Annals of Oncology Advance Access originally published online on June 12, 2008
Annals of Oncology 2008 19(11):1947-1954; doi:10.1093/annonc/mdn381
supportive care and palliative care |
Opinions concerning euthanasia, life-sustaining treatment and acceleration of death: results of an Italian Association of Medical Oncology (AIOM) survey
1 New Drugs Development Unit, Medical Oncology Division, European Institute of Oncology, Milan
2 Department of Oncology, ‘S. G. Calibita’ Hospital, Rome
3 Department of Oncology, General Hospital, Vicenza
4 Department of Oncology, Fatebenefratelli and Ophthalmic Hospital, Milan
5 Oncology Unit, Molinette Hospital, Turin
6 Oncology Unit, ‘M. Paternò’ Hospital, Ragusa
7 Oncology Unit, ‘S. Cuore, Don Calabria Hospital, Negrar
8 Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan
9 Unit for Medical Care European Institute of Oncology, Milan
10 Oncology Unit, National Cancer Research Institute and University of Genoa, Italy
* Correspondence to: Dr C. Catania, New Drugs Development Unit, Medical Oncology Division, European Institute of Oncology, Milan 20141, Italy. Tel: +39-02-57489482; Fax: +39-02-57489581; E-mail: chiara.catania{at}ieo.it
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Abstract |
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Background: Advance directives, acceleration of death, euthanasia and ‘life-sustaining treatment’ have sparked much heated debate among the media, the public, doctors and political leaders. We evaluate the personal opinions of Italian Association of Medical Oncology (AIOM) members.
Patients and methods: A 30-item questionnaire was developed and delivered to all 1832 AIOM members.
Results: Six-hundred and eighty-five (37%) oncologists completed and returned the questionnaires. Sixty-three per cent felt culturally and psychologically prepared to face these issues. Fifty-four per cent believed that what had been decided while the patient enjoyed good health is no longer applicable in an advanced state of terminal illness. Thirty-nine per cent believed that doctors should abide by these directives, while 49% believed that this should be discussed on a case-by-case basis. Fourteen per cent of oncologists were favourable towards euthanasia and 42% only in particular circumstances. Fifty-six per cent had received at least one request for accelerating death: 15% consented, 50% discussed it with the patient and 31% refused.
Conclusion: Advance directives, euthanasia, accelerated death and life-sustaining treatment represent considerable challenges for Italian oncologists. Although prepared to face these issues, AIOM members ask for a debate within the medical world and for a shared judicial regulation.
Key words: acceleration of death, advance directives, euthanasia, life sustaining treatment, oncological patients
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introduction |
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For some years now, the question of euthanasia and the debate over ethical procedures concerning terminal patients have sparked the interest of the Italian media and public. At present, in regard to these topics, there is a great deal of confusion and a wide range of varying opinions among citizens, doctors and political leaders.
Some proposals expressed by our citizens urge lawmakers to bring ‘advance directives for treatment’ (commonly known as the ‘living will’) into force as quickly as possible. Instead, the National Committee for Bioethics has changed the wording of advance directives for treatment to ‘prior declaration for treatment’ with the hope of emphasising and reinforcing the nonbinding character of the law for doctors [1]. Patients assert their right to participate in decisions concerning their own life, even to the point of requesting euthanasia, and most ethicists contend that it is morally difficult to justify denying this right [2, 3].
These differences in thought and behaviour are problematic, both in terms of managing the patient and in terms of the decisions that the doctor is called upon to make.
In Italy, furthermore, there are varying currents of thought among medical associations and even within the associations themselves.
Indeed, a recent statement by the National Federation of the Order of Physicians and Dentists confirms the ‘opposition to any form of euthanasia as is sanctioned by the Code of Medical Conduct’ [4, 5] and is soliciting, instead, ‘interventions and resources aimed at improving assistance to terminal patients, confirming, at the same time, the independence of the physician as a true guarantee for helping people who suffer and who have the right to be accompanied with skill, solidarity and love in the moment of their deaths’.
On the other hand, some voluntary Italian oncology associations have recently distanced themselves from bringing advance directives into law, while medical and palliative treatment associations have written directives without even trying to compare them with other medical communities. The existence of heterogeneous positions within the Italian medical community is comparable with the available data from other countries.
The percentage of physicians who approve of euthanasia and assisted suicide is increasing and ranges from 35% to 88% in different countries [6–10]; this is in agreement with findings from the general population [11–16]. The Italian Association of Medical Oncology (AIOM) believes that it is its duty to take a stand on this issue and has always believed that its own expression of intent should not exclude a investigation that would enable us to focus on the relevance of these problems and on the perception of them by the members of our community irrespective of their individual or specific professional experience and the contexts in which they have developed their seniority, their general religious and/or philosophical convictions.
The aim of this study was to evaluate the awareness and personal opinion of AIOM members regarding advance directives, acceleration of death, euthanasia and ‘life-sustaining treatment’.
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materials and methods |
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A questionnaire composed of 30 questions was created (Appendix): 28 of the questions are multiple choice and two questions are open ended. The questionnaire was proposed, created and elaborated by the AIOM working group named ‘Organization & Humanization’.
Afterwards, the AIOM board approved the questionnaire
We delivered the questionnaire, or sent it via email, to all the 1832 oncologists who are members of the association on February 2007. Data have been collected from April to June 2007 through an AIOM-dedicated secretary who guaranteed anonymity.
The questions, beyond those regarding the evaluation of age, religion, sex and the hospital where the oncologists work (Scientific Institute of Research and Cure (IRCCS), Public Health Facility or private hospitals), were broadly classified into four major domains:
- If Italian oncologists are aware about the sole Italian document dealing with advance directives (National Committee of Bioethics) and the proposed laws in this area and whether they feel culturally and psychologically prepared to face these issues (Q6, Q8, Q20, Q21).
- If Italian oncologists believe it correct that the Italian Parliament creates specific laws on such issues and that it also decides which paths must be followed in order to implement them (Q7, Q9, Q10, Q11, Q12, Q14, Q28, Q29, Q30).
- If the AIOM must deal with these issues (Q25, Q27).
- Italian oncologists’ thoughts and experiences regarding advance directives, acceleration of death, euthanasia and life-sustaining treatment (Q13, Q15, Q16, Q16bis, Q17, Q18, Q19, Q23, Q24).
statistical analysis
Statistical analysis was carried out on November 2007. Summary statistics for socio-demographic variables as well as the distribution of the frequency of answers are presented in Table 1. The key questions of domain number 4 (questions 14, 16, 16-bis and 24) were cross-tabulated with religion on two levels (Catholic or others), gender, geographical area, age, years of oncology practice and previous knowledge of the National Committee Bioethics’ directives.
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Associations among categorical variables were tested by means of the chi-square test. Age, among different levels of question 24, was tested using the Kruskal–Wallis test. All tests were considered statistically significant at the
level of 0.05. No adjustment for multiple comparisons was made. |
results |
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Six-hundred and eighty-five (37%) oncologists completed and returned the questionnaires. The characteristics of the responders are described in Table 1. Distribution of frequency of the answers to the questionnaires is fully reported in Appendix. Selected answers are fully described here. They have been grouped into the four major domains reported.
domain 1
Fifty-six per cent were not acquainted with the National Bioethics Committee's document (Q6) and 64% were not acquainted with the proposals for laws regarding Prior Declaration of Treatment, which is under discussion in the Chamber of Parliament (Q8). Sixty-three per cent of responders felt culturally and psychologically prepared to face these issues in their daily practice (Q20), 71% had faced these issues in their work team (Q21) and 87% reported the absence of specific provisions on their ward for these issues.
domain 2
Seventy-four per cent of participants believed that a law which would regulate advance directives is necessary (Q7) and 63% believed that possible legislation would surely mean a facilitation of the relationship between doctor and patient (Q11).
Regarding the necessity of following a written disposition from the patient (advance directives), 39% of participants believed that it is correct for doctors to abide by these directives, while 49% believed that this should be discussed on a case-by-case basis (Q9). Sixty-four per cent and 67% per cent of responders thought it correct for the Italian parliamentary officials to concern themselves with legislation regarding life-sustaining medical treatment and euthanasia, respectively (Q28, Q29). Thirty-nine per cent of the responders believed that a referendum on this issue is necessary (Q30). Thirty-five per cent think that these laws should be decided upon within the medical oncology world (Q10). Sixty-five per cent of responders believed that the solution to these issues should also be sought through communication and relationships built on the trust between doctor, patient and family (Q12). Fifty-four per cent believed that what had been decided while the patient was in a good state of health can no longer be applicable in an advanced state of terminal illness as the values and expectations have changed (Q14).
domain 3
Eighty-three per cent of responders thought AIOM should express an opinion on advance directives of treatment, euthanasia, life-sustaining medical treatment or other similar treatments (Q25) and 88% believed that it is AIOM's duty to face these issues during associates conventions (Q27).
domain 4
Fourteen per cent and sixteen per cent of oncologists were favourable to euthanasia from the professional and personal point of view, respectively; moreover, 42% and 37%, respectively, claimed they might be favourable, though only in specific situations (Q23, Q24), while 42%–46% were not favourable at all under any circumstances. Fifty-six per cent of participants had received at least one request for accelerating death in order to avoid further suffering; 15% of them claimed they had consented to the request of the patient, 50% discussed it with the patient and 31% refused to be involved in their request (Q15, Q16). For 59% of responders, religious belief played a part (25%: a lot; 34%: a little) in making this choice (Q16 bis).
Sixty-four per cent believed that acceleration of death and euthanasia in the oncological setting is not the same thing (Q17). When asked (Q18, Q19) to define life-sustaining treatment and acceleration of death, 78% of the participants had a similar definition for life-sustaining treatment, while for acceleration of death, there were many and widely diverse definitions. There was no significant association between answers to Q24 and the following variables: gender (P = 0.1688), geographical area (P = 0.5686), age (P = 0.1352), years of oncology practice (P = 0.2966) and previous knowledge of the National Bioethics Committee's directives (Q6) (P = 0.8798).
Religion was the only variable that was found to be significantly and strongly associated with answers to Q14, Q16 and 16-bis and Q24 (Table 2).
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discussion |
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It is the oncologists’ responsibility to care for their patients in a continuum that extends from the moment of diagnosis throughout the course of illness including the last phase of life (simultaneous care model) [17–19].
In this context, the ethical problems concerning advance directives, acceleration of death, euthanasia and life-sustaining treatment represent different aspects, often correlated, which strongly involve the oncologist [20, 21]. This is true not only from an emotional point of view but also from an ethical, cultural, professional and medico-legal point of view. Certain recent events have provided impetus towards a more in-depth examination of these problems in Italy, on the level of institutional bodies such as the National Bioethics Committee and the Italian Parliament. These institutions have been solicited by many parties to formulate guidelines and, overall, to fill a legal gap in order to address such a delicate moment in the duration of an illness and in the lives of the people involved.
In fact, beyond that which is sanctioned by the penal code concerning the issues of ‘consensual homicide’ and ‘physician-assisted suicide’, laws are lacking which would serve as reference points for doctors whose work, still today, is guided exclusively by their own knowledge, conscience and the relationship of trust that ties them to their patients and to the families of the patients.
Italian oncologists who had been called upon to face these problems directly in the field felt the need to actively contribute to the debate in progress. This work regards the position of AIOM members on euthanasia, life-sustaining treatment, advance directives and acceleration of death.
The completed questionnaires represent 38% of AIOM membership. The rate of nonresponders is similar to that reported in other works on the same theme and may be due to the nature of the subject as well as to the general tendency of many people not to participate in mailed surveys [22, 23].
Although we cannot exclude the possibility that nonresponse has to some extent biased our results, we believe that the data collected are adequate to represent AIOM's reality, particularly regarding those members who are principally involved in these issues. This observation is based mainly on the fact that data collected are extremely relevant quantitatively (684 questionnaires completed) and representative of many Italian regions, each with its own particular situation. Furthermore, a high percentage of the sample group that responded appears to be particularly involved in the management of the advanced stages of illness: >50% of those interviewed declare that they commonly follow 10 or more patients per month in terminal phase of disease. In all, 87.6% of the responders are of the Catholic faith. This percentage is consistent with the percentage of Catholics within the overall Italian population (90% as reported in the 2008 Central Intelligence Agency World Fact Book). This observation supports the absence of bias in response rate based on religion.
Regarding advance directives, the results collected show that, in Italy, oncologists must face the problem in their clinical practice, in spite of the fact that there is no widespread knowledge of the existing rules. The results also confirm the desire of these doctors to have specific rules regarding this issue.
Half of the oncologists (56%) interviewed claim to have received requests for advance directives from their patients, but only 43% of responders claim to have adequate knowledge of the documents available and the legal provisions under discussion on a regulatory level.
Seventy-five per cent of people interviewed express the need for a specific proclamation of legislative measures regarding advance directives. Meanwhile, 49% of the Italian oncologists interviewed said that the obligation of doctors to abide by written directives must be put under discussion.
Moreover, most of those interviewed are sceptical about the reliability, and therefore the applicability, of statements made in advance, while still in a full state of well-being or at least in a state of well-being that has not yet been compromised as much as it would be in the advanced stages of the illness.
With regard to euthanasia and accelerated death, the most relevant result is that most Italian oncologists must sooner or later face the problem and that, when they do, they face it with a heterogeneity of thought which does not exclude the possibility of euthanasia.
In fact, from the professional point of view, 14% of responders were favourable towards euthanasia, and another 42% were favourable only in particular cases; from the personal point of view 16% were favourable towards euthanasia and another 37% only in particular cases.
Fifty-six per cent of those interviewed admitted to having received requests from their patients to accelerate their deaths; 15% of them consented to the request of the patient by suspending ‘life support’ and 50% discussed it with the patient; for 59% of responders, religious belief played a part (25%: a lot; 34%: a little) in making this choice.
Religion was the only variable that we found significantly and strongly associated with answers to Q14, Q16, 16-bis and 24: 58% of Catholic oncologists do not believe that what is good for the patient when he is in good health is good for him when he is in an advanced state of illness, compared with 48% (non-Catholic others, Q14). Thirty-five per cent of Catholic physicians refused to suspend life support, compared with 21% (non-Catholic others, Q16); 49% of Catholic oncologists are never favourable to euthanasia, compared with 17% (non-Catholic others, Q24) (Table 2.). This could mean that, for most Italian oncologists, religious beliefs play an important role in making decisions about euthanasia, accelerated death and/or advance directives. These results are consistent with other studies [8–19]. Despite these differences (and considering the fact that Catholic doctrine, which is traditionally opposed to the taking of a human life in any circumstances), the results confirm that a good part (50.4%) of the Catholic doctors interviewed are capable of overcoming the religious teaching in terms of euthanasia, accelerated death and/or advance directives.
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conclusions |
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Advance directives, euthanasia, accelerated death, and life-sustaining treatment are problems for those in the field of medical oncology who are often called upon to deal with such issues in clinical practice. The majority of Italian oncologists do not appear adequately prepared to face these problems—on an ethical level, but also, and most importantly on a cultural level. This is true regardless of oncologists’ willingness to continue to help their patients, even in those dramatic situations that are often a prelude to such important ethical decisions as euthanasia. The desire not to avoid discussion is evident, and even more evident is the need to initiate a dialogue with institutions in order to fill the legislative gap which seems to weigh as much on those who express willingness and flexibility in these issues, as it does on those who express perplexity in regards to advance directives and disagreement with euthanasia. AIOM's members believe that these messages represent a very precise course of action for their association, and, overall, for the work that they will be called upon to carry out over the coming years.
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Acknowledgements |
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The authors wish to thank E. Moro for help in data collection.
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Footnotes |
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Both authors contributed equally to this work. 
Received for publication April 22, 2008. Revision received May 7, 2008. Accepted for publication May 8, 2008.
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