Attitudes toward palliative care, conceptions of euthanasia and opinions about its legalization among French physicians

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Social Science & Medicine 60 (2005) 1781–1793 www.elsevier.com/locate/socscimed

Attitudes toward palliative care, conceptions of euthanasia and opinions about its legalization among French physicians P. Peretti-Watela,b,, M.K. Bendianea,b, J.P. Moattib,c a Regional Center for Disease Control of South-Eastern France, Marseille, France Research Unit 379, Health and Medical Research National Institute, Social Sciences Applied to Medical Innovation, Institut Paoli Calmettes, Marseille, France c Department of Economics, University of Aix-Marseille II, France

b

Available online 5 November 2004

Abstract We assume that actors of the professionalization process of palliative care make a special effort to demarcate it from euthanasia, and that such an effort has a significant impact on beliefs and attitudes toward euthanasia among the whole medical profession. We investigated concurrently attitudes toward palliative care, conceptions of euthanasia and opinion toward its legalization among a sample of 883 French general practitioners, oncologists and neurologists. We found four contrasted profiles of attitudes toward palliative care, which were closely correlated with being in touch with palliative care providers. Attitudes toward palliative care were closely correlated with beliefs about which medical practices should be labelled euthanasia, and these beliefs were in turn strongly associated with opinions toward euthanasia legalization. Our results suggest that the relationship between palliative care and euthanasia mixes semantic and strategic aspects, beyond cognitive and conative ones. r 2004 Elsevier Ltd. All rights reserved. Keywords: Physicians; Palliative care; Euthanasia; Professionalization; France

Introduction The doctor–patient relationship in developed countries has been marked in recent decades by a shift in physicians’ attitudes and practices toward promoting patients’ greater autonomy, control and participation in the medical decision-making process (Ong, de Haes, Hoos, & Lammes, 1995). Seale (2000) has argued that this shift is closely connected with a broader tendency of late modern societies labelled by Giddens (1991) as the Corresponding author. ORS-PACA—Inserm U379, 23, rue Stanislas Torrents, Marseille 13006, France. Tel.: +33 04 96 10 28 61; fax: +33 04 96 10 28 99. E-mail address: [email protected] (P. Peretti-Watel).

‘risk culture’. In such societies, traditional notions of fate fade away, individuals are exhorted to manage their own ‘reflexive project’ by developing a calculative attitude to the open possibilities of action, thanks to expert systems that supply them with standardized knowledge and means. According to Seale, the will to control one’s life has extended to dying, especially in developed Anglophone countries. In these countries, people seem more prone to express a preference for open awareness of dying to the extent that they want to control the time and manner of their death (Seale, AddingtonHall, & McCarthy, 1997), and palliative care practitioners provide a relevant expertise to assist this will. Palliative care has its origin in the modern hospice movement, initiated 30 years ago in the UK to promote a new approach to the care of people dying from cancer.

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This movement was fuelled by widespread concerns about patients’ rights in the face of medical power and dissatisfaction toward ‘overmedicalization’ and excessive emphasis on curative efforts in care for the dying (Seale, 2000). Palliative care is dedicated to relieve symptoms of terminal illnesses but also to promote a ‘holistic’ model of care, focusing on the quality of life and integrating the physical, psychological, spiritual and social aspects of care of patients with life-threatening diseases (Saunders, 1996; Seale, 1998). Since the 1980s, this model has spread across western countries, and palliative care has been more and more integrated into the health care system, in a process of professionalization and specialization. Moreover, the desire to manage one’s life and death may imply preferring death to dependency, thus within ‘risk societies’ the wish for euthanasia may not be considered as an act of surrender due to unbearable suffering, but rather as a key indicator of the preference for autonomy and control (Seale & Addington-Hall, 1994, 1995). So according to some authors the contemporaneous development of palliative care and support for euthanasia may both reflect the same cultural forces that tend to offer opportunities for the patient’s autonomy near death (Seale et al., 1997).

boundaries of the relatively new discipline of palliative care. In general, such a demarcation is a crucial element in a strategy of ‘professionalization’, which is the key-word in occupational sociology to designate both the efforts made to improve an occupation’s status and their results.1 More specifically, the semantic battle around the demarcation from euthanasia may be a strategic issue for the professionalization of palliative care, especially since this process encounters fierce resistance from other medical specialities. Indeed, in the English context, previous studies have emphasized such resistance and the necessity for palliative care to negotiate the boundary between its own field of expertise and other specialities’ (Field & Addington-Hall, 1999; Hibbert et al., 2003). Such resistance is a good illustration of the relevance of classic works in occupational sociology and sociology of medicine: professions are made up of segments continuously competing for legitimacy, status and resources (Bucher & Strauss, 1961), and within the medical world there is a prestige hierarchy among specialities, which have distinct vested interests, goals and even conceptions of medical practice (Strong, 1979). Palliative care and euthanasia in France

Euthanasia and the building of a new medical speciality Such cultural similarity, contrasts with the results of several empirical studies carried out in developed countries that have emphasized the opposition introduced by the majority of health professionals between palliative care and euthanasia; improvements in palliative care is supposed to prevent patients from requesting euthanasia (Meier, Morrison, & Cassel, 1997; Emanuel & Emanuel, 1998) but also to reduce physicians’ support for it (Grassi, Magnani, & Ercolani, 1999; Bonn, 2000). Moreover, in some countries as the Netherlands, developing palliative care facilities is explicitly considered as a way to prevent euthanasia (Gordijn & Janssens, 2000). Through an analysis of euthanasia, as it is discussed in the professional journals of palliative care, Hermsen and ten Have (2002) show that this issue has been quite controversial within the palliative care community, with a semantic battle with regard to which practices should (or should not) be labelled as euthanasia. Nevertheless, the majority of the examined articles claim that there is no place for euthanasia in palliative care, and the authors argue that the dominant discourse, at least in the medical literature, has been an attempt to articulate palliative care as an alternative to euthanasia. Hermsen and ten Have conclude that further analysis is necessary to clarify the status of euthanasia in the evolution of palliative care, and they make the assumption that discussions about euthanasia may help demarcate the

The present article aims to translate and test Hermsen and ten Have’s assumption in the French context. Indeed, in this country, the euthanasia debate has started later than in Anglophone countries and has overlapped with concerns about the insufficient development of palliative care at the end of 1990s. Therefore, the French context provides a good opportunity to study jointly health care professionals’ attitudes toward both issues, and more precisely, to consider euthanasia as a semantic and strategic issue for the professionalization of palliative care. Moreover, considering the medical world as a juxtaposition of competing segments may prove especially relevant for the study of the French medical profession in which the proportion of medical specialists (circa 50%) compared to general practitioners is quite high in comparison to other European countries (Herzlich, Bungener, Paicheler, & Zuber, 1993). In France, palliative care has developed quite slowly.2 As in the United Kingdom, it has encountered resistance 1 Among other characteristics, an occupation becomes a profession if its members get legal monopoly over an area of expertise and activity, if they control the organisation and content of training for future members, and if they obtain the exclusive right to evaluate the way their tasks are performed (Freidson, 1986, 1988; Abbot, 1988). 2 In France, the first specialized unit for palliative care opened in 1987, and 10 years later only 50 out of 3500 hospitals had such a unit.

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from existing medical services and specialities, and its institutional integration within hospitals remains difficult since it is still reliant on the other medical departments’ ability and willingness to categorize patients as being ‘‘beyond’’ help (Lebeer, 2003). Moreover, the professionalization of palliative care is far less advanced in this country. In the United Kingdom, palliative medicine was recognized as a medical speciality as soon as 1987, but it is still not the case in France, where its spread is now mainly supported by Home Palliative Care Support Teams (HPCSTs) who provide counselling, training and support to health care workers and lay carers.3 However, other health professionals sometimes consider that HPCSTs’ activity is not ‘real care’ (Mino & Lert, 2003). Concurrently, the French Code of Medical Ethics clearly states that a physician has no right to intentionally induce a patient’s death, and euthanasia, defined as a medical act that deliberately causes death in order to end a situation considered unacceptable, is strictly forbidden by law. As such, the definition of euthanasia does not specify the corresponding medical practices, so French physicians may have difficulties to establish clear boundaries between euthanasia and several medical practices that are quite common in end-of-life care, such as high-doses morphine prescription, palliative sedation, and withdrawing life-sustaining treatments (WLST). For example, palliative sedation has been clearly defined only recently by the French medical society of specialists in palliative care (SFAP, 2002), and the confusion between such practice and euthanasia is probably made worst by the long-established use of ‘lytic cocktails’ in France.4 Euthanasia as a semantic and strategic issue for palliative care The propensity, especially among health professionals, to label as euthanasia some medical practices common in end-of-life and palliative care is very threatening for the professionalization of palliative care. The case of palliative sedation illustrates the efforts of the French medical society of specialists in palliative care devoted to challenge such labelling and to establish the legitimacy of its area of expertize through publishing guidelines that rigorously distinguish practices related to withholding or withdrawing life-sustaining treatments as well as pain and symptom treatment from euthanasia. Beyond the minority of those who are directly involved 3 HPCSTs typically gather physicians, nurses, psychologists, and social workers. 4 Such ‘cocktail’ combines a neuroleptic, an opioid and an antihistamine. It is used in end-of-life care with an ambiguous purpose that included pain relief but also sedation and sometimes hastening death.

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in the process of professionalization (i.e. physicians working in a palliative care unit or in a HPCST), we assume that such efforts may have a significant impact on beliefs and attitudes towards euthanasia among the whole medical profession, and especially among physicians who are in touch with this minority, and/or those who support the professionalization of palliative care. Thus to test this assumption, in the present study, we first characterize attitudes toward palliative care among a sample of French GPs and specialists who are more likely to be in touch with palliative care providers, and then we investigate the relationship between such attitudes and conceptions of euthanasia as well as opinions toward its legalization. As both opponents and supporters of the legalization of euthanasia claim that knowledge and experience in end-of-life care influence attitudes about euthanasia, in our analysis we have to control for the effects of such knowledge and experience. More precisely, once controlled for wellknow determinants of attitudes toward euthanasia, including experience and training in end-of-life care, medical speciality and religiosity, do attitudes toward the professionalization of palliative care and proximity with its providers influence beliefs about which medical practices should be labelled as euthanasia? And do they influence opinions toward the legalization issue? To investigate these issues, we use data from the first French national survey on physicians’ knowledge, attitudes, beliefs and practices towards palliative care and euthanasia, carried out in 2002 by the Regional Centre for Disease Control of South-Eastern France and the Health and Medical Research National Institute.

Methods Sampling The survey was conducted among a sample of French GPs, oncologists, and neurologists. The two latter groups were included in the survey because they are more likely to be involved in palliative care. Since these three groups of professionals greatly differ in size we built a stratified sample to include a sufficient number of specialists in the sample. Eligible respondents were randomly selected from the exhaustive file of practising French physicians kept by the private society CEGEDIMs, at the following sampling rates: three of every 200 GPs, one of every six neurologists and two of every five oncologists. Questionnaire The questionnaire included 202 closed-ended questions and was designed to be completed in 20 min. In addition to background variables (gender, age, medical

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speciality, usual number of medical consultations performed per day, attendance to religious services5), five questions specifically assessed respondents’ involvement in end-of-life care: specialized training in palliative care or pain management, participation in a specialized network associating hospital and ambulatory physicians to deliver palliative care (which is an indicator of proximity with palliative care providers), number of terminally ill patients followed up until death during the prior 12 months, whether the last terminally ill patient they had followed up until death received palliative care, and whether they feel uncomfortable with terminally ill patients (with a five-point Likert scale, from ‘‘very uncomfortable’’ to ‘‘very comfortable’’). In order to exclude from the sample physicians who were directly involved in the professionalization of palliative care, respondents were also asked whether they practised in a palliative care unit or a HPCST. With regard to attitudes toward palliative care, the questionnaire investigated respondents’ level of agreement with seven statements relating to the professionalization, the extension and the diffusion of palliative care (with a five-point Likert scale, from ‘‘strongly agree’’ to ‘‘strongly disagree’’). Concerning the euthanasia issue, three questions used the same scale to assess physicians’ opinions about whether or not three practices in end-of-life care should be considered ‘euthanasia’: prescribing high-dose morphine, prescribing palliative sedation and withdrawing life-sustaining treatments (WLST). Another question, also using this scale, investigated respondents’ attitude toward the statement that ‘‘euthanasia should be legalized as it is in the Netherlands’’ (where a 2001 law allows doctors to terminate the life of patients at their request ‘‘if they are suffering unbearably and hopelessly’’). Data collection As described above, we drew a random sample of addresses from the CEGEDIM physician file: 1018 GPs, 293 neurologists, and 266 oncologists. These physicians received a letter through the mail that introduced the survey and promised anonymity. The telephone survey began 3 weeks later and lasted from 12 February to 13 March 2002. Physicians were initially contacted from Monday to Friday between 8 a.m. and 8 p.m. Investigators proposed a later appointment if physicians were not free to respond at once. Statistical analysis First, we used Pearson’s w2 to compare the characteristics of respondents and non-respondents as well as 5 We did not ask for respondents’ religious affiliation, because in France surveys are seldom allowed to ask such questions, but Catholicism is the prevailing religion there.

characteristics and involvement in end-of-life care of the three groups of respondents according to their medical speciality. Secondly, we performed a cluster analysis on the seven questions related to statements dealing with palliative care. This statistical tool was useful to summarize the variety of respondents’ answers in a limited set of contrasted profiles, and then to detect meaningful patterns of attitudes expressed toward palliative care. Items measuring agreement were encoded from 1 (‘‘strongly disagree’’) to 5 (‘‘strongly agree’’). These scores were transformed to Z-score form prior to clustering with the usual agglomerative hierarchical procedure (Anderberg, 1973). We compared partitions with three, four or five clusters, and we opted for the four-cluster solution. We used F-ratio to compare means of each attitudinal score across clusters, and w2 to compare clusters according to respondents’ involvement in end-of-life care. Thirdly, we added these clusters to the set of explanatory variables designed to model the propensity to label prescribing high-dose morphine, prescribing palliative sedation and WLST as euthanasia (one logistic model for each belief, stepwise selection method with entry threshold=0.05%). Fourthly, we summed the three binary outcomes corresponding to these beliefs to obtain a score ranging from 0 to 3. This score was interpreted as a propensity to label end-of-life practices as euthanasia, and together with previous explanatory variables, it was introduced in another logistic modelling with the opinion about the legalization of euthanasia as the dependent variable. Finally, in order to grasp the global scheme of relationships between medical as well as non-medical characteristics, attitudes toward palliative care, beliefs about euthanasia and opinions about its legalization, we computed a hierarchical loglinear model using backward elimination and starting from a model including all interactions of first order.

Results Data collected Twenty-five physicians were not eligible because they were retired or relocated at a new address. Among the remaining 1552 physicians, 917 accepted to participate. The response rate was lower for GPs (50%) than for oncologists (83%) and neurologists (69%). Non-respondents were not significantly different from respondents concerning gender, age and size of town (characteristics available in the initial file). Thirty-four respondents were excluded from the sample because they worked either in a palliative care unit or in a HPCST.

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more terminally ill patients during the prior 12 months, they were more frequently trained in palliative care or pain management, and more prone to participate in a

Among remaining respondents, oncologists were more frequently women, and GPs were older than specialists (Table 1). Oncologists logically cared for

Table 1 Personal and medical background, involvement in end-of-life care and opinions toward euthanasia among GPs, oncologists and neurologists Column % GPs (n ¼ 488) Gender Female (n ¼ 300) Male (n ¼ 583)

Oncologists (n ¼ 202)

Neurologists (n ¼ 193)

pa

po0.01

30 70

43 57

35 65

25 42 33 (45)

48 29 23 (42)

39 37 24 (43)

po0.001

Attending religious services at least once per month No (754) Yes (129)

86 14

84 16

84 16

p=0.597

Specialised training in palliative care or pain management No (n ¼ 795) Yes (n ¼ 88)

92 8

83 17

92 8

po0.001

Participation in a specialised network delivering palliative care No (n ¼ 789) Yes (n ¼ 94)

91 9

83 17

91 9

po0.01

Caring for terminally ill patients during the prior 12 months o24 patients (n ¼ 777) X24 patients (n ¼ 140) (Mean of number of terminally ill patients)

94 6 (7)

62 38 (26)

89 11 (9)

po0.001

The last terminally ill patient followed up until death received palliative care No (n ¼ 711) 86 Yes (n ¼ 172) 14

64 36

84 16

po0.001

Feeling uncomfortable with terminally ill patients No (n ¼ 730) Yes (n ¼ 153)

83 17

92 8

71 29

po0.001

Opinions toward euthanasia ‘‘Should the following medical acts be considered as euthanasia?’’ Prescribing high-dose morphine to a terminally ill patient Do not agree (n ¼ 752) 83 ‘‘Agree’’ or ‘‘strongly agree’’ (n ¼ 131) 17

94 6

83 17

po0.001

Age o40 years (n ¼ 294) 41–49 years (n ¼ 333) X50 years (n ¼ 256) (Mean age in years)

Prescribing palliative sedation to a terminally ill patient Do not agree (n ¼ 649) ‘‘Agree’’ or ‘‘strongly agree’’ (n ¼ 234)

72 28

80 20

70 30

po0.05

Withdrawing life-sustaining treatments Do not agree (n ¼ 580) ‘‘Agree’’ or ‘‘strongly agree’’ (n ¼ 303)

61 39

79 21

64 36

po0.001

‘‘Euthanasia should be legalised as in the Netherlands’’ Do not agree (n ¼ 503) ‘‘Agree’’ or ‘‘strongly agree’’ (n ¼ 380)

55 45

65 35

53 47

po0.05

a

p-Value for the Pearson’s w2 testing independence between each row variable and the medical speciality.

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specialized network delivering palliative care. Oncologists also reported more frequently that the last terminally ill patient they had followed up until death received palliative care, while neurologists were more likely to feel uncomfortable with terminally ill patients. Only a small proportion of French physicians qualified the prescription of high-dose morphine to a terminally ill patient as euthanasia, about a quarter of respondents considered palliative sedation to be euthanasia, and one third so labelled WLST. About one third of oncologists agreed that euthanasia should be legalized, but almost half of other physicians did. Attitudes toward palliative care Table 2 presents results for the whole sample and for the four-cluster partition. Most respondents agreed that non-terminal patients suffering from a chronic illness should have access to palliative care, and that physicians in a HPCST should be allowed to make prescriptions for patients still followed by their own physician. On the contrary, only 7% considered pain as an unavoidable symptom of cancer that cannot be adequately alleviated by opioids. Agreement with other statements was more controversial. Cluster 1 (n ¼ 459) gathered physicians supporting both extension and professionalization of palliative care;

they were more likely to agree that palliative care should be extended to non-terminal patients with a chronic illness, and more prone to disagree that it should be used only after all curative treatments have failed; they were also more likely to agree that palliative care should be considered as a medical speciality, and that physicians in a HPCST should be allowed to make prescriptions. Respondents in Cluster 2 (n ¼ 184) supported extension of palliative care to non-terminal patients suffering from a chronic illness and easier availability of drugs used for palliative sedation, but they were more reluctant toward prescriptions by physicians in a HPCST and palliative care as a medical speciality. Such attitudinal profile may express support to diffusion but not professionalization of palliative care. Respondents in Cluster 3 (n ¼ 105) were more willing to consider palliative care as a last resort after curative treatments failure. They also underlined shortcomings of palliative care and pain management (concerning inadequacy of opioids for pain relief and patients’ reluctance to be directed to a palliative care unit). Nevertheless, they agreed with the enlargement of the prescriptive power of physicians working in a HPCST, and were more prone to consider palliative care as a medical speciality. Thus, they were in favour of both confinement and professionalization of palliative care.

Table 2 Cluster analysis on attitudes toward palliative care among GPs, oncologists and neurologists

Non-terminal patients suffering from a chronic illness should have access to palliative care. Drugs used for palliative sedation (Midazolam) should be more easily available outside hospitals. Palliative care should be used as a last resort after all curative treatments have failed. Patients agree with difficulty to be directed to a palliative care unit. Palliative care should be considered a medical speciality. Physicians in a HPCSTa should be allowed to make prescriptions for patients still followed by their own physician. Pain is an unavoidable symptom of cancer that cannot be adequately alleviated by opioids.

Cluster 1 (n ¼ 459)

Cluster 2 (n ¼ 184)

Cluster 3 (n ¼ 105)

Cluster 4 (n ¼ 135)

Total (means)

Total (%)

4.5***

4.3**

4.2 ns

1.8***

4.0

81

3.3 ns

3.5*

3.3 ns

3.0***

3.3

51

2.5***

2.9 ns

3.6***

3.6***

2.9

43

3.3***

3.4 ns

4.0***

3.5 ns

3.4

62

3.5***

2.6***

3.9***

3.4 ns

3.4

56

4.4***

1.8***

4.2***

3.9 ns

3.8

74

1.4***

1.5**

3.7***

1.6 ns

1.7

7

Columns give means for row variables (encoded from 1=strongly disagree to 5=strongly agree), except for the last one, that gives the percentage of respondents who answered ‘‘strongly agree’’ or ‘‘agree’’. ***, **, *, ns, respectively significant at po0.001, po0.01, po0.05, non-significant (for the F-ratio testing differences in means for each row variable across clusters). a Home Palliative Care Support Team.

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Lastly, physicians gathered in Cluster 4 (n ¼ 135) shared a restrictive conception of palliative care; they were less prone to consider that non-terminal patients should have access to palliative care, they were more likely to agree that it should be used only as a last resort after the failure of curative treatments, and they were more reluctant toward easier availability of drugs used for palliative sedation outside hospitals. Oncologists were more prone to support the extension and professionalization of palliative care; GPs were more likely to uphold diffusion but not professionalization, and

neurologists were the stronger advocates of the restrictive conception of palliative care (Table 3). Physicians who cared for many terminally ill patients during the prior 12 months were less likely to endorse the confinement and professionalization attitude; those who participate in a specialized network delivering palliative care were more frequently supporters of either extension and professionalization or confinement and professionalization. Lastly, those who reported feeling uncomfortable with terminally ill patients were more prone to uphold confinement and professionalization or the restrictive

Table 3 Attitudes toward palliative care: predictive factors (logistic regression) Adjusted odds ratios Attitudes toward palliative care: (ref.: extension and professionalization) Diffusion but not professionalization

Confinement & professionalization

Restrictive conception

1 0.29*** 0.28***

1 0.41** 0.80 ns

1 0.57* 1.58*

NS

NS

NS

1 1.78* 1.86*

NS

1 1.10 ns 1.65*

Attending religious services at least once per month No (ref.) NS Yes

NS

1 1.53y

Specialised training in palliative care or pain management No (ref.) NS Yes

NS

NS

Participation in a specialized network delivering palliative care No (ref.) 1 Yes 0.63y

NS

1 0.16***

1 0.51y

NS

Medical speciality GP (ref.) Oncologist Neurologist Gender Female (ref.) Male Age o40 years (ref.) 41–49 years X50 years

Caring for terminally ill patients during the prior 12 months o24 patients (ref.) NS X24 patients

The last terminally ill patient followed up until death received palliative care No (ref.) NS NS Yes Feeling uncomfortable with terminally ill patients No (ref.) 1 Yes 0.44**

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1 2.20**

***, **, *, y, ns, respectively significant at po0.001, po0.01, po0.05, po0.10, non significant. NS: variable not selected by the stepwise selection procedure (entry threshold po0.05).

NS

1 1.51y

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conception of palliative care rather than its extension and professionalization, but they preferred the latter option to the diffusion but not professionalization alternative. Concerning non-medical characteristics, older physicians were more likely to support either the diffusion but not professionalization or the restrictive conception of palliative care, and the more religious respondents were

also more frequently supporters of this restrictive conception. Beliefs toward end-of-life care and euthanasia Older physicians were more prone to label any of the three considered medical practices as euthanasia, while

Table 4 Attitudes toward euthanasia: predictive factors for labelling various medical acts as euthanasia (logistic regression) Adjusted odds ratios Medical acts in end-of-life care labelled as euthanasia: ‘‘agree’’ or ‘‘strongly agree’’ vs. do not agree High-dose morphine

Palliative sedation

WLSTa

1 0.46** 0.95 ns

NS

1 0.67y 0.99 ns

NS

NS

1 1.47*

1 1.42 ns 1.82*

1 1.07 ns 1.37y

1 1.71** 2.91***

NS

1 0.36***

1 0.28***

NS

Participation in a specialized network delivering palliative care No (ref.) NS Yes

NS

NS

Caring for terminally ill patients during the prior 12 months o24 patients (ref.) NS X24 patients

NS

1 0.51*

Medical speciality GP (ref.) Oncologist Neurologist Gender Female (ref.) Male Age o40 years (ref.) 41–49 years X50 years

Attending religious services at least once per month No (ref.) NS Yes Specialized training in palliative care or pain management No (ref.) 1 Yes 0.26*

The last terminally ill patient followed up until death received palliative care No (ref.) 1 NS Yes 0.50* Feeling uncomfortable with terminally ill patients No (ref.) NS Yes Attitude toward palliative care: Extension & professionalization (ref.) Diffusion; not professionalization Confinement & professionalization Restrictive conception

1 0.81 ns 2.70*** 1.86*

NS

NS

1 1.64*

1 1.77** 1.49y 1.89**

1 1.52* 1.61** 1.95***

***, **, *, y, ns, respectively significant at po0.001, po0.01, po0.05, po0.10, non significant. NS: variable not selected by the stepwise selection procedure (entry threshold po0.10). a Withdrawing life-sustaining treatments.

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females and religious physicians were less likely to put this label on WLST (Table 4). Concerning medical characteristics, prescribing high-dose morphine to a terminally ill patient was less frequently considered euthanasia by oncologists, physicians trained in palliative care or pain management, and those which last terminally ill patients followed up until death had received palliative care; labelling palliative sedation euthanasia was negatively correlated with specialized training, and oncologists and physicians who cared for many terminally ill patients during the prior 12 months were less likely to consider WLST euthanasia, while those who feel uncomfortable with such patients were more prone to do so. Finally, when compared with physicians gathered in other attitudinal profiles, supporters of the extension and professionalization of palliative care were less likely to label euthanasia, the three considered medical practices. Opinions toward the legalization of euthanasia Five factors were significantly and independently correlated to agreement with the statement that ‘‘euthanasia should be legalized as in the Netherlands’’. Supporting such a legalization was less frequent among physicians attending religious services at least once a month (OR=0.51), those trained in palliative care or pain management (OR=0.52), and those who participate in a specialized network delivering palliative care (OR=0.59). On the contrary, supporting euthanasia legalization was more frequent among physicians feeling uncomfortable with terminally ill patients (OR=1.39) as well as among those who were more prone to label endof-life practices as euthanasia (OR=1.43) (Table 5). A hierarchical loglinear model was used for investigating the pattern of factors associated with beliefs and opinions expressed toward euthanasia (Fig. 1). We only introduced in the model the propensity to label end-oflife practices as euthanasia, the opinion toward its legalization, and some of their main predictors: religiosity, specialized training in palliative care or pain management, participation in a specialized network delivering palliative care, feeling uncomfortable with terminally ill patients, and the extension & professionalization attitude toward palliative care. The propensity to label end-of-life practices as euthanasia remained at the very heart of the final model, with significant interactions with four other variables. Specialized training in palliative care or pain management and feeling uncomfortable with terminally ill patients held symmetric places; they were either positively or negatively correlated with both the propensity to label end-of-life practices as euthanasia and agreement about its legalization. Thus these two variables had a direct effect on opinion toward the legalization of euthanasia, and an indirect one, via their effect on the

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Table 5 Opinions toward the legalization of euthanasia (logistic regression) Adjusted odds ratios ‘‘Euthanasia should be legalized as in the Netherlands’’: ‘‘agree’’ or ‘‘strongly agree’’ vs. do not agree Medical speciality GP (ref.) Oncologist Neurologist Gender Female (ref.) Male Age o40 years (ref.) 41–49 years X50 years

NS

NS

NS

Attending religious services at least once per month No (ref.) 1 Yes 0.51** Specialized training in palliative care or pain management No (ref.) 1 Yes 0.52** Participation in a specialised network delivering palliative care No (ref.) 1 Yes 0.59* Caring for terminally ill patients during the prior 12 months o24 patients (ref.) NS X24 patients The last terminally ill patient followed up until death received palliative care No (ref.) NS Yes Feeling uncomfortable with terminally ill patients No (ref.) 1 Yes 1.39y Attitude toward palliative care: Extension & NS professionalization (ref.) Diffusion; not professionalization Confinement & professionalization Restrictive conception Number of medical acts 1.43*** labelled as euthanasia (0-3) ***, **, *, y, ns, respectively significant at po0.001, po0.01, po0.05, po0.10, non-significant. NS: variable not selected by the stepwise selection procedure (entry threshold po0.10).

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Attitude toward palliative care : extension & professionalization +

p<0.001

p<0.001 Specialised training in palliative care or pain management +

p<0.001

Participation in a specialised network

Propensity to label end-of-life practices as euthanasia p<0.001

p<0.05 + + p<0.001

-

Uncomfort with terminal patients p<0.05

+

p<0.01 p<0.01

Euthanasia should be legalised

p<0.001

Strong religiosity

Fig. 1. Non-medical and medical characteristics and opinions toward palliative care and euthanasia (hierarchical loglinear model).

conception of euthanasia. Lastly, supporting the extension and professionalization of palliative care was negatively correlated with the extensive conception of euthanasia, but there was not direct interaction between such an attitude and opinion toward euthanasia legalization.

Discussion Among French GPs, oncologists and neurologists, we found four profiles of attitudes toward palliative care; half of the respondents supported both its extension and professionalization, one out of five supported its diffusion but not its professionalization, and other respondents supported either confinement and professionalization or a restrictive conception of palliative care. Such attitudes were closely correlated with involvement in end-of-life care. Significant minorities also agreed to label as euthanasia, various medical practices that are common in end-of-life care, and about half of respondents agreed that euthanasia should be legalized. Attitudes toward palliative care were closely correlated with beliefs about which medical practices should be labelled euthanasia: those supporting extension and professionalization of palliative care were less willing to endorse an extensive conception of euthanasia. Limitations of the present study Before discussing our results, we must acknowledge several limitations of the present study. First, telephone surveys generally induce social desirability response bias (Holbrook, Green, & Krosnick, 2003), that may prevent respondents from reporting their ‘true’ opinion about a ‘sensitive’ topic such as euthanasia: so our data may underestimate agreement with the legalization of euthanasia, but also reluctance toward palliative care

development.6 Secondly, we lack information about non-respondents, even if they were not different from respondents according to the few characteristics that could be controlled from the initial file. Thirdly, our questionnaire investigated attitudes toward palliative care from a quite narrow perspective, dealing mainly with technical expertise in pain and symptom relief to the detriment of the ‘holistic approach’ that is a core component of the palliative care movement. This methodological choice reflects the current development of palliative care in France, where the holistic approach remains unknown for most physicians. Fourthly, any analysis based on cross-sectional data dealing with beliefs and practices must be interpreted cautiously, so one should consider our discussion as exploratory rather than conclusive. Lastly, we must acknowledge that a closed-ended questionnaire prevents physicians from qualifying or justifying their responses, and probably misses or at least inadequately deals with some aspects that would have been better captured with qualitative methods. Religiosity, involvement in end-of-life care and opposition to euthanasia With regard to predictors of opinions toward the legalization of euthanasia, the independent effect of religiosity has been already extensively discussed in previous studies, and some of them convincingly stated that beyond religious affiliation strong religiosity has an impact on opinion toward legalization because religiosity is related to beliefs in the sanctity of life and its belonging to God (Caddell & Newton, 1995; McDonald, 6 Phone surveys are usually preferred to postal ones because they warrant a higher response rate. For an authoritative discussion of advantages and shortcomings of telephone surveys, see Groves, Biemer, & Lyberg (1988).

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1998). Thus, the fact that we found higher levels of agreement with the legalization of euthanasia than those previously observed among Italian GPs or US oncologists (Grassi et al., 1999; Emanuel et al., 2000) may be partly explained by the contemporaneous process of secularisation which is probably more advanced in France than in Italy or the USA. Three indicators of involvement in end-of-life care were also significant predictors of opinions toward euthanasia legalization. Corresponding results contrast with the arguments usually brought up by supporters of this legalization, who relate the legal acceptability of this practice to the contemporaneous emphasis on individual autonomy. Indeed, according to the standard prolegalization arguments, there is a continuum between euthanasia and end-of-life care, and physicians must respect individuals’ autonomy, including the patients’ right to claim for a ‘‘death in dignity’’ (Wilkinson, 1990; Markiewicz, 1995). According to this line of argument, we should expect that physicians who were more involved in terminal care and who felt closer to terminally ill patients supported the legalization of euthanasia. We found inverse relationships: physicians trained in palliative care or pain management and those participating in a specialized network delivering palliative care were less prone to support legalization, while those feeling uncomfortable with terminally ill patients were more likely to do so. These findings are not specific to the French context. Previous studies already suggested that physicians involved in end-of-life care were less likely to agree with such a legalization (Portenoy et al., 1997; Grassi et al., 1999). The relationship between feeling uncomfortable with terminally ill patients and opposition to legalization is also congruent with other studies. Portenoy et al. found that a diminished empathy in the doctor–patient relationship was significantly correlated with willingness to endorse euthanasia; Emanuel, Fairclough, Daniels, and Clarridge (1996) observed that oncologists who spent more time to talk to terminally ill patients were less likely to support euthanasia. Lastly, FØrde, Aasland, and Falkum (2001) found that physicians with negative attitudes towards patient autonomy were more likely to uphold euthanasia. Specialized training in palliative care or pain management and participating in a specialized network delivering palliative care may provide physicians with skills and resources that are helpful to manage delicate situations in end-of-life care, leading to reject euthanasia as a solution to such situations. Conversely, feeling uncomfortable with terminally ill patients may be due to a lack of skills in end-of-life care: a previous analysis of our data showed that such feeling was more frequent among physicians who were not trained in palliative care or pain management, and was associated with

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reluctance to use morphine in pain management (Ben Diane et al., 2003). Supporters of euthanasia usually propose that it should be considered as an option in palliative care, provided that good care of the dying has been given (van der Meer, 1988); but our study suggests that many of those French physicians who are in favour of legalising euthanasia do not yet fulfil these conditions.

Euthanasia as a semantic issue and professionalization of palliative care We also took into account which end-of-life medical practices were considered or not as euthanasia by respondents. Not surprisingly, we found that an extensive conception of euthanasia was associated to agreement with its legalization. Empirical research on attitudes toward euthanasia should not underestimate the semantic battle surrounding the definition of this notion. Of course, ambiguities of the term ‘euthanasia’ may be especially pronounced in the French context, where the euthanasia debate began later, but such ambiguities are far from being specific to France (Mason & Mulligan, 1996; Watts, 2000). With regard to such ambiguities, only a small proportion of respondents qualified the prescription of high-dose morphine as euthanasia, especially among oncologists and physicians trained in palliative care or pain management. This is consistent with the fact that such prescription is a common practice in palliative care, especially for cancer patients. One should also notice that the most religious physicians were less prone to consider WLST as euthanasia, perhaps because they view life-sustaining treatments as an artificial mean to delay a natural death. Moreover, once controlled for the effect of other factors related to involvement and training in end-of-life and palliative care, our attitudinal profiles remained the strongest predictors of beliefs toward which medical practices should be labelled (or not) euthanasia. Physicians who supported the professionalization and extension of palliative care were less prone to label prescription of high-dose morphine, palliative sedation or WLST as euthanasia, especially when compared to those who endorsed a restrictive conception of palliative care. Thus, even if knowledge and experience in palliative care may influence physicians’ opinions toward euthanasia, as advocated by both opponents and supporters of its legalization, once controlled for such influence the relationship between attitudes toward palliative care and conceptions of euthanasia remained significant. This result gave empirical support to our hypothesis that the relationship between palliative care and euthanasia may mix semantic and strategic aspects, beyond cognitive and conative ones.

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Attitudes toward palliative care and tensions within the medical world The professionalization of palliative care may face resistance from existing medical specialities because all specialities compete for legitimacy and resources. Results from the cluster analysis illustrated one facet of such resistance. Our profiles combined attitudes toward the professionalization of palliative care and toward either restriction or extension of its area of expertise. One attitudinal profile clearly expressed reluctance toward palliative care, while two others reject either professionalization or extension of palliative care. GPs, who supported diffusion but not professionalization of palliative care, may feel especially threatened by such professionalization, because they ‘‘loose’’ patients directed to a palliative care unit, which is not the case for oncologists, as within French hospitals the department of oncology and the palliative care unit are generally close to each other. Our findings also suggest that supporting such professionalization may be a defensive strategy for some physicians who do not want to be involved in end-of-life care in any way: indeed, respondents with little experience in caring for the dying and those who reported feeling uncomfortable with terminally ill patients supported the confinement & professionalization option. Knowledge and experience in end-of-life and palliative care were loosely correlated to attitudinal profiles, while participation in a specialized network, and thus proximity to physicians involved in the professionalization of palliative care, was associated with support to this professionalization. Thus, such attitudes may reflect the efforts made by palliative care providers to promote their occupational status. Moreover, physicians participating in specialized networks supported the confinement and professionalization option as much as the extension and professionalization one. The fact that the professionalization was either associated with extension or with restriction of palliative care in attitudes expressed by physicians may reflect current tensions within the palliative care field itself. Indeed, the ongoing professionalization is sometimes blamed to compromise the founding principles of palliative care, because it emphasises a restrictive conception focusing on technical expertise in symptom relief to the detriment of the ‘holistic approach’ advocated by the original hospice movement (Clark & Seymour, 1999).7 Conversely, the ‘holistic approach’ is compromising for the professionalization of palliative care, because it blurs its boundaries (Hibbert et al., 2003). In the medical world, such 7 This may explain why some palliative care specialists promote the diffusion of their knowledge instead of defending their monopoly over a specific area of expertise (Hibbert et al., 2003).

boundaries usually refer to anatomical, disease or expertise criteria, and failing to meet such criteria may inhibit the process of professionalization. Thus, the coherence of current palliative care could be jeopardized by moves to extend it beyond its initial temporal and pathological fields of practice.

Conclusion The wide support for euthanasia observed among French physicians is probably due to non-medical as well as medical trends: the advanced secularisation of French society and the late development of palliative care, which is coextensive with the propensity to mix up end-of-life care and euthanasia. Nevertheless, this late development should not be understood solely in terms of lack of training and experience. Knowledge and experience in end-of-life and palliative care do influence physicians’ opinions toward euthanasia, as advocated by both opponents and supporters of its legalization, but the relationship between palliative care and euthanasia also mix semantic and strategic aspects, related to the professionalization of palliative care. Therefore, between palliative care and euthanasia there is neither a natural continuum nor a necessary radical contradiction: both alternatives are social constructs. Lastly, if developing palliative care is often considered as a way to prevent both patients’ request for euthanasia and physicians’ support for it, the first impact of such development on euthanasia may be a semantic one, as the development of palliative care contributes to reduce the range of medical practices labelled ‘euthanasia’.

Acknowledgements Special thanks to the members of the South-Eastern France Palliative Care Group: MK. Ben Diane, Dr. R. Favre, Dr. A. Galinier, Dr. JM. Lapiana, Dr. Y. Obadia and Dr. H. Pe´gliasco. Dr. H. Granier, Dr. B. PlanchetBarraud, Dr. F. Ravallec, Dr. M. Rotily and Dr. O. Priolo also contributed to the design of the survey. This study was supported by the Departmental Centre of Private Health Professionals (grant from the Fund for improving ambulatory care), by the Assistance Publique-Hoˆpitaux de Marseilles (within the hospital program for clinical research) and by the Cancer Research Foundation (ARC).

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