The physicians' attitudes in Israel towards euthanasia are quite positive when compared to other countries, such as U.K. (16), France (17), Italy (18), Finland (19), Greece (20). The statements with the highest degree of consent were those related to supporting decision-making by the patient or by family members. This finding underscores the value of discussing the quality of the terminally ill patient’s life with patient and their family, and the role of the family in supporting palliative options for the patient. We note the ethical questions in the face of pain and suffering and whether a physician can refuse a terminally ill patient and/or their family’s request suffering and pain.
We found that 53% of physicians disagreed with the statement "In any situation, the doctor should preserve the patient's life, even if he wishes for an expedited death", while Bentor et al. (9) found that 56% of physicians believed that patients' lives should be saved in any situation in spite of the patient’s request. Farber et al. (12) also found that a high percentage of physicians would not have prevented treatment even if the patient had requested it. Most doctors are of the opinion that treatments of terminally ill patients are not unnecessary, and in a situation where a patient suffers from severe pain, taking a lethal dose should not be allowed. At the same time the majority of physicians agreed that a patient has the right to decide to expedite their death, that the DNR procedure should be considered when the treatment team thinks that resuscitation is unnecessary, and don’t agree that disconnecting a patient in a coma from resuscitation/ventilation machines is immoral.
These findings indicate the dilemmas physicians face, when on the one hand, they are committed to protecting the sanctity of life, and yet, on the other hand, they are interested in alleviating the patient's suffering while respecting their autonomy and choice. We found no significant differences between men and women regarding attitudes toward euthanasia which is in line with other studies (21, 22). As for the positive relationship between seniority and attitudes toward euthanasia, previous studies have found that euthanasia is more favorable among older, veteran physicians who have had previous encounters with terminal patients, and are more likely to provide patients with lethal drugs if asked to by terminal patients seeking to end their lives (21, 23).
The negative relationship between the level of religiosity and attitudes has also been found in many studies (24, 25, 26, 27). We know that physicians with different specializations have different attitudes towards euthanasia, for example that oncologists receive many more euthanasia requests and are more willing to provide end-of-life assistance than other physicians (28). Geriatricians, in another study, had the highest frequency of caring for patients requiring end-of-life supportive care, in contrast to cardiologists where the frequency was less than one percent (29).
The strengths of our study include a good response rate from a broad range of specialties and physicians' status (specialist, residents, interns), as well as both Jewish and Arab physicians. Moreover, we used a validated attitudes questionnaire that demonstrated that the level of religiosity was found to be the most strongly predictive about attitudes toward euthanasia. The regression model produced significant predictive models regarding the following factors including the level of religiosity, religion, familiarity with the Dying Patient Act, country of birth, and past experiences encountering terminally ill patients’ attitudes toward euthanasia.
This article has several important limitations to consider. First, focusing on clinician perceptions relies on self-reports of current and past perceptions, which may be a source of richness but also a source of bias. These events could not be independently verified. Second, the sample was quite limited, and unlikely to have equal representation from all departments and specialties at one sampling point in time. Third, the data represent only one major teaching hospital, which limits the generalizability of our findings. Fourth, because of the workload and the sensitive nature of this topic, we had difficulty recruiting physicians to complete the questionnaire, and likely discouraged some participants from responding despite elaborate efforts to protect their anonymity. Fifth, we cannot tell if there are significant differences between the survey responders and the non-responders. Because of the anonymity of the subjects, nonrespondents could not be contacted for follow up.
The implications from our study demonstrate the feasibility and importance of using multi-variable models to understand the complex social attitudes towards end-of-life care decisions. The use of longitudinal study designs tracks variation in attitudes through, and beyond, training, should offer an ideal design to fully understand how and why more positive attitudes develop within healthcare professionals. Further work is required to replicate these findings, and explore qualitatively whether, and how, opinions of more religious or from other ethnicities effect the treatment choices of terminally ill patients in general, and their attitudes towards euthanasia, in particular. Further research is needed that combines in-depth interviews with policy makers, physicians, patients and family members, in order to more deeply understand the experiences and attitudes of all parties.
We would be remiss if we did not position these findings in the context of the unprecedented end-of-life questions that have arisen in the past 10 months due to the Coronavirus (COVID-19) outbreak. As of the end of January, 2,166,000 people have died from COVID-19 across the globe (WHO COVID-19 Dashboard) (30). The unprecedented global situation has forced health care providers across the world to consider end-of-life issues in the face of finite critical care support such as staff, beds and equipment are necessary now more than ever (31). Preparation for an impending death through end-of-life discussions and human presence when a person is dying is important for both patients and families. Pandemic planning must encompass the wider issues of deciding who to treat and who should not be treated and how to prepare physicians for these new emotional burdens. Clear and timely communication with the patient and their cares is essential. Conveying hope that treatments will help needs to be sensitively balanced with explicit acknowledgement that patients are sick enough to die (32). Dying from COVID-19 negatively affects the possibility of holding end-of-life discussions because of social distancing and restrictions on visits (33).
Of related concern, recent reports have suggested that the Do-not-resuscitate orders in the UK were wrongly allocated to some care home residents during the Covid-19 pandemic, causing potentially avoidable deaths (34). Compelling end-of-life decisions in these challenging times reinforces the urgency to act based on our study’s findings and raises the importance of supporting physicians in their efforts to provide ethical, and empathic communication for terminally ill patients.