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.
