Quantitative results
326 of the 1168 students contacted responded to the survey, giving a total response rate of 28% (326/1168). The response rates for the earlier years are higher than the latter years (2nd 35%, 105/x; 3rd 31%, 91/x; 4th 22%, 66/x; 5th 23%, 64/x). Independent demographics (Appendix, Table 4a) are similar across the years with respect to ethnicity and religiosity. Gender distribution is similar across 2nd, 3rd, and 4th years but in the 5th year there is a relative increase in the number of male respondents. Obviously, as there is a progression through the years of medical school education, there are more respondents in the 25+ age group category. When compared to the rest of the cohort (Appendix, Table 4b), age, ethnicity, and gender are similar. Age is largely identical. All categories in ethnicity except ‘other’ have similar proportions. The largest proportional difference for gender is 3rd year, where there is a 9% difference in proportion of male participants. If there is any other sampling bias, it would be reasonable to expect this to apply across year levels, and so the comparison between those year levels would still hold. Information about the religious affiliation of students is not kept by the Medical School, but comparison can be drawn with the general population. 68% of participants reported having ‘no religion’ compared to 42% of the general population in 2013, while 26% identified as Christian compared to 49% (24). This indicates that the participants were less religious as a group than the general population (which is perhaps unsurprising as the general population includes older people who are more likely to be religious), but it is unknown whether they were more or less religious than the rest of the cohort.
The responses to Q1 (section 2) are provided in Table 1 and Figure 1. Table 1 shows an overall 56% (184/326) support for the legalization of EAD, while 22% (71/326) are unsure, and 22% (71/326) oppose. Over the four years of medical education support decreases from 65% to 63% to 52% to 39%, while opposition increases from 14% to 20% to 24% to 34%.
Table 1: Participant year levels and answers to question 1 (section 2)
Q1: ‘Do you think the law in New Zealand should be changed to allow doctors, under certain circumstances, to provide or administer a medicine to a person, at their voluntary and competent request, that will bring about their death?’
|
Year levels
|
Yes
|
No
|
Unsure
|
Total
|
Response rate
|
2nd
|
68 (64.8%)
|
15 (14.3%)
|
22 (21.0%)
|
105
|
35%
|
3rd
|
57 (62.6%)
|
18 (19.8%)
|
16 (17.6%)
|
91
|
31%
|
4th
|
34 (51.5%)
|
16 (24.2%)
|
16 (24.2%)
|
66
|
22%
|
5th
|
25 (39.1%)
|
22 (34.4%)
|
17 (26.6%)
|
64
|
23%
|
For the support analyses (Table 2a), the univariate and adjusted models produced similar estimates and inferences: both religiosity and year of study were associated with a decreased odds of supporting EAD. Specifically, after adjustment for the potential confounders, medical students in their 5th year of training had 0.30 (CI: 0.15, 0.60; p=0.001) and 0.33 (CI: 0.16, 0.68; p=0.003) times the odds of supporting compared to students in their 2nd and 3rd years respectively.
The opposition results (Table 2b) were also predominantly comparative between the unadjusted and adjusted logistic regression models with religiosity and year of study again being presented as significant variables. After adjustment, medical students in their 5th year of training were associated with a 260% (OR=3.60; CI: 1.53, 8.50; p=0.003) increase in the odds of opposing EAD compared to 2nd year medical students. Although the univariate model suggested that 5th Year medical students were also more likely to oppose than their 3rd year counterparts (OR=2.12; CI: 1.02, 4.41; p=0.043), this significant association no longer remained after accounting for all covariates (OR=2.08; CI: 0.90, 4.83; p=0.087).
There were no significant associations between gender or ethnicity and support or opposition for EAD.
Table 2a: Unadjusted and Adjusted Odds Ratios (OR) for Potential Predictors of Support Euthanasia/Assisted Dying, with 95% Confidence Intervals (CI) and p-values
Demographic
(Reference category)
|
Unadjusted
|
Adjusted
|
|
OR
|
95% CI
|
p-value
|
OR
|
95% CI
|
p-value a
|
Year of Study
(2)
|
|
|
0.006 a
|
|
|
0.004 a
|
3
4
5
|
0.91
0.58
0.35
|
0.51, 1.64
0.31, 1.08
0.18, 0.66
|
0.758
0.087
0.001
|
0.91
0.57
0.30
|
0.48, 1.71
0.29, 1.13
0.15, 0.60
|
0.767
0.106
0.001
|
|
|
|
|
|
|
|
Gender
(Female)
|
|
|
|
|
|
|
Male
|
1.02
|
0.82, 1.28
|
0.842
|
1.04
|
0.62, 1.72
|
0.893
|
|
|
|
|
|
|
|
Ethnicity
(Non-Māori)
|
|
|
|
|
|
0.543
|
Māori
|
1.16
|
0.63, 2.11
|
0.638
|
0.98
|
0.51, 1.90
|
0.953
|
|
|
|
|
|
|
|
Religiosity
(No)
|
|
|
|
|
|
|
Yes
|
0.22
|
0.13, 0.36
|
<0.001
|
0.22
|
0.13, 0.37
|
<0.001
|
|
|
|
|
|
|
|
a For overall group differences
Table 2b: Unadjusted and Adjusted Odds Ratios (OR) for Potential Predictors of Opposition to Euthanasia/Assisted Dying, with 95% Confidence Intervals (CI) and p-values
Demographic
(Reference category)
|
Unadjusted
|
Adjusted
|
|
OR
|
95% CI
|
p-value a
|
OR
|
95% CI
|
p-value a
|
Year of Study
(2)
|
|
|
0.024 a
|
|
|
0.032 a
|
3
4
5
|
1.48
1.92
3.14
|
0.70, 3.14
0.88, 4.21
1.48, 6.66
|
0.307
0.103
0.003
|
1.73
2.15
3.60
|
0.75, 3.97
0.90, 5.15
1.53, 8.50
|
0.198
0.085
0.003
|
|
|
|
|
|
|
|
Gender
(Female)
|
|
|
|
|
|
|
Male
|
1.11
|
0.85, 1.46
|
0.426
|
1.45
|
0.77, 2.71
|
0.251
|
|
|
|
|
|
|
|
Ethnicity
(Non-Māori)
|
|
|
|
|
|
|
Māori
|
0.52
|
0.23, 1.22
|
0.134
|
0.58
|
0.23, 1.46
|
0.249
|
|
|
|
|
|
|
|
Religiosity
(No)
|
|
|
|
|
|
|
Yes
|
6.72
|
3.76, 12.02
|
<0.001
|
6.78
|
3.68, 12.50
|
<0.001
|
|
|
|
|
|
|
|
a For overall group differences
Qualitative findings
Eighty five percent of participants provided answers to the questions about the reasons for their answer to question one, and 69% described experiences that have influenced their thinking. See Tables 3 and 4 for the themed reasons and experiences respectively, and examples of each divided into year groups.
Table 3: Themes illustrating reasons given for answers ‘yes’, ‘no’ or ‘unsure’ to explain responses to questions 1 (section 2)
Years 2 & 3
|
Themes for supporting a law change
|
Example
|
Relieving suffering
|
“To stop patient suffering. If a patient is already going to die in 10 days and they are suffering miserably, I think euthanasia has a place by reducing the length of suffering. But I think this is one of the only situations in which it should be used.”
|
Autonomy
|
“At the end of the day people deemed "competent" should have no reason to not be able to make a choice about ending their life in a comfortable way if that is what they really desire.”
|
Enabling a dignified death
|
“Think people should be able to die with dignity if they want”
|
Financial reasons
|
“Thinking about hospital resources it would also save an incredible about of money and free up beds (for people who have a chance to improve their quality of life).”
|
Themes for opposing a law change
|
Example
|
Potential for misuse
|
“I do not support a law change due to lack of trust in the system. I see far too many opportunities for health care practitioners (not just doctors) to become 'trigger happy' or forceful about euthanasia. I also envision situations wherein patients feel pressured to accept this as an option. There is also quite a lot of room in the system for error and/or abuse of elders and those with disabilities.”
|
Sanctity of life
|
“…and I think euthanasia could have a strong follow on effect in the community in regards to how illness and life quality is viewed”
|
Slippery slope
|
“Concern over how this could be used and could progress to include mental illness and childhood illness”
|
Not the role of doctor
|
“Not the place of the medical profession to carry out this role; does not align with mission; could jeopardise public trust in the profession, with flow-on effects for public health (e.g. not following health advice, avoiding GP and hospitals)”
|
Themes for being unsure about a law change
|
Example
|
Potential for misuse
|
“It is very complex. On one hand I don't have a problem with easing the end for people with progressive conditions. On the other hand I have concerns about how the system will work and be used. My fear is that those with disabilities might be at risk. Or those with mental illness. Or those that see themselves as a burden, rather than actually wanting to end their own suffering, using it as a tool to "end" the suffering of those around them.”
|
Not the role of doctor
|
“Furthermore, this changes the perception of doctors. A profession that willingly participates in euthanasia is not one I signed up for.”
|
General uncertainty
|
“However, I have lived a fortunate life and have not know anyone to experience a drawn-out, painful death, so I can't pretend that I know what's best for people in that position - hence on the fence.”
|
Relieving suffering
|
“Because it is a complex issue and people's lives and connections to others are also complex as could be the influences on the person thought to be voluntarily and competently requesting to do this. On one hand this may well be the compassionate and empathetic thing to provide for a person who is in pain, suffering and terminally ill.”
|
Years 4 & 5
|
|
Themes for supporting a law change
|
Example
|
Relieving suffering
|
“In some circumstances, the end of life can be very prolonged and difficult and this can worsen suffering for the dying individual and their family.”
|
Autonomy
|
“It’s rooted in a fundamental respect of individual's right to choose for themselves.”
|
Enabling a dignified death
|
“It is the single best way to allow patients with debilitating terminal diseases to choose to have a good death.”
|
Relief for family
|
“In some circumstances, the end of life can be very prolonged and difficult and this can worsen suffering for the dying individual and their family.”
|
Themes for opposing a law change
|
Example
|
Potential for misuse
|
“Having seen abuses of patients within the healthcare system (outside of medical school) and aware as I am of our imperfect and socially unequal society, I am quite nervous about vulnerable people being under pressure either within the healthcare system or by family or personal circumstances to choose assisted dying when it would not have been their choice otherwise.”
|
Not the role of doctor
|
“It places doctors in a position where they take life.”
|
Palliative care as an alternative to EAD
|
“A comprehensive study regarding the symptoms a person at EOL experience showed that the process of dying itself can be very peaceful with appropriate palliative care input, e.g. pain is less of a concern than the general population would think. We have a robust palliative care system in NZ and I believe we would be demeaning its importance if we legalised euthanasia…” “…Rather than focusing on euthanasia, I think it would be more beneficial in the long-term to focus on a robust palliative care system…”
|
Personal values
|
“I personally believe that life is sacred and that no person should be legally allowed to end another person's life, even at the other person's request”
|
Themes for being unsure about a law change
|
Example
|
Undermines palliative care
|
“I would also want to ensure palliative care wouldn’t be neglected because euthanasia was brought in.”
|
Not the role of doctor
|
“Doctors could administer the euthanasia, but I don’t think they should have a role in assessing or deciding if someone should receive euthanasia.”
|
Potential for misuse
|
“i predict that assessing competence and the whole process in general may be fraught with danger and difficulties. The person could be persuaded/pressured by family and friends or they may feel pressure to end their life independent of anything the family have actually done.”
|
Autonomy
|
“I believe in autonomy - and have met many patients who are terminal and say they want to die. But I think legislating is fraught with difficulty.”
|
Table 4: Themes illustrating the experiences that influenced participants’ views
Years 2 & 3
|
Themes generated answering ‘yes’ to supporting EAD
|
Example
|
Death of family member or friend
|
“I have family who have since passed away from complications of dementia and I saw how it negatively impacted my family. I know that my family member who had dementia, would have hated to see herself in that condition.”
|
Experience in rest home
|
“I worked in the psychogeriatric ward of a rest home where I saw people who would soil themselves, dribble, become violent etc. I would absolutely HATE to see one of my loved ones or myself in a situation like this.”
|
Medical school teaching
|
“Lectures in ELM2 and ELM3 Palliative care and ethics vertical modules”
|
Public discussion/personal study
|
“A lot of debate over in school as we studied a film (which I forgot the name of) which touched on this subject. Have read up on several articles after this.”
|
Themes generated answering ‘no’ to supporting EAD
|
Example
|
Medical school teaching
|
“I previously supported the law, but after discussion with a variety of people and lectures regarding palliative care I've come to change my opinion.”
|
Discussion with family or friends
|
“My grandparents worrying constantly that they are a burden to their kids and grandkids”
|
Death/suffering of family member or friend
|
“a friend committing suicide”
|
Discussion with doctors
|
“Spending time with medical physicians and ward nurses who do not support euthanasia for the reasons I have listed above.”
|
Themes generated answering ‘unsure’ to supporting EAD
|
Medical school teaching
|
“I was set on it being a good thing to legalise until we had our lecture on it in third year where I was forced to practically think about it.”
|
Public discussion/personal study
|
“Did a lot of research and debating about the issue in school”
|
Experience in rest home
|
“On the other hand, after working in the rest home with many degenerative/debilitating illnesses it should be a choice. I would want the choice.”
|
Death/Suffering of family member or friend
|
“I have been with family and non-family deaths. Of adults and children. Hospice and non-hospice. My grandmother's passing from bowel cancer was managed beautifully by hospice, and with this management euthanasia wasn't even something that would have been relevant. Children with significant disability and health conditions would be at risk in circumstances where they couldn't clearly communicate. I just have concerns.”
|
Year 4 & 5
|
Themes generated answering ‘yes’ to supporting EAD
|
Experience in clinical training
|
“I have seen palliative patients experience significant suffering prior to their "natural" death e.g. severe pain, intense discomfort, intractable bleeding. I do not believe it is humane to allow suffering in such terminal cases if the patient wishes to end their own life.”
|
Death/suffering of family member or friend
|
“My grandfather had a stroke which left him paralyzed. Despite being of sound mind he could no longer move, something which would never improve. The last 6 months of his life were hell, without much joy and he was ready to go. I think he deserved the CHOICE, one last thing he could control if he wished to”
|
Public discussion/personal study
|
“Newspaper story about a patient with motor neuron disease who had to resort to starving himself as he no longer wished to live”
|
Medical school teaching
|
“Teaching on degenerative illnesses and palliative care”
|
Themes generated answering ‘no’ to supporting EAD
|
Medical school teaching
|
“Teaching in medical school have also shaped my opinions around palliative care and given me a lot of confidence in it - I believe it could be better, but I think it is the best way forward.”
|
Death/suffering of family member or friend
|
“I have a grandmother who was diagnosed with cancer 5+ years ago that at times has looked very unwell including needing a short stay in hospice care 4 years ago. She is the type of person who does not wish to burden others and I am convinced she would elect for physician assisted dying at the point she was admitted to hospice. She is still alive many years later and has managed to continue living at home with my grandfather who otherwise would be in a residential care facility. This has painted a pretty clear picture as to how vulnerable people's lives could be ended early under this law change to the detriment of those around them and society in general.”
|
Discussion with doctors
|
“Discussions with palliative care specialists”
|
Public discussion/personal study
|
“I was pro-euthanasia and the law change prior to the euthanasia debate hosted at the Clinical Leadership Forum earlier this year in Wellington. There were top people in their fields from either side of the argument so it created an ideal environment to form an educated opinion.”
|
Themes generated answering ‘unsure’ to supporting EAD
|
Experience in clinical training
|
“During my hospice visit in 4th year, we were assigned to visit a palliative patient in their home. I think they intended to show us how palliative care and hospice make a positive impact on patients’ lives, however I ended up visiting a patient who was absolutely depressed and suicidal. They had oesophageal cancer and couldn't swallow any food which made them miserable. There was nothing the hospice could do to ease their suffering. This was the first time I thought that euthanasia would be a good option.”
|
Medical school teaching
|
“Before I was a medical student I was very for this issue, I wanted it to become legal, because I thought people shouldn’t have their lives drawn out in suffering and have old people just waiting to die. When I became a medical student, the lack of education a lot of patients and family have around what doctors can do and medical ethics is very obvious”
|
Discussion with family or friends
|
‘I know that my nan would want to choose assisted dying if she deteriorated to an unsatisfactory condition and then I think assisted dying would be good. But then I think about it as if I was the doctor…’
|
Public discussion/personal study
|
“A panel at a medical leaders’ conference that included speakers Ben Gray and David Seymour. The discussions around anti-euthanasia about the emotional impact on doctors, the increase in health inequities and the happiness patients when palliative care is one right all made me re-evaluate my position. And I haven't settled on a position since then.”
|
For both year groups (years 2&3 and 4&5), the authors identified three main themes for the reasons most often cited by those who supported a law change: autonomy, relieving suffering, and enabling a dignified death. Several participants also mentioned the relief it would bring family, that it would provide a safe means for people to end their life who would do so anyway, that palliative care could not resolve all suffering, that current palliative care practice already involves EAD, and financial reasons. The identified themed reasons cited by those who were opposed to a law change were more varied. The most common were that there is a potential for the practice to be misused and that EAD is not compatible with the role of doctors. Several students also mentioned sanctity of life, the potential slippery slope, their own personal values, and that palliative care is an adequate alternative to EAD. Many of those who were unsure cited similar reasons to those who were opposed, but cited these as concerns, while many in this group also expressed sympathy for the reasons given by those who support a law change. There was no notable difference between the ELM and ALM groups in terms of the reasons given.
The themed experiences that participants described as influencing their thinking were largely similar across the ‘yes’, ‘no’ and ‘unsure’ groups, and also year levels. Several in each group mentioned medical school teaching as influential, along with discussions with family or friends, discussions with doctors, public lectures and personal study, among others. The death or suffering of a family member or friend was the most common type of experience mentioned by those who were supportive of a law change. Moreover, the death or suffering of a family member was a common theme that influenced the students’ views for all year groups and all responses except ‘unsure’.
A high number of those in ELM (years 2 &3) who supported a law change also mentioned their rest home placement, where second year students work as assistant caregivers in residential care facilities. Those who were opposed to a law change most often identified medical school teaching as having influenced their thinking, and a small number directly stated that their views had changed because of what they have learnt in medical school. Several in all groups demonstrated considerable prior and independent thinking on the issues.