Journal of medical ethics 1994; 20: 41-46

J Med Ethics: first published as 10.1136/jme.20.1.41 on 1 March 1994. Downloaded from http://jme.bmj.com/ on November 20, 2022 at Pakistan:BMJ-PG
Management of death, dying and euthanasia:
attitudes and practices of medical
practitioners in South Australia
Christine A Stevens and Riaz Hassan Flinders University of South Australia

Authors' abstract medical standards, and there is wide divergence of

This article presents the first results of a study of the opinion as to when intervention or no treatment
decisions made by health professionals in South should occur (1), and no unanimity on the moral and
Australia concerning the management of death, dying ethical status of decisions to forego treatment and
and euthanasia, andfocuses on thefindings concerning actions taken to withdraw or terminate treatment
the attitudes and practices of medical practitioners. (2). Neither is there consensus on the question of
Mail-back, self-administered questionnaires were posted whether the deliberate termination of life should

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in August 1991 to a ten per cent sample of 494 medical continue to be illegal in all situations (3, 4). Given
practitioners in South Australia randomly selected from medical ability to influence the manner and timing of
the list published by the Medical Board of South death, there is growing public desire for increased
Australia. A total response rate of 68 per cent was participation in medical decision-making, and a
obtained, 60 per cent of which (298) were usable recognition that it is no longer appropriate for the
returns. locus of authority in this area to be the sole
It was found that forty-seven per cent had received prerogative of medical practitioners (5).
requests from patients to hasten their deaths. Nineteen These issues were addressed by examining the
per cent had taken active steps which had brought about attitudes and practices of health professionals in
the death of a patient. Sixty-eight per cent thought that South Australia towards the management of death,
guidelines for withholding and withdrawal of treatment dying and euthanasia. The research aimed, firstly, to
should be established. Forty-five per cent were in favour examine whether medical practitioners and nurses
of legalisation of active euthanasia under certain were ever asked to hasten the death of patients, and
circumstances. the ways such requests were handled; and secondly,
to investigate how medical practitioners and nurses
consider such requests could be handled, and
Introduction whether guidelines should be established to clarify
Advances in medical knowledge and technology in the current legal position. This article focuses on the
western countries enable the medical profession to findings concerning the attitudes and practices of
exercise greater control over life and death processes, medical practitioners (6).
and this capacity creates a number of moral and
ethical dilemmas. People may live long periods with
chronic, painful, debilitating conditions which are Methods
not terminal, or not immediately fatal; while many The list of medical practitioners registered to
treatments, especially those of an invasive nature, or practise in South Australia, published by the
those used to treat the severely or chronically ill, also Medical Board of South Australia, was used to
involve some element of risk, pain, and the obtain a ten per cent sample of 494 medical
possibility of greater or lesser permanent damage or practitioners resident in South Australia. Mail-back,
temporary side-effects. There is increasing tension self-administered questionnaires were posted in
between the aim and the ability of medicine to August 1991. Twenty-five questions were included
sustain life and the requirement to relieve suffering, in the questionnaire, most of which could be
and in many situations the two objectives have answered with a tick, although five invited written
become incompatible. There is now considerable responses. To maintain confidentiality the question-
uncertainty about what constitute reasonable naires were not marked numerically, nor were
respondents required or asked to reveal their names
or addresses. Two reminder/thank you letters were
Key words sent to all participants. A total response rate of 68
per cent was obtained, 60 per cent of which (298)
Ethical decision-making; death and dying; euthanasia. were usable returns.
42 Management of death, dying and euthanasia: attitudes and practices of medical practitioners in South Australia

J Med Ethics: first published as 10.1136/jme.20.1.41 on 1 March 1994. Downloaded from http://jme.bmj.com/ on November 20, 2022 at Pakistan:BMJ-PG
Table 1
Have medical practitioners ever suggested withholding or withdrawing
treatment when discussing the options of medical treatment available to
patients
Withholding - Yes Withdrawing - Yes
Number Number
Age
20-29 years 15 83-3 12 63-2
30-39 years 87 92-6 77 81-1
40-49 years 68 81-9 59 72-8
50-59 years 32 82-1 24 66-7
60+ years 27 57-4 27 57.4
Sex
Male 170 80-6 150 71-4
Female 58 84-1 49 73-1
Religion
C of E 65 82-3 61 76-3
Other Prot 37 68-5 33 6141
Catholic 41 83-7 33 66-0

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Other 20 83-3 16 64-0
None 67 89-3 57 82-6
Years medical practice
<5 years 19 82-6 13 56-5
6-10 years 44 93-6 39 81-3
11- 15 years 48 92-3 43 82-7
16-20 years 38 80-9 33 70-2
21-30 years 52 81-3 44 74-6
>30 years 29 59-2 27 55-1
Total 231 81-6 201 71-8
(There are a few cases missing in each category where the age, sex, religion or number of years of
medical practice were not shown.)

Results pain', 'terminal illness' and 'incurable condition',

All respondents were asked if they ever received were the most frequently cited reasons for such
requests to hasten the death of a patient either by requests.
withdrawing treatment or by taking active steps, and The majority would or did discuss requests with
whether these requests came from the patient or the another medical practitioner (71 per cent), nursing
patient's family. No definition of the term 'active staff (63 per cent), or relatives of the patient (79 per
steps' was given in the questionnaire as it was cent), while lesser proportions were prepared to or
considered the meaning was implicit in the consulted with a religious adviser (27 per cent), a
juxtaposition of the term with the phrase 'withdrawal bioethics adviser (23 per cent) or someone else (18
of treatment', and that no confusion should per cent).
therefore exist between passive and active euthanasia Eighty-nine per cent of respondents believed that
in this context. a request to hasten death could be considered
Forty-seven per cent of medical practitioners had rational. Only ten per cent considered it was not,
received a request from a patient to hasten death by while one per cent felt it could be considered rational
withdrawing treatment, and the same proportion under some circumstances. An open-ended question
had received a request from a patient's family. invited further explanation, and the four main
Thirty-three per cent had received a request from a reasons were given for affirmative responses where:
-

patient to hasten death by taking active steps and 22 (a) the patient suffered intractable pain and
per cent had received a request from a patient's suffering, (40 per cent of respondents); (b) the
family. Age and gender were associated with patient was near death or death was inevitable, (35
differences in request rates, with males and persons per cent of respondents); (c) the patient experienced
aged 29 years and under, more likely than others to a quality of life which was extremely poor (30 per
have received requests. 'Persistent and irrelievable cent of respondents), and (d) this was a matter of
 Christine A Stevens, Riaz Hassan 43

J Med Ethics: first published as 10.1136/jme.20.1.41 on 1 March 1994. Downloaded from http://jme.bmj.com/ on November 20, 2022 at Pakistan:BMJ-PG
Table 2
Ever taken active steps which have brought about the death of a patient by age,
sex and religion
Active steps ever taken
Yes No Not known
A Age
20-29 years 15-8 73.7 10-5
30-39 years 13.7 77.9 8-5
40-49 years 18-8 70-6 10-6
50-59 years 30-8 59-0 10-6
60+ years 17-5 77-2 5.3
B Sex
Male 22-5 68-9 8-6
Female 5-6 84-7 9-7
C Religion
C of E 20-9 65-1 14-0
Other Prot 20-7 74-1 5-1

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Catholic 4-0 88-0 8-0
Other 16-0 84-0
None 23.7 68-4 7.9
Total 18.8 72-5 8-7
Total A= 295
B= 294
C= 295
(Data shown in percentages)

individual freedom of choice (17 per cent of response rates according to age, sex or religious
respondents). affiliation (see Table 2).
To ascertain attitudes towards passive and active While there was a strong association between
euthanasia, respondents were asked if it was ever taking active steps which had brought about a
right to bring about the death of a patient by patient's death and the receipt of a request, 49 per
withdrawing treatment, or by taking active steps. cent of those who had done so, had never received a
These questions did not define 'right' and respon- request from a patient, and 54 per cent had never
dents were free to interpret the meaning in a legal, received a request from the family of a patient.
moral or ethical sense. For withdrawal of treatment, Not surprisingly, there was a strong association
65 per cent said yes, 27 per cent said 'yes, but only if between taking active steps, and belief that such
requested by the patient', while 8 per cent said it was action was 'right'. Of all medical practitioners who
not. For active euthanasia, 18 per cent answered yes, had done so 50 per cent considered active steps to be
26 per cent said it was 'right', but only if requested 'right', and 32 per cent felt it was 'right' when
by the patient, and 55 per cent said it was not. requested by the patient. However, 18 per cent who
All respondents were asked whether, in discussing had undertaken active euthanasia did not think such
the options of medical treatment available to a patient, action was ever 'right', while ten per cent who had
they had ever suggested withholding or withdrawal of not, said active euthanasia was 'right', and a further
treatment as possible choices (see Table 1). There 21 per cent of this group said active euthanasia was
were statistically significant differences in response 'right' if requested by the patient.
rates for withholding treatment according to age (7) Persons who had practised active euthanasia (56
and number of years of medical practice (8). respondents) were asked if they felt they had done
In response to the question: 'Have you ever taken the 'right' thing. Eighty-five per cent said yes, 13 per
active steps which have brought about the death of a cent considered they had not, while one per cent
patient' which was asked of all respondents, 19 per were unsure. An open-ended question requested an
cent said yes (56 individuals), 73 per cent said no, 6 explanation, and the reasons given most frequently
per cent did not wish to answer, and 2 per cent were were: (i) this action had relieved pain, suffering and
unsure. There were no significant differences in distress experienced by the patient (42 per cent of
44 Management of death, dying and euthanasia: attitudes and practices of medical practitioners in South Australia

J Med Ethics: first published as 10.1136/jme.20.1.41 on 1 March 1994. Downloaded from http://jme.bmj.com/ on November 20, 2022 at Pakistan:BMJ-PG
Table 3
Suggested guidelines for withdrawal/withholding of treatment
Medical Practitioners
Number % Resp % Cases
Guidelines
Only on patient request 25 6-5 15-2
On patient and/or family request 19 4-9 11 6
Decision to be made by two or more doctors 28 7-2 17 1
Decision to be made by doctor, patient and family 12 3 1 7-3
Decision to be made by medical panel 9 253 5-5
Decision to be made by multi-disciplinary panel 10 2-6 6- 1
Document all decisions 14 3-6 8-5
Ensure there is legal indemnity for doctor 14 3-6 8-5
Psychiatric assessment of patient 11 2-8 6-7
Patient and family to be fully informed 19 49 11 6
When patient is terminally ill 36 93 22-0
When patient has incurable disease 14 3-6 8-5
When patient has intractable pain and suffering 23 5-9 14-0

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When patient is brain dead 6 1 6 3-7
Consider quality of life of patient 14 3-6 8-5
Exceptional cases to be defined 9 253 5-5
In situations where medical treatment is valueless 14 3-6 8-5
State the treatment to be withheld 7 1-8 4-3
Withdraw active treatment only 3 0-8 1-8
N=387 N= 164
(Table includes main guidelines only) (Resp Responses; Cases = Respondents)

respondents); (ii) the patient was near death (31 per practitioners regarding withholding and withdrawal
cent of respondents); (iii) the situation was hopeless of treatment could be clarified'. Sixty-eight per cent
(31 per cent of respondents); (iv) the patient had no said yes, 18 per cent said no, and 13 per cent were
prospect of a meaningful or independent existence unsure. The only significant differences on this issue
(15 per cent of respondents), and (v) acted on orders were between males and females, 21 per cent of the
(3 per cent of respondents). former of whom were opposed to the idea of
People who had not practised active euthanasia guidelines compared with only 8 per cent of females,
were asked if they had rejected a request because it while 23 per cent of females were undecided
would have been illegal. Only 16 per cent (40 compared with ten per cent of males. An open-
persons) responded in the affirmative, while 38 per ended question requested suggestions on what these
cent (91 individuals) said the question of legality was guidelines could be, and Table 3 lists those which
not a factor in their decision-making. Forty-five per were raised most frequently.
cent of respondents had received no request. Attitudes towards legalisation of active euthanasia
To ascertain the level of awareness of current were canvassed in the question: 'Do you think it
legislation in South Australia pertinent to the man- should be legally permissible for medical prac-
agement of death and dying, all respondents were titioners to take active steps to bring about a
asked firstly, whether they were aware of The Natural patient's death under some circumstances?'. Only 45
Death Act, 1983 (9), and secondly, how many times per cent of medical practitioners were in favour of
in the last five years they had been presented with legalisation of active euthanasia, while 39 per cent
declarations made under this act. Seventy-two per were opposed. An open-ended question asked those
cent were aware of the legislation, but only 24 per who answered yes to indicate the circumstances,
cent had been presented with declarations. which are listed in Table 4.
As the current legal position of medical
practitioners who withdraw or withhold medical
treatment is not clear (10), all respondents were Conclusion
asked if they thought 'guidelines should be The growing tension between the dual roles of
established so that the legal position of medical sustaining life and relieving suffering has resulted in
 Christine A Stevens, Riaz Hassan 45

J Med Ethics: first published as 10.1136/jme.20.1.41 on 1 March 1994. Downloaded from http://jme.bmj.com/ on November 20, 2022 at Pakistan:BMJ-PG
Table 4
Suggested circumstances under which it should be legally possible for medical
practitioners to take active steps to bring about a patient's death
Medical Practitioners
Number % Resp % Cases
Circumstances
Terminal illness 61 21-5 51-3
Incurable illness 38 13.4 31-9
Intractable pain and suffering 57 20-1 47.9
Physical handicap 10 3-5 8-4
Mental disability 19 6-7 16-0
Poor quality of life 24 8-5 20-2
Patient request 34 12-0 28-6
Patient and family request 21 7-4 17-6
Decision of one doctor 2 0-7 1-7
Decision of two or more doctors 10 3-5 8-4
Committee decision 5 1 8 4-2
Decision of health team 3 1 1 2-5

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N=284 N=119
(Table includes main circumstances only) (Resp=Responses; Cases=Respondents)

an expanding debate on what constitutes right, practitioners, and secondly, that questions of legality
correct or proper medical care, especially for the are currently not the principal considerations used
terminally or severely ill. The study confirmed a lack when making decisions to withhold or withdraw
of unanimity of opinion among medical practitioners treatment or to terminate the lives of patients.
concerning the moral, ethical and legal status of The research found that there was some
decisions to withhold or withdraw medical preparedness by medical practitioners to overlook
treatment, where the effect of these actions would be the law and take active steps to hasten the death of
to hasten the death of a patient. their patients, and that the majority of those who had
The legal ambiguity of the current situation were confident they had done the right thing in the
means that patients are often subject to the ethical circumstances. This suggests that a minority within
and moral codes of individual doctors when the medical profession perceive the law as too rigid
decisions are made, and variations are demon- to allow for the problems posed by individual
strated, not only in attitudes, but in practice between situations, and that legality, morality and ethical
individual medical practitioners in this sample. The behaviour are not necessarily regarded as
survey revealed majority support in this sample for synonymous. However, the disjunction between
guidelines to be established to clarify the legal medical practice and the law, and individual
position of medical practitioners regarding with- justifications for it given by those involved, do not by
holding and withdrawal of medical treatment. themselves constitute sufficient reasons for making
Increasingly, questions have been raised official changes to current codes of practice relating
concerning the question if, and/or when it is proper to active euthanasia.
in a medical, ethical or moral sense actively to Medical practitioners were divided on the
terminate the lives of patients. Not surprisingly, the question of the legalisation of active euthanasia, with
survey revealed considerable differences of opinion considerable and almost equal minorities opposed
on this issue, but the evidence indicates that what to, or in favour of changes in the law. Among those
many regard as reasonable or proper medical who favoured the legalisation of active euthanasia
practice is in conflict with the law. there was some agreement that terminal illness
The findings also indicate that higher proportions and intractable pain and suffering constituted
of respondents used internalised ethical and moral circumstances in which active euthanasia could or
values to guide their decision-making than the should be legal. However, there were minority
proportion who depended on externally imposed opinions that poor quality of life, mental disability
legal sanctions to circumscribe their actions. These and physical handicap should also be valid
and previous findings suggest, firstly, that altera- circumstances for active euthanasia. The diversity of
tion or clarification of the law would not neces- opinion on these issues invites caution to ensure that
sarily change the practices of individual medical in framing guidelines or legislation, current abuses
46 Management of death, dying and euthanasia: attitudes and practices of medical practitioners in South Australia

J Med Ethics: first published as 10.1136/jme.20.1.41 on 1 March 1994. Downloaded from http://jme.bmj.com/ on November 20, 2022 at Pakistan:BMJ-PG
which result from the enthusiastic and aggressive letting die. Journal of medical ethics 1988; 14:
pursuit of the aim of preserving life do not become 115-117.
transmuted into abuses due to lack of adequate (3) Parker M. Moral intuition, good deaths and ordinary
protection of life. medical practitioners. J7ournal of medical ethics 1990;
16: 28-34.
(4) Davies J. Raping and making love are different
Acknowledgement concepts: so are killing and voluntary euthanasia.
Jrournal of medical ethics 1988; 14: 148-149.
This research was funded by the Criminology (5) Loewy E H. Involving patients in Do Not Resuscitate
Research Council. (DNR) decisions: an old issue raising its ugly head.
Journal of medical ethics 1991; 17: 156-160.
Christine A Stevens, Dip Soc Stud, BA (Hons), PhD, is (6) Complete findings of the research are reported in
at present a Consultant in Social Issues Research. At the Stevens C A, Hassan R. Management of death, dying
time of this research she was a Research Fellow in and euthanasia: attitudes and practices of medical
practitioners and nurses in South Australia. Report
Sociology at the Flinders University of South Australia. prepared for the Criminology Research Council, 1992.
Riaz Hassan, BA, MA, PhD is Professor ofSociology at (7) Age, X2=25 7, DF=4, P=< 05
the Flinders University of South Australia. (8) Number of years of medical practice, X2 =24-8,
DF=5, P=< 05
(9) Patients over the age of 18 years may make an
References advance declaration (commonly referred to as a living
(1) Wanzer S H et al. The physician's responsibility will) that extraordinary means need not be taken if
towards hopelessly ill patients: a second look. New they are terminally ill and death is imminent.
(10) Pollard B J. Withdrawing life-sustaining treatment

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England journal of medicine 1989; 320, 1: 844-849.
(2) Gillon R. Euthanasia, withholding life-prolonging from severely brain-damaged persons. The medical
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News and notes

2nd World Congress of Bioethics
The International Association of Bioethics's Second Fundacion Dr Jose Mainetti, Calle 508e/1 6y1 7 (1897)
World Congress of Bioethics will be held in Buenos MB Gonnet, Buenos Aires, Argentina.
Aires, Argentina on October 24-26 1994. Telephone: (021) 71 1160 or 64 71 2616/3119; fax:
For further information contact: Silvina Mathen, 54/21/71 2222; Email: Postmast @funmai.org.ar.
Secretaria, Escuela Latinoamerican de Bioetica,

News and notes

Scientific (Mis)Conduct and Social (Ir)Responsibility
The Poynter Center for the Study of Ethics and required by April 15, 1994.
American Institutions at Indiana University will hold a More information on the conference may be
one-day conference on the relationship between obtained by contacting Dr Kenneth D Pimple at the
scientific misconduct and broader issues of social Poynter Centre, 410 North Park Avenue, Bloomington,
responsibility on May 27, 1994. Indiana 47405, phone 812-855-0261, e-mail
There is no conference fee, but pre-registration is [email protected].