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Journal of medical ethics, 1977, 3, 18-25
Attitudes towards euthanasia
Carolyn Winget,' Frederic T Kapp and Rosalee C Yeaworth
Department of PsychiatryCollege of Medicine, and College ofNursing
and Health, University ofCincinnati
There are an infinite variety of attitudes toeuthanasia, each
individual response to the conceptbeing influenced by many factors.
Consequentlythere is a literature on the subject ranging from
thepopular article to papers in specialized journals.This study,
however, has taken a well definedsample of people, inviting them to
answer aquestionnaire which was designed to elicit theirattitudes
to euthanasia in a way whichcould be analysed statistically. Not
surprisinglyattitudes appeared to 'harden' as those answering
thequestionnaire grew more experienced in dealing withpatients and
also more professionally established.Thus it was found that of the
seven groups questionedpractising physicians showed more positive
attitudesto euthanasia and their responses did not
differsignificantly from those of senior medical students.It is
these groups which actually or potentiallyhave to resolve the
clinical dilemma posed by thedying patient.
This study is a report on attitudes towards eutha-nasia as
reflected in a survey of medical, nursingand college students and
practising physicians andnurses. These attitudes are of crucial
significance inthe decision-making process when issues of
fightingfor life or maintaining existence are posed.The word
'euthanasia' arouses a mixture of
feelings and images in most people. On the basis ofits Greek
derivation, the word comes from eu,meaning well, and thanatos,
meaning death. Thus,euthanasia is defined as 'good' or easy,
painlessdeath. It is more fully defined in Webster's Dic-tionary
(I96I) as the 'act or practice of painlesslyputting to death
persons suffering from incurableand distressing disease'. As
medical technology hasadvanced, the subject of euthanasia has been
thetopic of debate not only by physicians and otherhealth
professionals, but also by lawyers, theolo-gians, politicians and
the lay public.The philosophical question may become a
clinical dilemma for physicians and nurses or forpatients and
their families when the questionof fighting for or maintaining life
is posed and adecision cannot be avoided. This decision makingmay
be an active or a passive process. Just as failureof those in
authority to exercise control does not'Please address
correspondence to: Carolyn Winget,Department of Psychiatry, College
of Medicine, 231Bethesda Avenue, Cincinnati, Ohio 45267, USA.
mean absence of control, but rather control exer-cised by other
forces, so, making a decision not todiscontinue treatment may imply
making a decisionto prolong marginal existence (Skinner, I97I).
Parsons and his colleagues (I973) have recentlyfocused our
attention on the importance of greatersocietal knowledge and
participation in decisionmaking in medical ethics. However, most of
theliterature stresses that the onus of making a decisionultimately
falls on the physician. This is a heavyburden for the physician,
but once the decisionis made, the nurse, the patient and the family
maylive more closely with it than the doctor (Braverman,I969;
Gustafson, I973).
Areas of conflict in attitudes to euthanasiaThere are a number
of areas in which attitudestoward euthanasia may give rise to
conflict. Oneway to conceptualize such problems is to classifythem
as primarily interpersonal in nature in con-tradistinction to those
that are intrapersonal. In thelatter area, one starts with the
premises that personsstrive for cognitive balance or consistency in
theirattitudes and beliefs (Brown, I965) and that theprocess of
socialization into a professional roleinvolves learning attitudes
and beliefs as well asskills (Voilmer and Mills, I966; Society
Today,1973). Hence, the intrapersonal problem is exem-plified by
the individual in whom there existsinconsistent attitudes relating
to a particularsubject, ie, the physician who believes
individualfreedom includes the freedom of choice to live or todie,
but who also believes that every effort should bemade to keep
patients alive as long as possible.There is the further possibility
that a professionalmay hold certain personal beliefs, attitudes
andvalues that are incongruent with what he perceivesas the
prescriptions or proscriptions for his pro-fessional role. Thus, a
physician or nurse mightbelieve that persons should ultimately have
freedomof choice regarding matters of life and death, butbelieve
that his or her professional role requiresdoing everything possible
to preserve or prolonglife for any patient in his care. The longer
thesocialization process for a role the more likely thatthe
attitudes and beliefs associated with that rolewill become
internalized and integrated into theindividual's overall belief
system.
Interpersonal attitudinal problems focused on
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Attitudes towards euthanasia I9
euthanasia exist when the attitudes and beliefs ofphysicians or
nurses are in conflict with each otheror with those of the larger
society, the patient, or thefamily. Such interpersonal issues are
confoundedand made more difficult to elucidate by the verylack of
congruence and consistency which maycharacterize the intrapersonal
area. In addition,very subtle nuances of definition become
magnifiedand of marked significance, as is true in the special-ized
literature on euthanasia.A recent survey of the American public
(Harris,
1974) indicated that 62 per cent of those polledbelieved that a
patient with a terminal disease oughtto be able to tell his doctor
to let him die rather thanto extend his life when no cure is in
sight. However,only 37 per cent believed that the patient who
wasterminally ill should be allowed to tell his doctor toput him
out of his misery. The American MedicalAssociation's stand reflects
this wider societalperspective. The statement adopted by the
Houseof Delegates of the American Medical Associationon 4 December
I973 was:
'The intentional termination of the life of onehuman being by
another - mercy killing - is con-trary to that for which the
medical profession standsand is contrary to the policy of the
AmericanMedical Association.
'The cessation of the employment of extraordinarymeans to
prolong the life of the body when thereis irrefutable evidence that
biological death isimminent is the decision of the patient and/or
hisimmediate family. The advice and judgment of thephysician should
be freely available to the patientand/or his immediate family.'The
second part of the AMA statement above
would put the onus of making the decision on thepatient and his
immediate family. But it is still thephysician who must make the
decision that bio-logical death is imminent. The statement does
notattempt to deal with situations where biologicaldeath might not
be imminent, but the judgment tobe made centres around the
possibility of the per-son's life ever being 'meaningful' or
'useful'.McCormick (I974) tries to resolve this dilemma
bysuggesting that 'life is a value to be preserved onlyinsofar as
it contains some potentiality for humanrelationships'.
Rachels (1975) has argued against the AMAstand on active
euthanasia or so-called 'mercykilling', pointing out that 'the
process of beingallowed to die' can be relatively slow and
painful,whereas being given a lethal injection is relativelyquick
and painless. He argues that there is no moraldifference between
active and passive euthanasia.The differentiation hinges on making
the decisionthat, for a given patient, death is less an evil
thanthat patient's continued existence.
Fletcher (I968) has defined four types of eutha-nasia: i) direct
voluntary; 2) indirect voluntary; 3)indirect involuntary; 4) direct
involuntary. 'In-
direct' implies discontinuing a treatment, while'direct'
involves initiating an action. The patientparticipates in the
direct voluntary type of euthana-sia by collaborating in an act to
bring about his owndeath, and in the indirect voluntary type by
askingthat life-sustaining measures be omitted or dis-continued. In
the two involuntary types of eutha-nasia a conscious decision by
the patient is notinvolved. For example, in the case of a
comatosepatient decisions are usually made by the family.
Shils and Schweitzer (Kohl, I972), proponentsof the
'sanctity-of-life principle', hold that life isthe most primordial
experience of man and there-fore that it ought always to be
inviolable. Theycontend that man cannot either create or destroy
lifefor life is sacred and must be so treated. To them,to take life
no matter how it is done or for whatreason, is to punish and any
violation of the sacred-ness of life must inevitably lead to
undesirableconsequences. Data relating to both the inter-personal
issues and to the problem of intrapersonalconflict are presented
below.
Method: The questionnaireAn interdisciplinary research group at
the Univer-sity of Cincinnati Medical Center, as part of a
largerstudy, developed a 'Questionnaire for understand-ing the
dying patient and his family'. The con-struction of the
questionnaire has been describedelsewhere (Yeaworth, Kapp, and
Winget, I974).Embedded in the 50 items of part I of the
ques-tionnaire are five items that relate to euthanasia.These
are:
ITEM IRegardless of his age, disabilities, and
personalpreference, a person should be kept alive as long
aspossible.
ITEM 13Those who support the principle of 'death withdignity'
endorse active as well as passive euthanasia.
ITEM I4No matter what my personal belief, in my role as amedical
or nursing professional I would fight tokeep the patient alive.
ITEM i6Individual freedom of choice ultimately shouldmean
freedom of choice to live or die within acontext of responsibility
for selfand others.
ITEM 33Some patients should be allowed to die withoutmaking
heroic efforts to prolong their lives.
Each item could be responded to on a five-pointscale ranging
from 'strongly agree' to 'strongly
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20 Carolyn Winget, et al
TABLE I Characteristics of groups studied
Type ofgroup
First-year Senior First-year SeniorCollege nursing nursing
Registered medical medicalstudents students students nurses
students students Physicians
No. in group 75 io8 69 75 II0 90 30Setting of data collectionl
Classroom Classroom Classroom Hospital Take home Mailed Mailed
SexAWle 17 (23)2 2 (2) 0 0 92 (84) 82 (9I) 30 (Ioo)Female 52
(69) Io6 (98) 69 (ioo) 75 (100) II (I0) 5 (6) 0Not answered 6 (8) 0
0 0 7 (6) 3 (3) 0
Age (yr)20 38 (5I) 99 (92) 0 0 0 0 020-25 26 (35) 2 (2) 56 (8i)
I7 (22) 97 (88) 28 (3I) 4 (3)26-35 5 (7) 2 (2) II (i6) 29 (39) 6
(6) 59 (66) 9 (30)35 0 0 0 29 (39) 0 0 17 (57)Not answered 6 (7) 5
(4) 2 (3) 0 7 (6) 3 (3) 0
ReligionCatholic 23 (31) 38 (35) 23 (33) 22 (29) 22 (20) 24 (27)
I (3)Protestant 33 (44) 52 (48) 37 (54) 5I (68) 4I (37) 30 (33) 2
(7)Jewish 4 (5) 4 (4) 2 (3) 0 I5 (I4) 14 (i6) 24 (80)None/other 8
(ii) 0 0 0 I7 (I5) I0 (II) 0Not answered 7 (9) 14 (13) 7 (I0) 2 (3)
I5 (4) II (3) 3 (io)
lProtocols were administered anonymously and subjects were
recruited after approval by appropriate committeesmonitoring
research on human subjects in the various colleges."Numbers in
parentheses are percentages, numbers rounded to equal I00 per
cent.
disagree'. Weights were assigned to statements sothat responses
indicative of a favourable attitudetoward euthanasia were assigned
a low score, ie, aweighting of I or 2, while attitudes favourable
tothe 'sanctity-of-life principle' were assigned a scoreof 4 or 5.
Responses indicative of indecision oruncertainty were weighted
3.The responses to the five euthanasia items were
abstracted from the completed questionnaires of avariety of
subjects: college students, first-year andsenior nursing students,
first-year and seniormedical students, practising registered nurses
andpractising physicians. Table I provides informationon the
composition ofthese samples.
ResultsTable II indicates the percentage responses to thefive
euthanasia items for each of the seven groups.Most individuals in
all the groups disagree withstatement no. I. This disagreement with
keeping apatient alive regardless of age, disability and per-sonal
preference is most marked in the seniormedical student group, and
is least marked in thefirst-year nursing students and the college
students.Both nursing students and medical students showa decided
difference in the proportion of those who
are undecided when first-year men are compared toseniors.
Item no. I3 asks for attitudes regarding the issueof equating
active with passive euthnasia within theoverall rubric of 'death
with dignity'. This itemcontains ambiguous cognitive and
attitudinalcomponents which apparently evoke ambivalenceand
uncertainty. The variance in weighted res-ponses is great and the
proportion of those answer-ing 'undecided' in each group is very
high comparedto responses to the other four items about
eutha-nasia. Physicians and nurses in practice showproportionately
the fewest 'undecided' and 'agree'responses and thus, the highest
percentage ofresponses presumably disdnguishing active frompassive
euthanasia.
Responses to the statement about fighting to keepa patient alive
(item no. I4) again reveal markeddifferences among the seven
sampled groups.Practising physicians, nurses and senior
medicalstudents are the three groups that indicate the
mostdisagreement with the notion of fighting to keep apatient alive
at any cost. Indecision in this areais greater for senior than for
first-year nursingstudents but is considerably less for senior than
forfirst-year medical students.
Issues of autonomy for the terminally ill patientare raised in
item no. I6. While the majority of all
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Attitudes towards euthanasia 2I
TABLE II Percentage response to five euthanasia items by seven
groups of respondents
Strongly Undecided Disagree StronglyNo. Group agree (%) Agree(%)
(%) (%) disagree (%)
Item I Regardless of his age, disabilities, and personal
preference, a person should be kept alive as long as possible.75
College students 8 I9 I9 37 I7io8 First-year nursing students 4 I3
30 41 1269 Senior nursing students 3 II 13 28 4575 Registered
nurses 4 II 23 34 28II0 First-year medical students 2 6 2I 36 35go
Senior medical students 0 0 9 38 5330 Physicians I0 7 I0 33 40
Item I3 Those who support the principle of 'death with dignity'
endorse active as well as passive euthanasia.75 College students 0
2I 59 I7 3Io8 First-year nursing students I I9 46 25 669 Senior
nursing students 0 14 54 22 I075 Registered nurses 0 I9 32 33 i6IIo
First-year medical students 4 2I 45 23 8go Senior medical students
0 9 35 40 i630 Physicians 3 I0 I3 50 23
Item I4 No matter what my personal beliefs, in my role as a
medicalprofessional I wouldfight to keep the patient alive.175
College students 25 35 24 I2 4io8 First-year nursing students 24 45
22 6 I69 Senior nursing students 13 28 32 I9 975 Registered nurses
II 36 24 25 4Iio First-year medical students 7 25 41 23 5go Senior
medical students 0 24 23 43 I030 Physicians 13 20 I7 40 10
Item i6 Individualfreedom of choice ultimately should mean
freedom of choice to live or die within a context
ofresponsibilityfor selfand others.75 College students I7 48 I9 15
IIo8 First-year nursing students I8 45 i8 14 469 Senior nursing
students 17 42 25 i6 075 Registered nurses I3 46 2I 15 5II0
First-year medical students I9 47 24 7 4go Senior medical students
23 SI i6 9 I30 Physiaans 3 67 I0 20 0
Item 33 Some patients should be allowed to die without making
heroic efforts to prolong their lives.75 College students 20 41 i6
13 9io8 First-year nursing students I9 47 I9 II 569 Senior nursing
students 29 59 7 I 375 Registered nurses 50 44 5 I 0II0 First-year
medical students 27 50 I9 3 Igo Senior medical students 62 34 3 I
030PhysicIans 40 53 0 7 0
1Non-medical personnel answering this question were asked to
respond as they thought they might if they were adoctor or a
nurse.
seven of our subject groups agree on the abstract 33 that 'some
patients should be allowed to dienotion of freedom of choice, the
two groups of without making heroic efforts to prolong
theirpractising professionals show greater disagreement lives'. For
both the nursing and medical studentsproportionately than any of
the student groups. there are markedly fewer 'undecided' responses
inFirst-year medical and senior nursing groups are, senior students
as compared with those of first-again, the two with the highest
proportion of year students.'undecided' responses. For each subject
within the seven groups, a scoreThere is overwhelming agreement
with item no. was derived for the five euthnaia items by
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22 Carolyn Winget, et al
TABLE i Means and standard deviations on euthanasia and other
attitudes towards death and dying
Five Other attitudeseuthanasia towards death &items
dying
PearsonGroup No. Mean S D Mean SD r P
College students 75 14.27 3.56 65.36 8.03 0.248
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Attitudes towards euthanasia 23
tested against every other mean. Table IV displaysthe
differences between the means for our sevengroups and allows ready
comparison. Thus, seniormedical students do not differ
significantly fromphysicians on euthanasia as measured by our
fiveitems, but are significantly lower than the fiveother groups.
Physicians, registered nurses, first-year medical students, and
senior nursing studentsare significantly lower than first-year
nursingstudents and college students, while the latter donot differ
significantly from each other.
If one looks at general issues of relating to thedying patient
and his family, as indicated in theresponses to the total
questionnaire, the mostunderstanding and emphatic responses, on
theaverage, are those of senior nursing students.Table III shows
that nurses and physicians whohave been working at their
professions yield thehighest mean scores. This difference in the
ratingof the euhanasia subscale and the 28 weighteditems of the
other areas of care of the dying patientis revealed in the wide
fluctuations in the correlationcoefficients for the seven groups.
For the threenursing groups, attitudes towards euthanasiaappear to
have no relationship to other attitudestowards the dying person and
his family. Forcollege students, the two measures of attitudes
aresomewhat correlated (P
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4 Carolyn Winget, et al
Statement no. i6, 'individual freedom of choiceultimately should
mean freedom of choice to liveor die within a context of
responsibility for self andothers', moves away from professional
role expec-tations and specific variables. It taps a
broadphilosophical approach to individual rights
andresponsibilities. Registered nurses and seniorstudent nurses
both have 59 per cent agreement withthis statement, less than the
other five groups.
If one discounts the responses to statement no.I3, which depend
more on cognitive than affectivecomponents of attitudes to
euthanasia, there is aconsistency among first-year medical
students,senior medical students and practising physicians.The
senior medical students have the most positiveattitudes toward
euthanasia, followed by practisingphysicians and first-year medical
students. There isless consistency among practising nurses and
nurs-ing students. The data also indicate that nurses'attitudes
toward euthanasia are not correlated withtheir overall attitudes
toward death and dying. Agreater proportion of nurses, whether
students orpractising professionals, have discrepant responsesto
statements about euthanasia.These findings pique our curiosity and
stimulate
speculation on a post hoc basis. Such a state ofindecision could
be favourably viewed as an open-ness to shift to one position or
another on the basisof additional information. Attitudinal
researchindicates that a strongly held attitude is usuallyresistant
to change. Krech et al (I962) indicate thatthe ability to alter our
concepts and beliefs isdetermined by our ability to deal with
ambiguitiesand inconsistencies. Studies of the nursing rolehave
shown that it is especially fraught withinconsistencies and
conflicting expectations notonly because of the nature of the job
itself butalso because 95 per cent of nurses are female andwomen's
role in our society is changing and haspoorly defined expectations.
This suggests thatwomen, especially nurses, have learned to
toleratemore indecision and inconsistencies in theirattitudes than
men, who are more likely to have aclearer professional identity. An
alternative ex-planation could be that women have not
thoughtthrough their attitudes to the point of an
integratedperspective. This would leave them more vulnerableto
emotional indecision. As more men enter thenursing profession and
more women becomephysicians it will be easier to delineate the
extent towhich professional identity rather than gender isthe
crucial factor.
Another possible explanation of the differencesbetween the
disciplines in consistency of personalattitudes may be attributed
to differences in sociali-zation to roles (Kramer, I968).
Sociological theoryindicates that the longer the socialization
process,the more likely the attitudes, values and beliefsassociated
with a role will be internalized. Medicalstudents have a longer
period of professional
training and so are more likely to internalize theattitudes,
values and beliefs that are associated withthe physician's role. If
this assumption is valid,practising physicians and physician
teachers there-fore have a more consistent set of attitudes,
valuesand beliefs to convey to students. Nurses not onlyhave
shorter periods of professional taining, butwith the multiplicity
of programmes, there aremarked differences in the length of nursing
educa-tion. Because of this variation, nurses are less likelythan
physicians to have a consistent set of attitudes,values and beliefs
to transmit to nursing students.
Conclusion
In a survey of medical, nursing and college studentsand
practising physicians and nurses there weresignificant attitudinal
differences in responses tostatements about euthanasia. Senior
medical stu-dents and practising physicians did not
differsignificantly from each other but were more posi-tively
orientated towards euthanasia than registerednurses, first-year
medical students, senior and first-year nursing students, and other
college students.Attitudes toward euthanasia were positively
corre-lated with other attitudes towards the dying patientand his
family for all groups but the two groups ofnursing students and the
practising nurses. Thesethree nursing groups and the college
students alsoshowed proportionately the greatest
within-personinconsistency in responses to the euthanasia
items.
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