) between 50 and 59 years, and 9 (2.5%) were 60 years or older. Regarding marital status, 165 (46.6%) were single, 107 (30.2%) married, 57 (16.1%) lived in a stable union, 24 (6.8%) were divorced/separated, and 1 (0.3%) was a widow. Regarding religious orientation, 272 (76.8%) were Catholic, 33 (9.3%) were Protestant/Evangelical, 26 (7.3%)were Spiritist, 13 (3.7%) Agnostic/Atheists, 5 (1.4%) declared themselves simultaneously Catholics and Spiritists and 5 (1.4%) declared other religions.

Of the 354 participants, 260 (73.4%) reported knowing the meaning of “assisted suicide” prior to the survey and 94 (26.6%) did not. When asked about the knowledge of the term “euthanasia”, 342 (96.6%) stated that they knew the meaning and 12 (3.4%) did not know it.

The number of participants who had already received a request for help to accelerate the death of a patient was 39 (11%), and 315 (89%) had never received this request. In the responses of the professional groups with more than 50 participants, it was found that 14 (21.9%) physicians, 4 (7.3%) nurses, 14 (12.4%) nursing technicians and 2 (3.3% ) medical students had already received this request. There was a statistically significant difference (p <0.05) in the “yes” answers of nursing technicians when compared to those of medical students, physicians and nurses; and among medical physicians and students (Table 1).

Table 1
Experiências dos participantes sobre a ajuda no processo de morte

Question	Answer	Physicians % (n)	Nurses % (n)	Medical Students % (n)	Nursing Technicians % (n)
Has any patient ever asked you for help to accelerate the process of dying?	Yes	21.9 (14)*#	7.3 (4)*	3.3 (2)*	12.4 (14)
	No	78.1 (50)	92.7 (51)	96.7 (58)	87.6 (99)
	Total	100 (64)	100.0 (55)	100.0 (60)	100.0 (113)
Have you ever considered the idea of helping end the suffering of a patient by accelerating their death?	Yes	39.1 (25)*	18.2 (10)*#	30.0 (18)*	7.1 (8)
	No	60.9 (39)	81.8 (45)	70.0 (42)	92.9 (105)
	Total	100.0 (64)	100.0 (55)	100.0 (60)	100.0 (113)

• * p<0.05 vs nursing technicians; ^#p<0.05 vs medical students

When questioned if they had ever considered the idea of offering help to end the suffering of a patient by accelerating their death, 72 (20.3%) participants answered “yes” and 282 (79.7%) “no”. In the responses of the professional groups with more than 50 participants, 25 (39.1%) physicians, 10 (18.2%) nurses, 8 (7.1%) nursing technicians and 18 (30%) had already considered this idea. There was a statistically significant difference (p <0.05) due to a lower number of “yes” answers from nursing technicians when compared to medical students, physicians and nurses; and of nurses when compared to medical students (Table 1).

Concerning the question: “If you had a terminal illness, in which you were in unbearable suffering, would you seek the help of someone to speed up your death process?”, 54 (15.3%) answered “decidedly yes”; 169 (47.7%) “probably yes”; 86 (24.3%) “probably not”; and 45 (12.7%) “decidedly not”.

About agreeing to the creation of a law in Brazil that allows assisted suicide in cases of terminal diseases, 102 (28.8%) totally agreed; 139 (39.3%) partially agreed; 50 (14.1%) disagreed partially; and 63 (17.8%) disagreed totally. In the large groups, 76 (77.6%) students, 104 (74.3%) graduated professionals and 61 (52.6%) technical professionals agreed to the legalization of assisted suicide in cases of terminal diseases. There was a statistically significant difference (p <0.05) in the answers “totally agree” and “totally disagree” by technicians in relation to students and graduates (Table 2).

Table 2
Perception of the participants about the legalization of assisted suicide and/or euthanasia in Brazil and the intention to commit them, if legal, in cases of terminal diseases or progressive neurodegenerative diseases or tetraplegia.

Question	Answer	Students % (n)	Graduates % (n)	Technicians % (n)
Legalization of assisted suicide in cases of terminal diseases	Totally agree	36.7 (36)*	31.4 (44)*	19.0 (22)
	Partially agree	40.8 (40)	42.9 (60)	33.6 (39)
	Partially disagree	18.4 (18)	12.9 (18)	12.1 (14)
	Totally disagree	4.1 (4)*	12.9 (18)*	35.3 (41)
	Total	100.0 (98)	100.0 (140)	100.0 (116)
Legalization of euthanasia in cases of terminal diseases	Totally agree	38.8 (38)*	34.3 (48)*	19.8 (23)
	Partially agree	44.9 (44)	45.7 (64)	36.2 (42)
	Partially disagree	12.2 (12)	12.9 (18)	8.6 (10)
	Totally disagree	4.1 (4)*	7.1 (10)*	35.3 (41)
	Total	100.0 (98)	100.0 (140)	100.0 (116)
Legalization of assisted suicide or euthanasia in cases of progressive neurodegenerative diseases	Totally agree	12.2 (12)	6.4 (9)	11.2 (13)
	Partially agree	43.9 (43)*	45.7 (64)*	21.6 (25)
	Partially disagree	27.6 (27)	22.9 (32)	25.0 (29)
	Totally disagree	16.3 (16)*	25.0 (35)*	42.2 (49)
	Total	100.0 (98)	100.0 (140)	100.0 (116)
Legalization of euthanasia in cases of tetraplegia	Totally agree	6.1 (6)	10.0 (14)	7.8 (9)
	Partially agree	36.7 (36)*	24.3 (34)*	8.6 (10)
	Partially disagree	24.5 (24)	25.0 (35)	20.7 (24)
	Totally disagree	32.7 (32)*	40.7 (57)*	62.9 (73)
	Total	100.0 (98)	100.0 (140)	100.0 (116)
Assisted suicide would be committed if the participant himself had a terminal illness	Decidedly yes	9.2 (9)	10.7 (15)	11.2 (13)
	Probably yes	43.9 (43)*	38.6 (54)*	21.6 (25)
	Probably not	36.7 (36)	35.0 (49)	33.6 (39)
	Decidedly not	10.2 (10)*	15.7 (22)*	33.6 (39)
	Total	100.0 (98)	100.0 (140)	100.0 (116)
The participant would require euthanasia in case he/she had a terminal illness	Decidedly yes	15.3 (15)	17.1 (24)	14.7 (17)
	Probably yes	58.2 (57)*	42.9 (60)*	25.0 (29)
	Probably not	20.4 (20)	28.6 (40)	26.7 (31)
	Decidedly not	6.1 (6)*	11.4 (16)*	33.6 (39)
	Total	100.0 (98)	100.0 (140)	100.0 (116)

• *p<0,05 vs technicians

Regarding agreement to the creation of a law that allowed euthanasia in cases of terminal diseases in Brazil, 109 (30.8%) totally agreed, 150 (42.4%) partially agreed, 40 (11.3%) partially disagreed and 55 (15.5%) disagreed completely. In the large groups, agreement to the legalization of euthanasia in cases of terminal diseases was: 82 (83.7%) students; 112 (80%) graduated professionals; and 65 (56%) technical professionals. As in the previous question, the result was significant (p <0.05) in the “totally agree” and “totally disagree” answers of the technicians in relation to students and graduates (Table 2).

Regarding the creation of a law that allows assisted suicide or euthanasia in cases of progressive neurodegenerative diseases, 34 (9.6%) totally agreed, 132 (37.3%) partially agreed, 88 (24.9%) agreed, partially disagreed and 100 (28.2%) disagreed completely. In the large groups, 55 (56.1%) students, 73 (52.1%) graduated professionals and 38 (32.8%) technical professionals agreed to the legalization of assisted suicide or euthanasia in cases of progressive neurodegenerative diseases. In this result, there was a difference (p <0.05) between students’ and graduates’ “partially agree” and “totally disagree” responses compared to those of the technicians (Table 2).

Regarding the creation of a law to allow euthanasia in Brazil in cases of tetraplegia, 29 (8.2%) totally agreed, 80 (22.6%) partially agreed, 83 (23.4%) partially disagreed, and 162 (45.8%) disagreed completely. In the large groups, the agreement with the legalization of euthanasia in cases of tetraplegia was 42 (42.9%) students, 48 (34.3%) graduated professionals and 19 (16.4%) technical professionals. There was a significant difference (p <0.05) in the “partially agree” and “totally disagree” answers of the technicians compared to the students and graduates (Table 2).

Participants were asked to disagree partially or totally to the creation of laws that allow assisted suicide or euthanasia in the different cases exposed, which would indicate the reason for the disagreement, being able to choose more than one alternative. This question was answered by 275 participants (total of 322 chosen options), who claimed the following reasons: “personal reasons”, marked 135 times (41.9%); “Moral / legal principles”, 92 times (28.6%); “Religious principles”, 34 times (10.6%); and “other reasons”, 61 times (18.9%).

In the hypothetical case of a law that allowed assisted suicide and / or euthanasia in Brazil, and the existence of a participant with terminal illness in physical or psychological suffering, 159 (44.9%) of all respondents would commit suicide of which 37 (10.5%) answered “decidedly yes” and 122 (34.5%) “probably yes”. Under the same conditions, 202 (57.1%) would request euthanasia, of which 56 (15.8%) answered “decidedly yes” and 146 (41.2%) “probably yes”.

In the large groups, 52 (53.1%) students, 69 (49.3%) graduated professionals and 38 (32.8%) technical professionals would commit assisted suicide, as well as 72 (73.5%) students, 84 60%) graduated professionals and 46 (39.7%) technical professionals would request euthanasia. There was a statistically significant difference (p <0.05) in the answers “probably yes” and “decidedly not” due to the greater disagreement of the technicians when compared with students and graduates (Table 2).

When asked if they would provide drugs for a patient to commit assisted suicide, if a law were approved in Brazil, 30 (8.5%) answered “decidedly yes”, 99 (28%) “probably yes”, 100 (28.2%) “Probably not” and 125 (35.3%) “decidedly not”. In the responses of professional groups with more than 50 participants, 39 (65%) medical students, 28 (43.8%) physicians, 23 (41.8%) nurses and 16 (14.2%) technicians would give the drugs for a patient to commit assisted suicide.

There was a statistically significant difference (p <0.05) in the answers “probably yes” and “decidedly not” due to the greater disagreement of the nursing technicians when compared with physicians, nurses and medical students; and among medical students, by their greater agreement, when compared with physicians, nurses and nursing technicians (Table 3).

Table 3
Perspective of the participants in providing medicines for a patient to commit assisted suicide or to apply medication to accelerate their death, if it were legal

Question	Answer	Physicians % (n)	Nurses % (n)	Medical students % (n)	Nursing technicians % (n)
Would provide medicines for a patient to commit assisted suicide	Decidedly yes	6.3 (4)	12.7 (7)	13.3 (8)	5.3 (6)
	Probably yes	37.5 (24)*#	29.1 (16)*#	51.7 (31)*	8.8 (10)
	Probably not	35.9 (23)	27.3 (15)	26.7 (16)	24.8 (28)
	Decidedly not	20.3 (13)*#	30.9 (17)*#	8.3 (5)*	61.1 (69)
	Total	100.0 (64)	100.0 (55)	100.0 (60)	100.0 (113)
Would apply the drugs to accelerate the death of a patient	Decidedly yes	9.4 (6)	12.7 (7)	13.3 (8)	5.3 (6)
	Probably yes	43.8 (28)*	36.4 (20)*#	50.0 (30)*	12.4 (14)
	Probably not	28.1 (18)	23.6 (13)	28.3 (17)	27.4 (31)
	Decidedly not	18.8 (12)*	27.3 (15)*#	8.3 (5)*	54.9 (62)
	Total	100.0 (64)	100.0 (55)	100.0 (60)	100.0 (113)

• * p<0,05 vs nursing technicians; ^#p<0,05 vs medical students

When asked if they would apply the drugs to accelerate the death of a patient, if a law allowed euthanasia in Brazil, 31 (8.8%) answered “decidedly yes”, 110 (31.1%) “probably yes”, 98 27.7%) “probably not” and 115 (32.5%) “decidedly not”. In the responses of professional groups with more than 50 participants, 38 (63.3%) medical students, 34 (53.1%) physicians, 27 (49.1%) nurses and 20 (17.7%) nursing technicians drugs to speed up the death of a patient. There was a statistically significant difference (p <0.05) in the answers “probably yes” and “decidedly not” with greater disagreement of the nursing technicians when compared with physicians, nurses and medical students; and among medical students, by their greater agreement, when compared with nurses and nursing technicians, according to Table 3.

Discussion

In the present study, 21.9% of physicians, 7.3% of nurses, 12.4% of nursing technicians and 3.3% of medical students have already been asked to accelerate the death process of some patients. In a survey conducted in Greece with 215 physicians, 250 nurses, 218 family members of advanced cancer patients and 246 lay people, 20.5% of physicians, 3.6% of nurses, 11% of relatives and 6.1% of lay people reported having received a patient’s request to shorten life ⁸. In both studies, the group of physicians obtained a higher percentage of requests for termination of life, possibly because it is responsible for the prescription of drugs and the choice of treatment of their patients, which could give more hope in relation to the request.

Even in Belgium, where legislation allows for euthanasia, applications go through a palliative filter, and pass by an active and comprehensive approach to palliative care, with the possibility of making the request for euthanasia irrelevant ⁹. In this context, palliative care can enable patients to live their last days as fully as possible, with maximum comfort, and have the best possible medical management of death ¹⁰.

However, one can not confuse quantity of life with quality of life; and fears and taboos that present death as an enemy, a failure or disclosure of professional incompetence, must be overcome ⁹. Palliative care is not always available or sufficient ¹, so there is the possibility of assisted suicide and euthanasia, and 39.1% of the physicians, 30% of the medical students, 18.2% of the nurses and 7.1% of the nursing technicians of our research have already considered ending the suffering of some patients accelerating their death.

Here, a high rate of agreement was reached provided there was the creation of a law that would allow euthanasia and assisted suicide in cases of terminal illnesses in Brazil, with euthanasia having a slightly higher percentage of acceptance (73.2%) than assisted suicide (68.1%), a result in conformity with a study performed in the United States, where euthanasia had greater support than assisted suicide among the participants ². A survey of 390 nurses in Andalusia, Southern Spain, also showed greater support for the legalization of euthanasia (76.5%) than for assisted suicide (65%) ¹¹. However, studies conducted in the United States, in European countries, and in Australia generally show greater support from physicians for assisted suicide than to euthanasia ².

A study carried out in South Korea, involving 1,242 cancer patients, 1,289 family caregivers, 303 oncologists and 1,006 members of the Korean population, showed that almost 50% of participants in the patient and population groups supported active euthanasia and assisted suicide for the terminally ill; however, less than 40% of family caregivers and less than 10% of oncologists supported these acts ¹². A survey conducted in Belgium, where euthanasia is legal, found that 90.4% of the 914 participating physicians agreed to practice euthanasia for patients of terminal disease involving uncontrollable pain or other extreme suffering ¹³, showing the existing difference in perception.

This difference in acceptance is due to cultural differences, since countries that have a higher rate of acceptance are more conducive to personal autonomy (for example, European and North American countries), and countries that have a lower rate of acceptance are more favorable to paternalistic or family-centered decision-making models (e.g., Asian countries) 12. In our study, the rate of acceptance of assisted suicide and euthanasia for terminal illnesses was around 70%, similar to European and North American countries, which value patients’ autonomy. However, this work involved only professionals and students in the health area, not extending to patients or the general population.

In the present study, the agreement of the participants to a law allowing assisted suicide or euthanasia in cases of progressive neurodegenerative diseases was lower than in cases of terminal diseases (46.9%). In cases of tetraplegia, agreement was even lower (30.8%). This difference of acceptance, depending on the patient’s situation, was also found in a survey of 677 New Zealanders, in which 49% of the interviewees understood that euthanasia or assisted suicide were the most appropriate responses for a tetraplegic patient who asks for assistance in dying ¹⁴. However, the percentage of New Zealanders who chose euthanasia or assisted suicide as the most appropriate response for a patient suffering from an incurable disease was higher, reaching 78% ¹⁴.

In the present study, 63% of all respondents would seek the help of someone to accelerate their death process if they were suffering from a terminal illness in which they were in unbearable suffering; this question did not mention the method that would be used to accelerate the process of death, nor the legality of the act. In the questions that mentioned the method (assisted suicide or euthanasia), in case the act was legalized in Brazil, affirmative answers decreased, 57% of all participants would request euthanasia and 45% would commit assisted suicide.

Research carried out with 588 medical students from two Polish universities showed that in the hypothetical situation of the student himself or a person close to him or her face an incurable disease, 60.38% would choose natural death, 17.35% would choose euthanasia, 16.50% assisted suicide and 5.77% did not have an opinion ¹⁵. In another study conducted in Portugal with 143 oncologists, it was concluded that 35.7% of the participants would like to have the euthanasia option available and 23.8% would like to have the assisted suicide option available in case the participant himself or herself is a terminal illness ¹⁶.

In our study, the majority of nursing technicians were decisive in stating that they would not give the medications for a patient to commit assisted suicide (85.9%), nor would they apply them to accelerate the death of a patient (82.3% ), if there was a law that allowed such acts in Brazil; the “decidedly not” answers of the nursing technicians, for both questions, were significantly higher in comparison to the other professional groups. However, a large part of the groups of medical students (63.3%), physicians (53.2%) and nurses (49.1%) would be willing to assist euthanasia; and 65% of medical students, 43.8% of physicians, 41.8% of nurses would be willing to assist assisted suicide (Table 3).

Differing from studies conducted in other countries, where the intention to assist these acts was smaller, a survey carried out in Germany, for example, with participants in a congress on palliative care, counted with the participation of 198 physicians and 272 nurses, showed that 15.7% of physicians and 11% of nurses would be willing to assist assisted suicide in terminally ill patients, and 7.1% of physicians and 4% of nurses would be willing to assist euthanasia in terminally ill patients ¹⁷. In another survey conducted in Italy with 855 physicians, it was concluded that 16% of physicians would assist assisted suicide and 12% would assist euthanasia at the request of the patient ¹⁸. In a survey conducted in Poland with the participation of 588 medical scholars, only 11.73% of scholars would support euthanasia or assisted suicide ¹⁵.

These studies conducted in Germany and Italy showed that the participants were more supportive of assisted suicide than euthanasia, thus leaving ultimate responsibility for the patient himself, which guarantees his autonomy and, at the same time, spares the professional the direct action ¹⁷. These results differed from those obtained with the groups of physicians, nurses and nursing technicians of the present study, who were more willing to assist euthanasia. A study with cancer patients showed that in severe and irrecoverable end-of-life situations, most patients do not want to be kept alive, which corroborates the need for more reflections on the termination of life ¹⁹.

Final considerations

The majority of the participants stated that they knew the meaning of the terms “euthanasia” and “assisted suicide” and few participants had already received a request to help speed up the death process of some patients, and physicians were the professionals who received the most.

There was a high concordance rate for euthanasia and assisted suicide in patients with terminal diseases, if they were legal procedures in Brazil, and euthanasia had a higher rate of acceptance than assisted suicide. Agreement to the creation of a law that allowed assisted suicide or euthanasia in Brazil was smaller in cases of progressive neurodegenerative diseases and even smaller in cases of tetraplegia.

If legalized, approximately half of the participants would request euthanasia and/or commit assisted suicide, if they were personally suffering from a terminal illness. Likewise, approximately half of the groups of medical students, physicians and nurses would be willing to assist euthanasia and assisted suicide if a law allowing such acts was approved in Brazil. The groups of physicians, nurses, and nursing technicians were more willing to aid euthanasia than assisted suicide. In all the questions, both regarding legalization and whether assisted suicide and euthanasia would be requested or helped, there was less agreement among technical professionals compared to other groups.

In Brazil, health care is still a long process of humanization, especially the care of pain and suffering, as well as the care of vulnerable people at the end of life, in which cases the increase in the supply of palliative care within the Unified Health System (“Sistema Único de Sáude”) can greatly improve patients’ quality of life. However, many patients’ rights develop in the Ministry of Health and other ones can move forward in the legislative sphere. In this context, based on the results of this research, the acceptance of the legalization of the practices of euthanasia and assisted suicide emphasizes the need to broaden the discussion in the society about the topic of the present study.

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Annex

Questionnaire

Dear participant, we kindly as you to honestly this questionnaire. No information that identifies you will be disclosed.

Part 1. Social-demographic profile

Gender:

( ) Masculine

( ) Feminine

( ) Other

Age group:

( ) From 18 to 29 years old

( ) De 30 to 39 years old

( ) De 40 to 49 years old

( ) De 50 to 59 years old

( ) 60 years old or above

Marital status:

( ) Single

( ) Stable union

( ) Married

( ) Divorced / Separated

( ) Widow(er)

Religious orientation:

( ) Catholic

( ) Protestant/evangelical

( ) Spiritist

( ) Agnostic/atheist

( ) Other:_______________________________________

Professional field:

( ) Nurse

( ) Nursing technician

( ) Physician

( ) Pharmacist

( ) Physiotherapist

( ) Speech Therapist

( ) Nutritionist

( ) Psychologist

( ) Medical student

( ) Nursing student

( ) Physiotherapy student

( ) Psychology student

( ) Other: ______________________________________

Part 2. Read the following text and then answer the questions, marking the alternative that best represents your thoughts.

Assisted suicide and euthanasia are practices performed to shorten the lives of patients who are in unbearable suffering and with no prospect of improvement. In assisted suicide the patient, intentionally, with the help of third parties, ends his own life, ingesting or self-administering lethal drugs. In active euthanasia, a third person, at the request of the patient, administers a lethal agent with the intention of shortening the patient’s life to end his/her suffering. There are countries such as the Netherlands, Belgium and the USA that authorize and regulate assisted suicide and/or euthanasia for specific cases. In Brazil both practices are illegal.

1) Before reading the previous text, did you know what assisted suicide was?

( ) Yes. ( ) No.

2) Before reading the previous text, did you know what euthanasia was?

( ) Yes. ( ) No.

3) Has any patient ever asked you for help to accelerate the process of dying?

( ) Yes. ( ) No.

4) Have you ever considered the idea of helping end the suffering of a patient by accelerating their death??

( ) Yes. ( ) No.

5) If you had a terminal illness, in which you were in unbearable suffering, would you seek the help of someone to speed up your death process?

( ) Decidedly yes.

( ) Probably yes.

( ) Probably not.

( ) Decidedly not.

6) Do you agree to the creation of a law that allows assisted suicide in Brazil in cases of terminal illnesses?

( ) Totally agree.

( ) Partially agree.

( ) Partially disagree.

( ) Totally disagree.

7) Do you agree to the creation of a law that would allow euthanasia in Brazil in cases of terminal diseases?

( ) Totally agree.

( ) Partially agree.

( ) Partially disagree.

( ) Totally disagree.

8) Do you agree to the creation of a law in Brazil that allows assisted suicide or euthanasia in cases of progressive degenerative diseases such as Alzheimer’s or Amyotrophic Lateral Sclerosis?

( ) Totally agree.

( ) Partially agree.

( ) Partially disagree.

( ) Totally disagree.

9) Do you agree with the creation of a law in Brazil that allows euthanasia in cases of tetraplegia?

( ) Totally agree.

( ) Partially agree.

( ) Partially disagree.

( ) Totally disagree.

10) If you answered “partially disagree” or “totally disagree” in any previous question, what was the main reason for the disagreement? (you can tick more than one alternative)

( ) Religious principles (my religion is against assisted suicide and euthanasia).

( ) Moral/legal principles (in our society it is wrong to perform assisted suicide and euthanasia).

( ) Personal reasons.

( ) Other: ______________________________________

_______________________________________________

_______________________________________________

11) If a law that would allow assisted suicide were approved in Brazil, and if you were suffering from a terminal illness, in which you were suffering physically or psychologically, would you commit assisted suicide?

( ) Decidedly yes.

( ) Probably yes.

( ) Probably not.

( ) Decidedly not.

12) If a law allowing euthanasia were approved in Brazil, and if you had a terminal illness, in which you were suffering physically or psychologically, would you request euthanasia?

( ) Decidedly yes.

( ) Probably yes.

( ) Probably not.

( ) Decidedly not.

13) If a law allowing assisted suicide were approved in Brazil, would you provide drugs for a patient to commit assisted suicide?

( ) Decidedly yes.

( ) Probably yes.

( ) Probably not.

( ) Decidedly not.

14) If a law allowing euthanasia were approved in Brazil, would you apply the drugs to accelerate the death of a patient?

( ) Decidedly yes.

( ) Probably yes.

( ) Probably not.

( ) Decidedly not.

Publication Dates

• Publication in this collection
  Apr-Jun 2018

History

• Received
  16 Sept 2017
• Reviewed
  28 Nov 2017
• Accepted
  29 Jan 2018