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Attitudes of oncologists toward euthanasia in Turkey

Published online by Cambridge University Press:  03 March 2006

ATILLA SENIH MAYDA ,
ERDEM ÖZKARA  and
FUNDA ÇORAPÇIOĞLU
ATILLA SENIH MAYDA
Affiliation:
Düzce Medical School, İzzet Baysal University
ERDEM ÖZKARA
Affiliation:
Faculty of Medicine, Dokuz Eylül University
FUNDA ÇORAPÇIOĞLU
Affiliation:
Department of Pediatric Oncology, Kocaeli University
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Abstract

There have been intensive debates about euthanasia and attempts to change laws on euthanasia in all countries. What doctors and particularly oncologists think about euthanasia must be taken into consideration, as their voices are crucial in this dialogue. The aim of this study was to find out how Turkish doctors approach euthanasia in the context of cancer. A questionnaire was used to collect data from 85 oncologists out of a total 800 in active oncology practice.

Of the oncologists surveyed, 43.8% did not object to euthanasia. Some 33.7% had been asked to perform euthanasia and 41.5% believed that euthanasia was performed secretly although it is against the law in Turkey. Forty-two doctors (50.6%) noted that they had withdrawn treatment in patients.

Doctors who encounter terminally ill patients with cancer should update their knowledge about patients' rights and euthanasia. Doctors, who are often asked to perform euthanasia, especially in the cancer setting, can help to illuminate the debates about euthanasia.

Keywords

EuthanasiaAttitudes of doctorsOncologyPatient rights
Type
BRIEF REPORT
Information
Palliative & Supportive Care , Volume 3 , Issue 3 , September 2005 , pp. 221 - 225
Copyright
© 2005 Cambridge University Press

INTRODUCTION

There is an intensive debate on euthanasia and assisted suicide in the world. Doctors, patients, lawyers, and all health staff illuminate the public discourse by contributing their views and experiences. Doctors have a special role to play in these discussions (Dickinson et al., 1997–1998, 2002; Ozkara, 2001; Ozkara et al., 2001, 2004b; Akabayashi, 2002). Cancer patients often experience unbearable pain and may seek relief by requesting euthanasia (Kaplan et al., 1999–2000; Suarez-Almazor et al., 2002; Maltsberger, 2003). In a study of oncologists and palliative care doctors in Japan, the rate of physician-assisted suicide (PAS) was reported by 2% of the doctors (Morita et al., 2002). Because doctors are in close contact with cancer patients and are often asked to perform euthanasia, we believe the study's data will inform our understanding of this contemporary and growing public health policy issue.

METHODS

This is an observational and cross-sectional study. Dependent variables were doctors' approach to euthanasia, definition of euthanasia, legal basis of euthanasia, whether the doctors were asked to perform euthanasia, whether they directed patients toward passive euthanasia and their expectations about euthanasia. Independent variables were age, gender, title, workplace, and work experience.

There are 80,000 doctors in Turkey, 800 of whom are medical or surgical oncologists. A hundred and fifty oncologists attending a scientific meeting in Turkey in 2003 were asked to complete a questionnaire (see the appendix). Eighty-five agreed to participate in the study, making the response rate 56.7%. Because the sample consisted of oncologists attending this particular medical meeting, the results of the study cannot be generalized to all 800 doctors practicing oncology in Turkey.

A questionnaire was composed of 18 multiple choice items related to age, sex, work place, title, specialty, and duration of practice. Participants were given the dictionary definition of euthanasia (see the questionnaire) and asked if they wanted to add to or change this definition. The last part of the questionnaire asked the oncologists if they had ever performed euthanasia and what opinions they had about the practice of euthanasia in Turkey today.

Data were evaluated using the Epi Info 6 package program. The proportions in independent groups of categorical data were analyzed with a chi-squared test.

RESULTS

The mean age of the 85 participating oncologists was 37.5 ± 5.6 years and their mean work experience was 8.0 ± 5.6 years. Fifty-five (60.0%) of the participants were male. Of the 80 doctors who identified their positions, 40 (50%) were academicians or consultants, 62 (72.9%) were working at state hospitals, and 23 (27.1%) at university hospitals. Table 1 shows in which branch of oncology the doctors specialized.

Distribution of doctors by branches

All 85 oncologists expanded the dictionary definition of euthanasia: 79 (92.9%) added “patient must request euthanasia”; 63 (74.1%) said “patients must be conscious when they request euthanasia”; and 37 (43.5%) stated “doctors had to be present when euthanasia was performed.”

Thirty-five (43.8%) of 80 oncologists replying to question number 9 did not object to euthanasia. Forty-five (56.2%) did object for the following reasons: 21 (46.7%) said “Euthanasia was unethical,” 16 (35.6%) felt “It may be abused,” 14 (31.1%) noted “It was illegal,” and 14 (31.1%) believed “It was against their religious tenets.” Fifteen (18.8%) were in favor of punishing doctors who performed euthanasia. There was no statistical significance between this view and gender, workplace, or title.

Eighty-one of 85 oncologists answered the question of who should decide to perform euthanasia. Forty-four (54.3%) oncologists replied the patients, 34 (42%) said the families and doctors of the patients together, and 3 (3.7%) relied on the patients' families.

Twenty-eight (33.7%) of 83 doctors who replied to question number 11 indicated that they had been asked to perform euthanasia. There was a significant difference between the gender of the physician and a request for euthanasia. Twenty-three of 51 male doctors (45.1%) and 5 of 32 female doctors (15.6%) noted that they had been asked to perform euthanasia (χ2 = 6.3, p = 0.012). However, no significant relationship was found between request for euthanasia and workplace, title, or specialty.

Thirty-four of 82 doctors (41.5%) believed that euthanasia had been performed secretly in Turkey, whereas 48 (58.5%) denied this. Thirty-one physicians (37.8%) admitted that they advised patients with incurable diseases not to start therapy. Twenty-eight doctors (34.1%) had given the advice more than once and three doctors (3.7%) once only. Eighteen (39.1%) of the doctors who did not believe euthanasia was performed in Turkey did, in fact advise their patients with untreatable cancer not to start treatment, and 24 (51.1%) admitted that they had withdrawn treatment. There was no relationship between the advice not to start therapy and gender, workplace, or title.

Eighty-three physicians responded to the question of withdrawal of treatment in patients with incurable disease. Forty-two doctors (50.6%) admitted that they had withdrawn treatment in patients, 41 (49.4%) noted that they withdrew treatment more than once, and one doctor said he had done so only once. No association was found between withdrawal of therapy and gender, workplace, or title. Twenty-seven of 42 (64.3%) doctors who performed euthanasia declared that patients' relatives, doctors, or doctors' colleagues had decided to withdraw treatment from the patient. Fifteen (35.7%) doctors wanted the patient's voice to be part of the collective that decides to withdraw treatment. Only 2 (4.8%) doctors thought that only the patient himself could decide to stop treatment.

The distribution of pediatric and other oncologists was not statistically significant relative to starting or withdrawing treatment. Ten of 29 (34.5%) pediatric oncologists declared that they had counseled patients not to start treatment, and 20 of 47 (42.6%) adult oncologists offered similar advice. However, 19 of 29 (65.5%) pediatric oncologists and 21 of 45 (46.7%) adult oncologists declared they had withdrawn treatment from their patients.

Seventy of 83 (84.3%) oncologists agreed that euthanasia should be under discussion in Turkey, whereas 11 (13.3%) held the opposite view and 2 did not comment.

DISCUSSION

There is an ongoing global debate about euthanasia and it resonates strongly in the cancer setting. Generally speaking, the key questions are: In which cases can euthanasia apply? How should euthanasia be carried out? Should informed consent be obtained from patients? The prevailing thought in present-day Turkey (Ozkara, 2001) would restrict euthanasia to the cessation of suffering and only in patients with fatal illnesses. Consistent with this approach, there have been other Turkish studies that reveal the following definition of euthanasia: “the practice of killing someone with a progressive, unbearable and fatal disease and with no hope for recovery despite today's medicine and done painlessly after a long and painful period at a patient's request with the assistance of a physician.” This definition was reported to be accepted by 85.3% of law students, 87% of health sciences students, and 88–96% of doctors (Ozkara et al., 2001, 2002, 2003, 2004a; 11–13). In our current study, we found that 43.8% of the oncologists supported this broader definition and added the following conditions: the patient must request euthanasia, the patient must be conscious in making this request, and the doctor must be present when it is performed.

Dickinson et al. (2002) in their study in England reported that 80% of geriatricians found active voluntary euthanasia (AVE) and PAS unethical. In a study in Washington and South Carolina, USA, it was demonstrated that 80%–84% of doctors were against euthanasia because it could be abused and 56%–67% believed it was in conflict with their religious beliefs (Dickinson et al., 1997–1998). In two recent studies, on terminally ill cancer patients, it was shown that 69% of the patients supported euthanasia and PAS (Suarez-Almazor et al., 2002; Maltsberger, 2003). Kaplan et al. (1999–2000) and Bachman et al. (1996) found in their research that the two main reasons for rejecting euthanasia were (1) its illegal status, and (2) its contrariness to religious beliefs. Studies in Turkey (Ozkara et al., 2002, 2003, 2004b) (11–13) have shown the following to be the most frequently given reasons for objecting to euthanasia: the possibility of its abuse (41.6%–72.8%) and conflict with ethical values (24.9% and %32.9) or with religious beliefs (18.7% and %21.7) (11–13). In our study, the most frequently cited reasons for objecting to euthanasia were its unethical nature and the possibility of abuse. Although the overwhelming majority of the population in Turkey is Muslim, religious rules are not seen as the leading cause of objection to euthanasia. In fact, secularism and education may have influenced people's attitudes toward euthanasia. This is clearly reflected in the questionnaire completed by doctors, who have a high level of education.

Passive euthanasia is understood to mean that treatment is withdrawn or not initiated (Ozkara, 2001) (4). In our study, almost half the doctors noted that they had advised their patients to withdraw from or not to start therapy at all, although the doctors suggested that they did not do so directly. Although the proportion of pediatric oncologists who directed patients not to start treatment was found to be lower than that of adult oncologists, the proportion of pediatric oncologists who had withdrawn treatment was found to be higher than that of other oncologists in our study. This somewhat contradictory finding may be explained by the fact that pediatric cancer patients are more likely to start treatment but suffer more pain than adult patients and they are more likely to be separated from social life during cancer therapy and experience more severe psychosocial problems.

Currently, euthanasia is not on the agenda of public debate in Turkey. Nevertheless, in a multicenter study (Ozkara et al., 2004b) (13), 33.7% of the oncologists and 19% of physicians had been requested to perform euthanasia and 41.5% of oncologists and 55.9% of 949 physicians believed that it had been practiced secretly. Moreover, 42 of 48 oncologists in this study, who believed euthanasia was not practiced in Turkey, admitted to directing patients toward passive euthanasia by suggesting that they not start treatment or request the withdrawal of their treatment. Thus, this subject must be brought into discussion in scientific circles in Turkey. The findings of our study as well as those of the other Turkish researchers referenced in this Brief Report clearly indicate the need for health staff to be provided with in-service training regarding euthanasia and patients rights.

APPENDIX: EUTHANASIA QUESTIONNAIRE FOR ONCOLOGISTS

We aim to collect data about euthanasia in our country with this study. Thank you for your contribution.

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Figure 0

Distribution of doctors by branches