The Hospice Journal
ISSN: 0742-969X (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ippc19
Right-to-Die Responses from a Random Sample of 200 Ruth Huber, Virginia Meade Cox & William B. Edelen To cite this article: Ruth Huber, Virginia Meade Cox & William B. Edelen (1992) Rightto-Die Responses from a Random Sample of 200, The Hospice Journal, 8:3, 1-19, DOI: 10.1080/0742-969X.1992.11882727 To link to this article: https://doi.org/10.1080/0742-969X.1992.11882727
Published online: 29 Aug 2017.
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Citing articles: 4 View citing articles
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Right-to-Die Responses from a Random Sample of 200 Ruth Huber Virginia Meade Cox William B. Edelen
ABSTRACT. Seeking public attitudes toward the right-to-die, 200 telephone interviews were conducted with a random sample of resi dents in a midwestem city in the summer of 1990. Overall, 90% favored some kind of personal control over death circumstances. With semantics as an independent variable (euthanasia, mercy kill ing, physician-assisted suicide, or some form of personal control over death) only the group to whom "physician-assisted suicide" had been presented as a choice said "no" or "probably not" to a legaliz.ation question (p = < .0001). INTRODUCTION We conducted a study during the summer of 1990, the purposes of which were (a) to learn the general attitudes of citizens toward right-to die issues, and -(b) to see if responses varied according to the tenns used to refer to it: "euthanasia"; "mercy killing"; "physician-assisted suiRuth Huber, PhD, MSW, is Assistant Professor at Kent School of Social Work, University of Louisville, Louisville, KY. Virginia Meade Cox, MSSW, is Psychiatric Social Worker at Norton Hospital, Louisville, KY. William B. Edelen, MSSW, LSW, is Outpatient Therapist with Communicare, Inc., Leba non, KY. Address correspondence to Dr. Ruth Huber, Kent School of Social Work, University of Louisville, Louisville, KY 40292. The authors appreciate Dr. Naomi Gottlieb's review of an earlier version of this article. This paper was presented at the National Hospice Organization, November 20, 1991, Seattle, WA. The Hospice Journal, Vol. 8(3) 1992 «:> 1992 by The Haworth Press, Inc. All rights reserved.
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cide"; or "some form of personal control over your own death." This paper reports on the responses. Following a brief review of the literature, we present the methodology, the findings and a discussion of their impli cations.
LITERATURE Advances in medical technology have surpassed our ability to ethically decide how, when, and even whether to use it (Darbyshire, 1987; Ikuta, 1989; Syme, 1991). In many cases, biological life can now be prolonged almost indefinitely. For proponents of the notion that people have deci sion-making rights when it comes to their own dying, the overuse of such technology can mean a life of mere biological functioning devoid of those qualities that make it worth living (Callahan, 1989; Canadian Medical Association Journal, 1990; Glover & Lynn, 1991). Liacos (1989) pin pointed the dilemma: thanks to medical technology we now have choices, but with these choices come difficulties. The notion of the right-to-die concept is based on the belief that dying "naturally," without tubes and machines, is more dignified, and that people should have a say in these decisions. McIntyre (1989), however, said there is no such thing as death with dignity. Indeed, "death is the opposite of dignity" even as "joy is the antithesis of sorrow" (p. 405). Although McIntyre is not in favor of family participation in death related decisions, he does endorse statutes protecting the integrity of living wills. Holder (1991), on the other hand, believes that "a formal living will is much too complicated" and an unnecessary step: "... doctors ought to realiz.e that they have the responsibility to talk to patients in general terms about how they feel about life-saving interventions" (p. 3). Hollowell and Eldridge (1988) believe that patients have the "right to die via informed refusal of medical treatment," but that this right is not absolute and must be balanced against competing interests (p. 44). Koop (1989) articulated some of the fears of those who are opposed to euthanasia. "In spite of being assured that freedom of choice is the issue, legaliz.ed euthanasia would never stop at allowing people to choose their own death [sic]. The acceptance of suicide is the first step on the slippery slope" (pp. 229-230). Koop pointed to the 1948 work of Dr. Leo Alexander, a native of Austria who became a professor of psychiatric medicine in Boston and an investigator of the medical experiments con ducted by the Nazi regime. Alexander (1948) reported that the crimes of the Nazi holocaust began with physicians' acceptance of the idea that a
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life can be such that it is not worth living. Once this wedge was in place, according to Alexander, the notion was enlarged to include all unproduc tive and non-rehabilitatable people, and finally, all non-Germans. Koop's position was countered by a fear of "medicine-gone-wild" as Callahan (1989) showed concern for devalued populations on the opposite side: Lives . . . are steadily being lengthened, and particularly for those who are the most powerless: sick children and the very old, the mentally ill and mentally retarded, the disabled and the demented. That reality points most obviously, I believe, to the main reason for the increased support of active euthanasia. The power of medi cine to extend life under poor circumstances is now widely and increasingly feared. (p. 4) Despite differences among professionals, public attitudes appear to favor wresting some control from medicine and technology over the circumstances of death. Ostheimer (1980) illustrated that support for euthanasia has grown steadily since 1947. The Society for the Right to Die (1990) discussed a public poll conducted by the American Medical Association in 1986, in which 73 % of respondents approved "withdraw ing life-support systems, including food and water, from hopelessly ill or irreversibly comatose patients if they or their families request it" (p. 3). Joseph and Grenier ( 1990) reported that the majority of respondents (62%) in an East Baton Rouge parish said that they would consider sign ing a living will or a durable power of attorney, designating a health care agent to speak in their behalf. There have been other indications of the public's support for individuals' rights in death circumstances. In the fall of 1990, The Soci ety for the Right to Die received over 400,000 requests for living wills following a dramatic decision by the Supreme Court. This decision per mitted the family of Nancy Cruzan to remove the feeding tube that had maintained her in a persistent vegetative state since an automobile acci dent in 1983. The court's decision recognized, for the first time, that the right to refuse treatment is protected by the Constitution. Quigley ( 1990) held that "the effect of the (Cruzan) decision will be to increase public awareness of the issues . . . " (p. 464-465). Other evidence of the public's heightened interest in the idea of a right-to-die is the recent proliferation of state laws concerning control over death circumstances. According to Choice in Dying (personal com munication, November, 1991), only Nebraska had not enacted any kind
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of living will legislation. Other states have varying laws indicating that it is permissible to withhold or withdraw tube feeding (The Society for the Right to Die, 1990). Most states have laws governing the use of durable powers of attorney and advance directives to specify health care agents and proxy appointments which name others to act on behalf of individuals when they cannot speak for themselves. In November, 1991, however, Washington State voters narrowly defeated (54%) Initiative 119 which for the first time would have provided legal protection for physi cians who chose to assist terminally ill people with intractable pain wish ing to end their own lives. Although any activity that aids the death of another person is illegal in the United States, court decisions are generally supportive of individuals' wishes, as well as those of family members who attempt to enact them. A review of 54 right-to-die court decisions since 1976 revealed that 87 % found in favor of the rights of individuals and family members to decide when life support systems should be discontinued. Most of these decisions were reversals of lower court decisions which had denied discontinuance of life supporting treatment. The common thread in these decisions is the notion of common law-that individuals' rights to refuse are inherent in their consents to receive treatment (Henderson, 1990; The Society for the Right to Die, 1991). Another theme in the court decisions is that "participating in the rejec tion of life support does not constitute murder or assisted suicide" (Jane Doe, 16 Philadelphia 229, 1987; The Society for the Right to Die, 1990). This opinion was supported, in principle, in the decision to acquit Dr. Jack Kevorkian of Michigan of criminal charges in the suicide death of Janet Adkins who activated the suicide machine he invented. These court deci sions add to the growing body of evidence that people are concerned about gaining control of events preceding their deaths. The literature continues to speak to the need for people to make their desires known by executing advance directives (Markson & Steel, 1990), and specifying guardians for subsequent decision making (Gibson & Nathanson, 1990; Iris, 1990). The medical profession is usually sensitive to the rising concern for more personal control. When subsequent litigation by family members does not appear likely, many physicians quietly provide their terminally ill patients, who are in extremely painful and hopeless conditions, with either the means or the information to quietly end their lives. In March 1991 Timothy E. Quill, MD, broke with this tradition of anonymity by reporting that he had prescribed a sleep-inducing drug to a terminally ill cancer patient and had given her specific information about the dosage required to bring about her death, in which she later succeeded. Further complicating this sensitive area of research has been the prob-
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lem of semantics. Recent discussions have been saddled with ambiguity and the lack of distinction and clear definition between the terms euthana sia and mercy killing (Parachini, 1989). There has also been concern that the results of polls might have been influenced by hidden ideological tilt (Parachini, 1989) or by wording that preconditioned negative responses (Ostheimer, 1980). Sawyer (1982) found that ".. . certain issues (name ly, euthanasia and suicide in the present context) are more discriminating than other terms in their ability to differentiate among divergent belief systems" (p.530). On the other hand, Smith (1990) held that "Passive euthanasia and rational suicide are offensive words from the parlance of a time gone by. Autonomy and enlightened self-determination are the more contemporary watchwords of today" (p. 30). While professionals and theorists debate the weighty issues of life, death, and the right-to-die, there is the very real need to further define and validly measure public attitudes. Finlay (1986) called for studies with samples more representative of the adult population. We need to learn how the use of terms such as euthanasia, mercy killing, and suicide af fects public responses to right-to-die kinds of questions. Toward this end, we designed a study to address two general questions: l. What is the public's attitude about right-to-die issues? 2. Are responses affected by semantics? More specifically, does the use of four key phrases ("euthanasia," "mercy killing," "physi cian-assisted suicide" or "some form of personal control over death") affect response pertaining to the legalization of these prac tices?
METHOD We conducted telephone interviews of a random sample of 200 adults in a midwestern city with a population of about 270,000. The systematic random sample of 200 was selected from the City Directory listing most residents by address and phone number. A power analysis indicated that 46 subjects would be adequate to detect a moderate effect (r = .40, power = .80, p = < .05; Cohen, 1969). We therefore conducted 50 telephone interviews in each of four groups. Thus, our findings do not represent citizens without telephones. The main independent variable relevant to this paper is the difference in semantics used between the four groups-whether the central question included "euthanasia," "mercy killing," "physician-assisted suicide" or "some form of personal control over death" (Figure 1).
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6
Mercy Killing 50
MD Assisted Suicide 50
Eutharasia 5C
Some Kind of Control 5J
Figure 1. Independent Variable: Semantics (N=200) After a few opening questions concerning demographics (i.e., age, gender, occupation), three "rights" questions were posed: 1. Do you think that people who are terminally ill should have any right to decide the circumstances of their deaths? 2. If you were terminally ill, would you want some say about your own death? 3. If your loved one were terminally ill, would you think that he (or she) should have any say about how their own death was to come about? Then the central question was presented using one of the terms ''euthana sia," "mercy killing," "physician assisted suicide," or "some form of personal control over death'':
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4. If adequate safeguards could be developed, would you like to see (one of the four terms) legalized? Responses to these questions were selected from 4-point Likert scales (No, Probably Not, Probably Yes, and Yes).
Demographic Characteristics of the Sample Sixty-eight percent of the respondents were women and 32% were men. Ages ranged from 21 to 93; the mean age was 54: The estimated median income derived from $5,000 categories, was $29,700. The occupations most frequently reported by respondents were busi ness/sales (25%), and homemaker (19%), followed by 13% in blue collar or service jobs (i.e., food service). Twelve percent of the re spondents said they were retired and 10% were professionals in medi cine and health related fields, i.e., physicians, nurses, and social work ers. The remaining 21% reported various occupations, i.e., 6% in education, 3% in religion related work and 3% in legal positions; another 3% were unemployed. Nearly one-fourth of the respondents had not finished high school; 22% held degrees at the bachelors level or higher (Table I). Respondents represented various religious denominations with Bap tists comprising the largest group (60%). Analyses of denominational differences in responses will be reported elsewhere. Eighty-five percent of the sample said they had experienced the death of someone close to them.
FINDINGS Findings of the three "rights" questions will first be presented, fol lowed by responses to the legalization question.
Responses to the Three "Rights" Questions All three of the "rights" questions dealt with the same concept: whether people should have any say about circumstances surrounding death. These three questions differed only as to who should have such rights. In general terms, over 90% of the entire sample answered the three questions with Probably Yes or Yes. More specifically, responses to the three separate questions were as follows:
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8 Table l
Respondents' Education Number of Respondents
Percent
Less than high school
48
24%
High school graduate
48
24%
Some vocational training
10
5%
some college
41
21%
9
4%
Bachelors degree
22
11%
Masters degree
18
9%
4
2%
2JC
100%
Associates degree (2 years)
I. Do you think that people who are tenninally ill should have any right to decide the circumstances of their deaths? Ninety-three percent responded "Probably Yes" or "Yes." 2. If you were terminally ill, would you want some say about your own death? Ninety-two percent responded "Probably Yes" or "Yes." 3. If your loved one were terminally ill, would you think that he (or she) should have any say about how their own death was to come about? Ninety-five percent responded "Probably Yes" or "Yes" (Figure 2). These findings are similar to the results of a Gallup Poll reported by Holthaus, Koska, Eubanks and Hudson (1989): 70% would want life support systems removed if they themselves lapsed into irreversible co mas, although only 46 % were willing to make such decisions for others.
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80% 60% · ---·- ---
40% 20% -- ------·
0%
If People
- No/Probably Not
If You
If Loved One
B Yes/Probably
Yes
Figure 2. Responses to three "rights· questions pertaining to persona l control (N=200) Reasons Given for Responses. After each of the three "rights" ques tions above, the interviewer posed an open-ended question as to why individuals had responded as they did. These responses provided further insight into respondents' attitudes. The main reason given following all three of the "rights" questions was the importance of individual autonomy and dignity-individuals' rights to choices. Other reasons reflected concern about unnecessary suffering, burdens on families, and support for living wills. Some respondents
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expressed concern for the legal implications for physicians; others com mented negatively about artificially prolonging life, preferring to "let God come.'' The following sections provide findings regarding relation ships between relevant demographics and responses. Advanced Age. Consistent with Finlay (1986), we found advanced age to be a significant predictor of being less in favor of personal controls; p = < .01 on the first question, pertaining to people in gener al; p = < .OOCH on the second question concerning the individual being interviewed (if you); and p = < .01 on the third question pertaining to the rights of loved ones who might be terminally ill. Finlay (1986) specu lated that this age difference in attitude could have been due to the more imminent threat of death to older people, or simply representative of "a more conservative morality among the elderly" (p, 550). We thought the difference in attitude of age cohorts merited further examination to see at just how "advanced" an age these differences appeared. Table 2 reveals that a high level (over 85% ) of the responses to all three questions were "Yes" or "Probably Yes" across all four age groups. Notice, however, that people who were 60 and over were less likely to want some control of their own death circumstances than were people under 60 (Table 2). Notice also that the respondents who were 80 and older were less likely than those under 80 to believe that terminally ill people in general should have any control of the dying process. Our finding that respondents were slightly less likely to want some control over their own circumstances, but a little more likely to be will ing to make similar decisions for loved ones, differs from Steiber's (1987). Steiber reported on a Gallup Poll in which 70% of the 995 re spondents were very willing to have a life support system disconnected from themselves, compared to only 46 % who were willing to make such decisions for relatives. Gender. Although no gender differences were found in responses to the question about the rights of terminally ill people in general, women were significantly more likely to be in favor of some form of control of their own deaths (p = < .05), and for their loved ones to have some personal control (p = < .02). Education. Although eight different educational levels were captured in the interviews, there was a distinction among responses from those who had only high school educations (or less), or some vocational train ing beyond high school (but no college); and those who had attended college. Results of a Chi-Square analysis indicated that respondents with at least some college education (or degrees) were significantly more likely
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Huber, Cox, and &Jelen Table 2 Percent of "Yes" or "Probably Yes" Responses to "Rights" Questions by Age Groups, and Overall Percentages < 40
40-59
60-79
80-93
Overall If People (A)
95%
95%
92%
86%
93%
If You (B)
95%
95%
87%
86%
92%
If Loved One (C)
96%
98%
91%
91%
95%
rl
Do you think that peoole who are terminally ill should have any right to decide the circumstances of their deaths?
B
If you were terminally ill, would you want some say about your own death?
C
If your loved one was terminally ill, would you think that he (or she) should have any say about how their own death was to come about? to favor some kind of personal control over death circumstances for themselves if they were terminally ill (p = < .05), but not for the public generally nor for loved ones. Income. Consistent with the finding that more highly educated people were more likely to favor some form of personal control, respondents with higher incomes were significantly more likely to favor control in all three circumstances; p = < .02 on the first question pertaining to people in general; p = < .02 on the second question concerning the individual being interviewed; and p = < .01 on the third question pertaining to the rights of terminally ill loved ones. Responses from Subjects in Health Related Professions. Interesting to note are the responses from those in health-related professions (physi-
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cians, nurses, and social workers in health care settings) to the rights questions: 100% responded Yes or Probably Yes to all three questions. These respondents (n = 21) comprised 10% of the sample (N = 200).
Responses to the Legalh.ation Questions Following the three "rights" questions, we asked the legalization question containing the semantic independent variable ("euthanasia," ''mercy killing,'' ''physician assisted suicide,'' or ''some form of person al control over your own death"). If adequate safeguards could be developed, would you like to see (one of the four phrases) legalized? Overall, 64% responded "Probably Yes" or "Yes." However, respon dents in the "physician assisted suicide" group answered significantly more negatively, "No" or "Probably Not," than those in the other three groups (p = < .0001; Figure 3). "Miat Might those Adequate Safeguards Be?" We asked a difficult follow-up question of those who had favored any type of legalization with adequate safeguards: What might those safeguards include? Forty-six percent did not know. The next two most freq uent responses were that people should have executed a legal document such as a living will (18%), and that a terminal or hopeless condition should exist (13%). Age and Gender. Similar to responses to the "rights" questions, age was a significant predictor of negative responses to the legalization question (p = < .01; Figure 4). No gender differences were found when respon dents were asked whether one of the four phrases should be legalized. Education and Income. Consistent with their responses to the "rights" questions, subjects with college educations and higher incomes were again more likely to favor legalization of (one of the four phrases); col lege p = < .001; income p = < .001. Responses from Subjects in Health Related Professions. Overall, 71% of subjects who were health professionals responded with "Yes" or "Probably Yes" to the legalization questions, compared with 64% of the entire sample of 200. Figure 5 compares their responses, by specific terms, to the rest of the sample. These findings are curious. Notice that all of the health professionals to whom the term "euthanasia" was used in the legalization question responded "Yes" or "Probably Yes." In response to the legalization question when presented with the phrase ''physician assisted suicide,'' nearly twice the percentage of health pro-
100%
13
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1 I I
80%
1 I
60% l 40%
l __,
20% 0%
Euthanasia
Mercy Killing
- No/Probably Not
MD Assisted Suicide
Some Form Control
R Yes/Probably
Yes
Figure 3. Responses to legalization question by semantic group (N=200; p =
ISSN: 0742-969X (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ippc19
Right-to-Die Responses from a Random Sample of 200 Ruth Huber, Virginia Meade Cox & William B. Edelen To cite this article: Ruth Huber, Virginia Meade Cox & William B. Edelen (1992) Rightto-Die Responses from a Random Sample of 200, The Hospice Journal, 8:3, 1-19, DOI: 10.1080/0742-969X.1992.11882727 To link to this article: https://doi.org/10.1080/0742-969X.1992.11882727
Published online: 29 Aug 2017.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 4 View citing articles
Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ippc20
Right-to-Die Responses from a Random Sample of 200 Ruth Huber Virginia Meade Cox William B. Edelen
ABSTRACT. Seeking public attitudes toward the right-to-die, 200 telephone interviews were conducted with a random sample of resi dents in a midwestem city in the summer of 1990. Overall, 90% favored some kind of personal control over death circumstances. With semantics as an independent variable (euthanasia, mercy kill ing, physician-assisted suicide, or some form of personal control over death) only the group to whom "physician-assisted suicide" had been presented as a choice said "no" or "probably not" to a legaliz.ation question (p = < .0001). INTRODUCTION We conducted a study during the summer of 1990, the purposes of which were (a) to learn the general attitudes of citizens toward right-to die issues, and -(b) to see if responses varied according to the tenns used to refer to it: "euthanasia"; "mercy killing"; "physician-assisted suiRuth Huber, PhD, MSW, is Assistant Professor at Kent School of Social Work, University of Louisville, Louisville, KY. Virginia Meade Cox, MSSW, is Psychiatric Social Worker at Norton Hospital, Louisville, KY. William B. Edelen, MSSW, LSW, is Outpatient Therapist with Communicare, Inc., Leba non, KY. Address correspondence to Dr. Ruth Huber, Kent School of Social Work, University of Louisville, Louisville, KY 40292. The authors appreciate Dr. Naomi Gottlieb's review of an earlier version of this article. This paper was presented at the National Hospice Organization, November 20, 1991, Seattle, WA. The Hospice Journal, Vol. 8(3) 1992 «:> 1992 by The Haworth Press, Inc. All rights reserved.
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cide"; or "some form of personal control over your own death." This paper reports on the responses. Following a brief review of the literature, we present the methodology, the findings and a discussion of their impli cations.
LITERATURE Advances in medical technology have surpassed our ability to ethically decide how, when, and even whether to use it (Darbyshire, 1987; Ikuta, 1989; Syme, 1991). In many cases, biological life can now be prolonged almost indefinitely. For proponents of the notion that people have deci sion-making rights when it comes to their own dying, the overuse of such technology can mean a life of mere biological functioning devoid of those qualities that make it worth living (Callahan, 1989; Canadian Medical Association Journal, 1990; Glover & Lynn, 1991). Liacos (1989) pin pointed the dilemma: thanks to medical technology we now have choices, but with these choices come difficulties. The notion of the right-to-die concept is based on the belief that dying "naturally," without tubes and machines, is more dignified, and that people should have a say in these decisions. McIntyre (1989), however, said there is no such thing as death with dignity. Indeed, "death is the opposite of dignity" even as "joy is the antithesis of sorrow" (p. 405). Although McIntyre is not in favor of family participation in death related decisions, he does endorse statutes protecting the integrity of living wills. Holder (1991), on the other hand, believes that "a formal living will is much too complicated" and an unnecessary step: "... doctors ought to realiz.e that they have the responsibility to talk to patients in general terms about how they feel about life-saving interventions" (p. 3). Hollowell and Eldridge (1988) believe that patients have the "right to die via informed refusal of medical treatment," but that this right is not absolute and must be balanced against competing interests (p. 44). Koop (1989) articulated some of the fears of those who are opposed to euthanasia. "In spite of being assured that freedom of choice is the issue, legaliz.ed euthanasia would never stop at allowing people to choose their own death [sic]. The acceptance of suicide is the first step on the slippery slope" (pp. 229-230). Koop pointed to the 1948 work of Dr. Leo Alexander, a native of Austria who became a professor of psychiatric medicine in Boston and an investigator of the medical experiments con ducted by the Nazi regime. Alexander (1948) reported that the crimes of the Nazi holocaust began with physicians' acceptance of the idea that a
Huber, Cox, and Edelen
3
life can be such that it is not worth living. Once this wedge was in place, according to Alexander, the notion was enlarged to include all unproduc tive and non-rehabilitatable people, and finally, all non-Germans. Koop's position was countered by a fear of "medicine-gone-wild" as Callahan (1989) showed concern for devalued populations on the opposite side: Lives . . . are steadily being lengthened, and particularly for those who are the most powerless: sick children and the very old, the mentally ill and mentally retarded, the disabled and the demented. That reality points most obviously, I believe, to the main reason for the increased support of active euthanasia. The power of medi cine to extend life under poor circumstances is now widely and increasingly feared. (p. 4) Despite differences among professionals, public attitudes appear to favor wresting some control from medicine and technology over the circumstances of death. Ostheimer (1980) illustrated that support for euthanasia has grown steadily since 1947. The Society for the Right to Die (1990) discussed a public poll conducted by the American Medical Association in 1986, in which 73 % of respondents approved "withdraw ing life-support systems, including food and water, from hopelessly ill or irreversibly comatose patients if they or their families request it" (p. 3). Joseph and Grenier ( 1990) reported that the majority of respondents (62%) in an East Baton Rouge parish said that they would consider sign ing a living will or a durable power of attorney, designating a health care agent to speak in their behalf. There have been other indications of the public's support for individuals' rights in death circumstances. In the fall of 1990, The Soci ety for the Right to Die received over 400,000 requests for living wills following a dramatic decision by the Supreme Court. This decision per mitted the family of Nancy Cruzan to remove the feeding tube that had maintained her in a persistent vegetative state since an automobile acci dent in 1983. The court's decision recognized, for the first time, that the right to refuse treatment is protected by the Constitution. Quigley ( 1990) held that "the effect of the (Cruzan) decision will be to increase public awareness of the issues . . . " (p. 464-465). Other evidence of the public's heightened interest in the idea of a right-to-die is the recent proliferation of state laws concerning control over death circumstances. According to Choice in Dying (personal com munication, November, 1991), only Nebraska had not enacted any kind
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of living will legislation. Other states have varying laws indicating that it is permissible to withhold or withdraw tube feeding (The Society for the Right to Die, 1990). Most states have laws governing the use of durable powers of attorney and advance directives to specify health care agents and proxy appointments which name others to act on behalf of individuals when they cannot speak for themselves. In November, 1991, however, Washington State voters narrowly defeated (54%) Initiative 119 which for the first time would have provided legal protection for physi cians who chose to assist terminally ill people with intractable pain wish ing to end their own lives. Although any activity that aids the death of another person is illegal in the United States, court decisions are generally supportive of individuals' wishes, as well as those of family members who attempt to enact them. A review of 54 right-to-die court decisions since 1976 revealed that 87 % found in favor of the rights of individuals and family members to decide when life support systems should be discontinued. Most of these decisions were reversals of lower court decisions which had denied discontinuance of life supporting treatment. The common thread in these decisions is the notion of common law-that individuals' rights to refuse are inherent in their consents to receive treatment (Henderson, 1990; The Society for the Right to Die, 1991). Another theme in the court decisions is that "participating in the rejec tion of life support does not constitute murder or assisted suicide" (Jane Doe, 16 Philadelphia 229, 1987; The Society for the Right to Die, 1990). This opinion was supported, in principle, in the decision to acquit Dr. Jack Kevorkian of Michigan of criminal charges in the suicide death of Janet Adkins who activated the suicide machine he invented. These court deci sions add to the growing body of evidence that people are concerned about gaining control of events preceding their deaths. The literature continues to speak to the need for people to make their desires known by executing advance directives (Markson & Steel, 1990), and specifying guardians for subsequent decision making (Gibson & Nathanson, 1990; Iris, 1990). The medical profession is usually sensitive to the rising concern for more personal control. When subsequent litigation by family members does not appear likely, many physicians quietly provide their terminally ill patients, who are in extremely painful and hopeless conditions, with either the means or the information to quietly end their lives. In March 1991 Timothy E. Quill, MD, broke with this tradition of anonymity by reporting that he had prescribed a sleep-inducing drug to a terminally ill cancer patient and had given her specific information about the dosage required to bring about her death, in which she later succeeded. Further complicating this sensitive area of research has been the prob-
Huber, Cox, and Edelen
5
lem of semantics. Recent discussions have been saddled with ambiguity and the lack of distinction and clear definition between the terms euthana sia and mercy killing (Parachini, 1989). There has also been concern that the results of polls might have been influenced by hidden ideological tilt (Parachini, 1989) or by wording that preconditioned negative responses (Ostheimer, 1980). Sawyer (1982) found that ".. . certain issues (name ly, euthanasia and suicide in the present context) are more discriminating than other terms in their ability to differentiate among divergent belief systems" (p.530). On the other hand, Smith (1990) held that "Passive euthanasia and rational suicide are offensive words from the parlance of a time gone by. Autonomy and enlightened self-determination are the more contemporary watchwords of today" (p. 30). While professionals and theorists debate the weighty issues of life, death, and the right-to-die, there is the very real need to further define and validly measure public attitudes. Finlay (1986) called for studies with samples more representative of the adult population. We need to learn how the use of terms such as euthanasia, mercy killing, and suicide af fects public responses to right-to-die kinds of questions. Toward this end, we designed a study to address two general questions: l. What is the public's attitude about right-to-die issues? 2. Are responses affected by semantics? More specifically, does the use of four key phrases ("euthanasia," "mercy killing," "physi cian-assisted suicide" or "some form of personal control over death") affect response pertaining to the legalization of these prac tices?
METHOD We conducted telephone interviews of a random sample of 200 adults in a midwestern city with a population of about 270,000. The systematic random sample of 200 was selected from the City Directory listing most residents by address and phone number. A power analysis indicated that 46 subjects would be adequate to detect a moderate effect (r = .40, power = .80, p = < .05; Cohen, 1969). We therefore conducted 50 telephone interviews in each of four groups. Thus, our findings do not represent citizens without telephones. The main independent variable relevant to this paper is the difference in semantics used between the four groups-whether the central question included "euthanasia," "mercy killing," "physician-assisted suicide" or "some form of personal control over death" (Figure 1).
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Mercy Killing 50
MD Assisted Suicide 50
Eutharasia 5C
Some Kind of Control 5J
Figure 1. Independent Variable: Semantics (N=200) After a few opening questions concerning demographics (i.e., age, gender, occupation), three "rights" questions were posed: 1. Do you think that people who are terminally ill should have any right to decide the circumstances of their deaths? 2. If you were terminally ill, would you want some say about your own death? 3. If your loved one were terminally ill, would you think that he (or she) should have any say about how their own death was to come about? Then the central question was presented using one of the terms ''euthana sia," "mercy killing," "physician assisted suicide," or "some form of personal control over death'':
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4. If adequate safeguards could be developed, would you like to see (one of the four terms) legalized? Responses to these questions were selected from 4-point Likert scales (No, Probably Not, Probably Yes, and Yes).
Demographic Characteristics of the Sample Sixty-eight percent of the respondents were women and 32% were men. Ages ranged from 21 to 93; the mean age was 54: The estimated median income derived from $5,000 categories, was $29,700. The occupations most frequently reported by respondents were busi ness/sales (25%), and homemaker (19%), followed by 13% in blue collar or service jobs (i.e., food service). Twelve percent of the re spondents said they were retired and 10% were professionals in medi cine and health related fields, i.e., physicians, nurses, and social work ers. The remaining 21% reported various occupations, i.e., 6% in education, 3% in religion related work and 3% in legal positions; another 3% were unemployed. Nearly one-fourth of the respondents had not finished high school; 22% held degrees at the bachelors level or higher (Table I). Respondents represented various religious denominations with Bap tists comprising the largest group (60%). Analyses of denominational differences in responses will be reported elsewhere. Eighty-five percent of the sample said they had experienced the death of someone close to them.
FINDINGS Findings of the three "rights" questions will first be presented, fol lowed by responses to the legalization question.
Responses to the Three "Rights" Questions All three of the "rights" questions dealt with the same concept: whether people should have any say about circumstances surrounding death. These three questions differed only as to who should have such rights. In general terms, over 90% of the entire sample answered the three questions with Probably Yes or Yes. More specifically, responses to the three separate questions were as follows:
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8 Table l
Respondents' Education Number of Respondents
Percent
Less than high school
48
24%
High school graduate
48
24%
Some vocational training
10
5%
some college
41
21%
9
4%
Bachelors degree
22
11%
Masters degree
18
9%
4
2%
2JC
100%
Associates degree (2 years)
I. Do you think that people who are tenninally ill should have any right to decide the circumstances of their deaths? Ninety-three percent responded "Probably Yes" or "Yes." 2. If you were terminally ill, would you want some say about your own death? Ninety-two percent responded "Probably Yes" or "Yes." 3. If your loved one were terminally ill, would you think that he (or she) should have any say about how their own death was to come about? Ninety-five percent responded "Probably Yes" or "Yes" (Figure 2). These findings are similar to the results of a Gallup Poll reported by Holthaus, Koska, Eubanks and Hudson (1989): 70% would want life support systems removed if they themselves lapsed into irreversible co mas, although only 46 % were willing to make such decisions for others.
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Huber, Cox, and Edelen
80% 60% · ---·- ---
40% 20% -- ------·
0%
If People
- No/Probably Not
If You
If Loved One
B Yes/Probably
Yes
Figure 2. Responses to three "rights· questions pertaining to persona l control (N=200) Reasons Given for Responses. After each of the three "rights" ques tions above, the interviewer posed an open-ended question as to why individuals had responded as they did. These responses provided further insight into respondents' attitudes. The main reason given following all three of the "rights" questions was the importance of individual autonomy and dignity-individuals' rights to choices. Other reasons reflected concern about unnecessary suffering, burdens on families, and support for living wills. Some respondents
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expressed concern for the legal implications for physicians; others com mented negatively about artificially prolonging life, preferring to "let God come.'' The following sections provide findings regarding relation ships between relevant demographics and responses. Advanced Age. Consistent with Finlay (1986), we found advanced age to be a significant predictor of being less in favor of personal controls; p = < .01 on the first question, pertaining to people in gener al; p = < .OOCH on the second question concerning the individual being interviewed (if you); and p = < .01 on the third question pertaining to the rights of loved ones who might be terminally ill. Finlay (1986) specu lated that this age difference in attitude could have been due to the more imminent threat of death to older people, or simply representative of "a more conservative morality among the elderly" (p, 550). We thought the difference in attitude of age cohorts merited further examination to see at just how "advanced" an age these differences appeared. Table 2 reveals that a high level (over 85% ) of the responses to all three questions were "Yes" or "Probably Yes" across all four age groups. Notice, however, that people who were 60 and over were less likely to want some control of their own death circumstances than were people under 60 (Table 2). Notice also that the respondents who were 80 and older were less likely than those under 80 to believe that terminally ill people in general should have any control of the dying process. Our finding that respondents were slightly less likely to want some control over their own circumstances, but a little more likely to be will ing to make similar decisions for loved ones, differs from Steiber's (1987). Steiber reported on a Gallup Poll in which 70% of the 995 re spondents were very willing to have a life support system disconnected from themselves, compared to only 46 % who were willing to make such decisions for relatives. Gender. Although no gender differences were found in responses to the question about the rights of terminally ill people in general, women were significantly more likely to be in favor of some form of control of their own deaths (p = < .05), and for their loved ones to have some personal control (p = < .02). Education. Although eight different educational levels were captured in the interviews, there was a distinction among responses from those who had only high school educations (or less), or some vocational train ing beyond high school (but no college); and those who had attended college. Results of a Chi-Square analysis indicated that respondents with at least some college education (or degrees) were significantly more likely
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Huber, Cox, and &Jelen Table 2 Percent of "Yes" or "Probably Yes" Responses to "Rights" Questions by Age Groups, and Overall Percentages < 40
40-59
60-79
80-93
Overall If People (A)
95%
95%
92%
86%
93%
If You (B)
95%
95%
87%
86%
92%
If Loved One (C)
96%
98%
91%
91%
95%
rl
Do you think that peoole who are terminally ill should have any right to decide the circumstances of their deaths?
B
If you were terminally ill, would you want some say about your own death?
C
If your loved one was terminally ill, would you think that he (or she) should have any say about how their own death was to come about? to favor some kind of personal control over death circumstances for themselves if they were terminally ill (p = < .05), but not for the public generally nor for loved ones. Income. Consistent with the finding that more highly educated people were more likely to favor some form of personal control, respondents with higher incomes were significantly more likely to favor control in all three circumstances; p = < .02 on the first question pertaining to people in general; p = < .02 on the second question concerning the individual being interviewed; and p = < .01 on the third question pertaining to the rights of terminally ill loved ones. Responses from Subjects in Health Related Professions. Interesting to note are the responses from those in health-related professions (physi-
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cians, nurses, and social workers in health care settings) to the rights questions: 100% responded Yes or Probably Yes to all three questions. These respondents (n = 21) comprised 10% of the sample (N = 200).
Responses to the Legalh.ation Questions Following the three "rights" questions, we asked the legalization question containing the semantic independent variable ("euthanasia," ''mercy killing,'' ''physician assisted suicide,'' or ''some form of person al control over your own death"). If adequate safeguards could be developed, would you like to see (one of the four phrases) legalized? Overall, 64% responded "Probably Yes" or "Yes." However, respon dents in the "physician assisted suicide" group answered significantly more negatively, "No" or "Probably Not," than those in the other three groups (p = < .0001; Figure 3). "Miat Might those Adequate Safeguards Be?" We asked a difficult follow-up question of those who had favored any type of legalization with adequate safeguards: What might those safeguards include? Forty-six percent did not know. The next two most freq uent responses were that people should have executed a legal document such as a living will (18%), and that a terminal or hopeless condition should exist (13%). Age and Gender. Similar to responses to the "rights" questions, age was a significant predictor of negative responses to the legalization question (p = < .01; Figure 4). No gender differences were found when respon dents were asked whether one of the four phrases should be legalized. Education and Income. Consistent with their responses to the "rights" questions, subjects with college educations and higher incomes were again more likely to favor legalization of (one of the four phrases); col lege p = < .001; income p = < .001. Responses from Subjects in Health Related Professions. Overall, 71% of subjects who were health professionals responded with "Yes" or "Probably Yes" to the legalization questions, compared with 64% of the entire sample of 200. Figure 5 compares their responses, by specific terms, to the rest of the sample. These findings are curious. Notice that all of the health professionals to whom the term "euthanasia" was used in the legalization question responded "Yes" or "Probably Yes." In response to the legalization question when presented with the phrase ''physician assisted suicide,'' nearly twice the percentage of health pro-
100%
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Huber, Cox, and Edelen
1 I I
80%
1 I
60% l 40%
l __,
20% 0%
Euthanasia
Mercy Killing
- No/Probably Not
MD Assisted Suicide
Some Form Control
R Yes/Probably
Yes
Figure 3. Responses to legalization question by semantic group (N=200; p =
