This study reveals new and more in-depth knowledge about physicians’ actions when facing a request for assisted death in a country where euthanasia and PAS are not legal. Physicians have adopted various ways to deal with a request for assisted death, as they also have different attitudes toward euthanasia and PAS.

In our study, only 13% fully agreed with the statement “I could assist a patient in a suicide”. In previous studies, willingness to perform euthanasia or PAS among physicians has varied widely from 2 to 16% in Germany, 8% in the United States, and 30% in Italy [30,31,32]. A recent questionnaire study from Sweden showed that 33% of respondents were willing to prescribe the drugs needed to perform assisted suicide in 2020 [5]. On the other hand, in the Netherlands and Belgium, where assisted death has been legal for decades, 86% and 81% of physicians could imagine a circumstance in which they might participate in the practice of euthanasia or PAS [3].

Most participants agreed that euthanasia should be accepted only in difficult physical symptoms in the end stage of a disease. Difficult physical symptoms have been one of the reasons for euthanasia or PAS in many countries [30, 31]. Others include for example, loss of function, dependency or loss of independence, deterioration, loss of dignity, and hopelessness [33, 34]. In a study from Oregon, as many as 57% of patients reported loss of independence as a reason for requests for PAS [33]. In our study, only 3% fully agreed with the statement “If euthanasia would be legalized in Finland, life turning into an unbearable burden, should also be accepted as a reason for euthanasia”. Males and physicians who had faced these requests agreed fully or partly agreed more often (16% in both groups) with this in our study. This question aimed to ask whether the responder thinks that euthanasia with unbearable suffering without unbearable physical symptoms would be an acceptable reason for euthanasia. In many countries ‘unbearable suffering’ is a criterion for euthanasia, but only when it occurs together with a disease. The complexity of unbearable suffering is reflected by the ongoing debates regarding whether euthanasia and assisted suicide should be permitted for psychiatric disorders. In some countries, including Belgium and the Netherlands, it is legal to perform assisted death based on psychiatric disorders [30]. A systematic review from 2020 showed that articles providing ethical reasoning and opinions in favor of or against assisted death based on psychiatric disorders were evenly distributed [35].

In our study, male and young physicians thought more often that they could assist in a suicide, which probably reflects the overall more positive attitude in these groups regarding practicing PAS and euthanasia [4, 5, 32]. In addition, if a physician had faced a request for assisted death, they were more likely to have positive attitudes toward euthanasia and PAS. No previous studies were found to support this finding.

The amount of experience in the care of dying patients was associated with less agreement with assisting in a suicide and with the general view that physicians should not assist in a suicide. In a study from Germany, physicians with special qualifications in palliative care were more reluctant to hasten a patient’s death through euthanasia or PAS [30], which is in line with our findings. It is also known from previous studies, that physicians with the most experience with end-of-life care and palliative care have been most reluctant toward euthanasia and PAS [36, 37], and this finding is again repeated in this study. The reasons behind this have not been profoundly studied. However, it can be argued that knowledge and experience with palliative and end-of-life care can provide more options to take care of the patient. It might also be better understood among physicians with experience in dealing with end-of-life issues that a patient’s wish to hasten death does not always imply a genuine wish to die [38,39,40]. It might be a result of overwhelming physical, psychological, social, and existential suffering, all of which have an impact on the patient’s sense of self, dignity, and meaning in life [38,39,40].

This study showed that physicians face the request for assisted death in their everyday practice even if it is not legal in Finland. However, the requests were not very common, as only 16% of participants reported having been asked for euthanasia or assistance in suicide. In a study from Sweden, half of the physicians who participated in that study had heard their patients expressing a wish to die, but only a few had asked for euthanasia or assisted suicide [21]. In an older study from England, as many as 45% of physicians who responded to a questionnaire, reported having been asked for euthanasia [20].

Physicians reported diverse ways of responding to the request and actions they took when meeting the request for assisted death. There is relatively little research about requests for assisted death when it is not legal. It is known that the patient´s wish for euthanasia could persist for at least one year despite the wish being declined [41]. Additionally, a small qualitative study from the Netherlands found that the wish to die is not abandoned, although the request has been refused [42]. Based on these results, ongoing discussions and suggestions for practice are needed when these requests are faced in countries where assisted death is not a legal option or when the request is rejected in the countries allowing assisted death.

In the results of the qualitative data of this study, many physicians expressed that knowledge of the possibility of palliative sedation at the end of life could comfort patients frightened of suffering at the end of life when assisted death is not a legal possibility. There is only a limited amount of knowledge on the relationship between assisted death and palliative sedation. In a study from Switzerland, continuous deep sedation was not considered an alternative to assisted suicide, but temporary or intermittent sedation was sometimes introduced in response to a request for assisted suicide [43].

In this study, the request was also sometimes seen as a possibility to enhance the care and find the underlying reasons for the death wish. The results also showed that physicians were seeking alternatives to alleviate suffering, including improving symptom management, maintaining hope and a sense of meaning in life, and providing an appropriate place of care and adequate support for the patient. In a Swedish study, some respondents answered that a request for euthanasia might express wishes for the alleviation of symptoms or wider communication: after talking, these requests disappear [21].

Ignoring the request was one way of dealing with the request in our study. However, ignoring the request for assisted death could indicate that the reasons behind the death wish are ignored [41]. Therefore, it could be stated that refusal without further discussion or support is not the optimal way to act when meeting the request for assisted death.

Some physicians responded to comply or partly comply with the request, e.g. describing drugs or recommending contacting a Swiss clinic. In Scandinavia, euthanasia or assistance in suicide is very rarely reported by physicians [21, 44,45,46]. This is understandable, as euthanasia is under the criminal code in all Scandinavian countries.

Some fears of whether one´s actions had hastened the patient´s death were reported in this study. Hastening a patient’s death or a fear of doing so when alleviating severe symptoms or withdrawal of treatment, is by far more difficult and ethically challenging question, and is sometimes confused with euthanasia or PAS [47]. A large multinational study performed in 2005 found that there was general approval for alleviating symptoms with possible life-shortening treatment among physicians [48]. Similar findings were discovered in a European study from six different countries, where 57–95% of physicians were willing to intensify the drug therapy to alleviate pain and/or other symptoms, although they considered that there was a probability or certainty that this would shorten a patient’s life [49].

Some of the physicians expressed mixed feelings about what would be the right way to act when facing a request for assisted death. This calls for recommendations or guidelines on how to act when meeting the request. Only a few recommendations have been published where practical guidance on how to respond to the request for assisted death is provided and some of them apply merely in countries where assisted death is possible to practice [50,51,52]. The most important recommendation for health care professionals in these articles is to try to understand the meaning behind the request and to be able to face the difficult emotions the request evokes both in a patient and in the professionals [50,51,52].

Strengths and limitations

The study population is a large and representative sample of Finnish physicians [53], although the response rate was rather low, and possible nonresponse bias must be taken into account. The sampling, data collection, and analysis process were reported in detail, which increases the reliability of the study. The sample included physicians with different backgrounds, such as different specialties and amounts of experience. Therefore, it can be assumed that the study population gave a large and versatile view of physicians’ attitudes toward assisted death and how they act when facing a request for assisted death. Furthermore, dependability was strengthened by presenting the figure of all the categories (Fig. 1), and authenticity was strengthened by providing authentic citations of the data. It should also be noted that the researchers constantly discussed the analysis throughout the study. Confirmability was strengthened by focusing on the manifest content during the analysis when it can be assumed that the results would represent the views of the physicians [28].

There are also several limitations in this study. Nonresponse bias might have affected the results, but the number of respondents was, however, substantial. Furthermore, there was no possibility to return the qualitative findings to the physicians for comments or corrections [24]. The questionnaire used in this study is the same that has been used in a series of surveys and to maintain comparability, the questions and statements were similar to the previous ones [4]. There are clear differences in the ethical and practical issues between euthanasia and PAS, but in the open-ended question and some other parts of our results, these two methods of assisted death were combined. This should be taken into account when interpreting our results. However, the request for assisted death may be presented without a specific definition of PAS or euthanasia and both are unlegalized in Finland. Thus, we do believe the answers of the respondents reflect the overall views of the Finnish physicians concerning assisted death and experiences when facing the request for this.

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Officially, there is only one documented case of bird flu spilling over from cows into humans during the current U.S. outbreak.

But epidemiologist Gregory Gray suspects the true number is higher, based on what he heard from veterinarians, farm owners and the workers themselves as the virus hit their herds in his state.

“We know that some of the workers sought medical care for influenza-like illness and conjunctivitis at the same time the H5N1 was ravaging the dairy farms,” says Gray, an infectious disease epidemiologist at the University of Texas Medical Branch in Galveston.

“I don’t have a way to measure that, but it seems biologically quite plausible that they too, are suffering from the virus,” he says.

Gray has spent decades studying respiratory infections in people who work with animals, including dairy cattle. He points out that “clustering of flu-like illness and conjunctivitis” has been documentedwith previousoutbreaks involvingbird flu strains that are lethal for poultry like this current one.

Luckily, genetic sequencing of the virus doesn’t indicate it has evolved to easily spread among humans.

Still, epidemiologists say it’s critical to track any possible cases. They’re concerened some human infections could be flying under the radar, especially if they are mild and transient as was seen in the Texas dairy worker who caught the virus.

“I think based on how many documented cases in cows there are, probably some decent human exposure is occurring,” says Dr. Andrew Bowman, associate professor of veterinary preventive medicine at The Ohio State University. “We just don’t really know.”

Limited testing raises concerns

There have been 36 herds affected in nine states. Local and state health departments have tested about 25 people for the virus and monitored over 100 for symptoms, federal health officials said at a briefing on Wednesday.

These people are in “the footprints of where the bovine detections are,” says Dr. Demetre Daskalakis, who’s with the Centers for Disease Control and Prevention, although he didn’t provide details on the actual locations.

“There’s a very low threshold for individuals to get tested,” he adds.

The lack of testing early in the outbreak isn’t necessarily surprising. In places like Texas and Kansas, veterinarians weren’t thinking about bird flu when illnesses first cropped up in early March and it took time to identify the virus as the culprit.

But the total number of tests done on humans at this point seems low to Jessica Leibler, an environmental epidemiologist at Boston University School of Public Health.

“If the idea was to try to identify where there was spillover from these facilities to human populations, you’d want to try to test as many workers as possible,” says Leibler, who has studied the risk of novel zoonotic influenza and animal agriculture.

Also, notes Gray, the virus is probably much more geographically widespread in cattle than the reported cases show, “possibly spilling over much more to humans than we knew, or then we know.”

The federal government has been quick to assess the safety of the dairy supply. On Wednesday, the Food and Drug Administration released findings, showing that infectious virus wasn’t present in about 200 samples collected from dairy products around the country. Initial results on ground meat are also reassuring.

However, there still remain “serious gaps” in public health officials’ ability to detect bird flu among those who work with cows, a task made all the more difficult by the fact that some cases may not be symptomatic, says Leibler. “There’s really widespread opportunity for worker exposure to this virus.”

Only complicating matters — the true scale of the outbreak in cattle remains murky, although new federal testing requirements for moving cattle between states may help fill out the picture.

“Some of the dairy herds seem to have clinically normal animals, but potentially infected and [that] makes it really hard to know where to do surveillance,” says Bowman.

Calls for proactive steps to track down possible human cases

The health care system would likely catch any alarming rise in human cases of bird flu, according to modeling done by the CDC.

Federal health officials monitor influenza activity in emergency departments and hospitals. Hundreds of clinical laboratories that run tests are tasked with reporting findings. And in early April, a CDC health alert was sent to clinicians advising them to be on the lookout for anyone with flu-like symptoms or conjunctivitis who’d worked with livestock.

But even these safeguards may not be sufficient to get ahead of an outbreak.

“I worry a bit that if we wait until we see a spike in those systems that perhaps we would already be seeing much more widespread community transmission,” says Dr. Mary-Margaret Fill, deputy state epidemiologist for the Tennessee Department of Health. Instead she says there should be proactive testing.

Fill notes there are anecdotes about farmworkers with mild illness while working with cattle in some of the areas where the virus has spread and “not enough visibility on the testing that’s happening or not happening in those populations to understand what might be going on.”

To get ahead of the virus, Leibler says not only do workers need to be screened but also their family members and others in the community, in the event that the virus does evolve to spread easily among humans.

Dr. Rodney Young says doctors in the Texas panhandle have been vigilant about any cases of influenza, particularly among those who are around livestock, but so far there are no indications of anything out of the ordinary.

“We just haven’t seen people who fit that description in order to suddenly be testing a lot more,” says Young,regional chair of the Department of Family and Community Medicine at the Texas Tech Health Sciences Center School of Medicine in Amarillo.

Getting buy-in from dairy farms

Gray says it can be hard to detect and measure the illness in these rural workers for many reasons — their remote location, a reluctance to seek out health care, a lack of health insurance, concerns about immigration status, and a reticence among farmers “to wave the flag” that there are infections.

The farms he works with consider protecting workers and curbing the spread of this virus “a huge priority,” but right now they bear all the risks of going public, he says.

Dr. Fred Gingrich says this is a major barrier to closer cooperation between federal health officials and the industry during the current crisis.

Dairy cattle farmers currently don’t get compensated for reporting infections in their herds — unlike poultry farmers who receive indemnity payments for losses related to culling birds when they find cases, says Gingrich, executive director of the American Association of Bovine Practitioners.

“So what is their incentive to report?” he says, “It’s the same virus. It just doesn’t kill our cows.”

Gray has managed to start collecting samples from humans and cattle at several dairy farms that recently dealt with the virus. It’s part of a study that he launched before the H5N1 outbreak in response to concerns about SARS-CoV-2 spillover on farms.

They’ll look for evidence of exposure to novel influenza, including bird flu –something he’s able to pull off because of his background in this area and his guarantee that the farms will be kept anonymous in the published work.

What concerns him most is the possibility the outbreak could wind up at another kind of farm.

“We know when it hits the poultry farms because the birds die, but the pigs may or may not manifest severe illness,” he says, “The virus can just churn, make many copies of itself and the probability of spilling over to those workers is much greater.”

Copyright 2024 NPR

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BURNABY, B.C. – The brains of older adults feel a sense of reward when listening to music, even if it’s a song they don’t particularly like, a researcher at British Columbia’s Simon Fraser University says. 

Sarah Faber said her work on how healthy brains respond to music as they age creates a baseline for future research on people who have Alzheimer’s or dementia to better understand those diseases.

“There’s a lot of interest in how to predict who might be going to develop dementia or Alzheimer’s disease and then once people do develop Alzheimer’s and dementia, who is going to respond to treatment and what kind of treatment,” she said.

“The brain is fascinating, but it doesn’t exist in a jar. It’s attached to a body, that’s attached to an environment, and community, and a social structure.”

The research published in the journal Network Neuroscience featured 80 participants, including university students and people as old as 90, who took functional MRI scans.

The younger group of adults had an average age of 19, while the other group had an average age of 67.

Everyone listened to 24 samples, including songs they selected themselves, popular music intentionally chosen by researchers and songs composed specifically for the study.

Faber said they found reward sections of the brain were activated in younger adults while they listened to music they liked or were familiar with, but older adults showed the same area being stimulated even when the music was new to them, or they didn’t like it.

“There wasn’t this gatekeeping functionality that we see in younger adults with their auditory network kind of being like, ‘OK, well, if we like this, we get rewards. But if we don’t like this, we don’t get rewards,'” she said.

“Whereas for older adults, it was just like, ‘Music! Reward! Yes!'”

Faber, who was a music therapist before becoming a neuroscientist, said research into people with Alzheimer’s can be challenging if someone is unable to speak, or explain what they are thinking or feeling in a moment.

She said anything they can learn about how to make the music therapies more effective would be helpful, but the benefits go beyond that.

“Just understanding … how the brain deals with complex stimuli, through Alzheimer’s, that would be a really good and a very useful bunch of information to get for people that are working in Alzheimer’s, not necessarily just in music,” Faber said. 

This report by The Canadian Press was first published May 2, 2024.

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