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Attitudes towards legalising physician provided euthanasia in Britain: The role of religion over time
Social Science & Medicine 128 (2015) 52e56
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Short report
Attitudes towards legalising physician provided euthanasia in Britain: The role of religion over time* Andriy Danyliv, Ciaran O'Neill* J.E. Cairnes School of Business and Economics, National University of Ireland Galway, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 30 December 2014
Hastening the death of another whether through assisted suicide or euthanasia is the subject of intense debate in the UK and elsewhere. In this paper we use a nationally representative survey of public attitudes e the British Social Attitudes survey e to examine changes in attitudes to the legalisation of physician provided euthanasia (PPE) over almost 30 years (1983e2012) and the role of religious beliefs and religiosity in attitudes over time. Compatible questions about attitudes to euthanasia were available in the six years of 1983, 1984, 1989, 1994, 2005, and 2012. We study the trends in the support for legalisation through these time points and the relationship between attitudes, religious denomination and religiosity, controlling for a series of covariates. In total, 8099 individuals provided answers to the question about PPE in the six years of the study. The support for legalisation rose from around 76.95% in 1983 to 83.86% in 2012. This coincided with an increase in secularisation exhibited in the survey: the percentage of people with no religious affiliation increasing from 31% to 45.4% and those who do not attend a religious institution (e.g. church) increasing from 55.7% to 65.03%. The multivariate analysis demonstrates that religious affiliation and religiosity as measured by religious institution attendance frequency are the main contributors to attitudes towards euthanasia, and that the main increase in support happened among the group with least religious affiliation. Other socio-demographic characteristics do not seem to alter these attitudes systematically across the years. Our study demonstrates an increase in the support of euthanasia legalisation in Britain in the last 30 years coincided with increased secularisation. It does not follow, however, that trends in public support are immutable nor that a change in the law would improve on the current pragmatic approach toward hastening death by a physician adopted in England and Wales in terms of the balance between compassion and safeguards against abuse offered. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Britain Euthanasia Religion Religiosity Public attitudes
1. Introduction Both physician assisted suicide and euthanasia share the common effect of hastening death. In assisted suicide the individual with the assistance of a physician acts to hasten their own death while in euthanasia e with physician involvement e the physician acts to hasten the death of the individual. Assisted suicide has been legalised in five states of the USA (Washington, Oregon, Vermont, New Mexico and Montana) as well as Luxembourg, the
*
Ciaran O'Neill was funded under a HRB Research Leader Award RL/2013/16. * Corresponding author. E-mail address: [email protected] (C. O'Neill).
http://dx.doi.org/10.1016/j.socscimed.2014.12.030 0277-9536/© 2014 Elsevier Ltd. All rights reserved.
Netherlands, Germany, and Switzerland. Euthanasia has been legalised in Belgium (though not mentioned explicitly in legislation), the Netherlands and Luxembourg. Despite its legalisation in several jurisdictions, hastening death, remains the subject of intense debate in these and other jurisdictions (Hendry et al., 2013; Steck et al., 2013) as does interpretation of trends in their rates in those jurisdictions where it has been legalised (Gamondi et al., 2014; Onwuteaka-Philipsen et al., 2012). In the UK, there is an ongoing debate on the issue of legalising assisted suicide, though less attention is devoted to euthanasia. The current legal position with respect to assisted suicide might be described as pragmatic. In England, Wales, and Northern Ireland, for example, individuals who assist in the death/suicide of another could face prosecution under 1961 Suicide Act. However, in 2010,
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the Director of Public Prosecutions issued guidelines detailing provisions under which a prosecution would not be pursued (Crown Prosecution Service, 2010) in England and Wales. Since 2002 of over 90 cases examined none has resulted in a prosecution in England and Wales (Curtice and Field, 2010). Attempts to provide clarity around the legal position of those assisting others to end their lives through a private member's Bill in the UK's House of Lords in July 2014, provoked intense debate. A number of studies have demonstrated public support for legalisation of assisted suicide/dying and/or euthanasia across a number of countries including the UK (Albanese, 1996; Caddell and Newton, 1995; Dietz, 1997; McLean and Britton, 1996; Seale and Addington-Hall, 1994, 1995a, 1995b; Wise, 1996; O'Neill et al., 2003). These attitudes vary depending on for whom legal protection is sought e whether family members or physicians (O'Neill et al., 2003) e as well as on whose opinions are sought and on the precise wording of the question posed (Clements, 2014). A body of literature has demonstrated the importance of religious beliefs in attitudes to these subjects both in terms of the strength of the religious affiliation e religiosity (Bachman et al., 1996; Baume et al., 1995; Jorgenson and Neubecker, 1980; Kalish, 1963; O'Neill et al., 2003; Suarez-Almazor et al., 1997; Ward, 1980), and in terms of the religious denomination with which one is affiliated (Anderson and Caddell, 1993; Caddell and Newton, 1995; O'Neill et al., 2003). Interestingly studies have shown that a majority of doctors in the UK oppose legalisation of physician assisted suicide and euthanasia and that their religiosity appears to affect their attitudes (McCormack et al., 2012), a finding echoed elsewhere (Gielen et al., 2009). Given the recent debate in the UK on legalisation of assisted suicide/dying it is perhaps timely to review public attitudes to the subject. In this paper we use a nationally representative survey of public attitudes in Britain e the British Social Attitudes survey e to examine attitudes to the legalisation of the physician hastening the death. Specifically, we study (i) if these attitudes changed over almost 30 years (1983e2012) and (ii) the role of religious beliefs and religiosity in attitudes and the role of religion and religiosity in attitudes over time.
53
frequency of church (religious institution) attendance, this being split into groups of frequent users (once a week), less frequent users (less often than once a week), occasional attendants (varies), and those who do not attend religious services or state having no religion. A series of socio-demographic factors were included in the analysis: education, age, sex, household income (quintiles), and marital status. We assume that the attitudes towards euthanasia might be correlated with respondent's satisfaction with the health care system as an indicator of unmet need (Largey and O'Neill, 1996; Seale and Addington-Hall, 1995b), and hence, control for this relation. Again following O'Neill et al. (2003) we sought to capture an individual's autonomy of opinion regarding attitudes to the law by incorporating their stated willingness to ignore a law they disagreed with. Difference in proportion tests of respondents supporting legalisation in the whole sample and in the sample partitioned by religiosity and religious denomination over time were undertaken; these are presented in the Supplement 1. A series of multivariate logistic regressions for each time point were also undertaken to assess the impact of the covariates on the binary indicator: support for the legalisation of euthanasia in each year. These results are reported in Table 2. To study specifically the presence of an annual trend, adjusted for the effects of other covariates, a pooled logistic regression with the number of years since 1983 as a covariate was also estimated and reported in Table 2. Sampling weighting factors provided in BSAS data were applied in the analyses. Changes to questions across years necessitated changes to the precise format of regression models. Hence, where information on certain characteristics were not available in certain years these were omitted (e.g. education level for 1983 and 1984, satisfaction with NHS for 2012). The level of (dis)obedience to law is proxied by different questions in 1983/84, i.e. “Would you break a law under certain circumstances if you are strongly opposed to it?”, and 1989e2012, i.e. “The law should always be obeyed even if one feels that it is wrong/unjust”. In the pooled regression, the covariates that were not available for all six years were omitted as they would have been collinear with the year effect if introduced. 3. Results
2. Methods In this study, we use British Social Attitudes Survey data available since 1983 (National Centre for Social Research, 1983e2012). As our study involved secondary analysis of an anonymised publicly available dataset, no ethical approval was necessary. Compatible questions about attitudes to legalisation of hastening death were available in the years of 1983, 1984, 1989, 1994, 2005, and 2012. The respondents were asked: “Suppose a person has a painful incurable disease. Do you think that doctors should be allowed by law to end the patient's life, if patient requests it?” with the options to answer “yes” or “no”, or “don't know”. While we interpret the data as reflective of attitudes to euthanasia we concede the possibility of confusion on the part of the respondents with assisted suicide in the responses provided. We study the trends in the support for legalisation of euthanasia through the time points and the relationship between attitudes, religious denomination and religiosity, controlling for a series of covariates identical to those used by O'Neill et al. (2003) in a cross sectional analysis of 1994 data. Religious denomination was aggregated into five groups, based on the numbers present in the sample: those with no religious affiliation, Roman Catholics, Church of England, other Christians, and non-Christians. The latter group is small though its size has substantially increased in the sample over the study period. We include a proxy factor for the strength of religious beliefs e
In the six years of the study, 8099 individuals provided answers to the question about euthanasia: 1640 in 1983, 1541 in 1984, 1288 in 1989, 956 in 1994, 1751 in 2005, and 923 in 2012 (see Table 1). The lowest support is observed in 1983 and 1984, i.e. 76.95% and 75.95% respectively, support growing to 83.86% in
Table 1 Summary statistics.
Supportive of PAS No Yes Religiosity (church attendance) No religion Never Once a week Less often than once Varies Religious denomination No religion Roman Catholic Church of England Other Christian Non-Christian
1983
1984
1989
1994
2005
2012
1640 23.05% 76.95% 1747
1541 24.21% 75.79% 1667
1288 20.96% 79.04% 2982
956 16.21% 83.79% 3455
1751 18.10% 81.90% 4241
923 16.14% 83.86% 3246
31.14% 24.56% 13.17% 30.62% 0.52% 1754 31.01% 9.69% 40.36% 17.10% 1.82%
31.73% 23.58% 12.78% 31.37% 0.54% 1667 31.73% 11.40% 40.73% 14.46% 1.68%
5.40% 48.42% 13.01% 32.49% 0.67% 3024 34.29% 11.11% 37.10% 15.77% 1.72%
8.08% 50.71% 12.50% 28.25% 0.46% 3461 37.99% 9.48% 34.44% 15.49% 2.60%
11.04% 52.82% 9.88% 25.61% 0.66% 4243 39.24% 9.33% 28.40% 18.74% 4.29%
16.94% 48.09% 10.29% 23.69% 0.99% 3229 45.40% 9.01% 23.66% 17.25% 4.68%
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Table 2 Results of a weighted logit regression analysis of attitudes to physician assisted suicide. 1983
1984
1989
1994
2005
2012
Odds ratios for religion and religiosity (95% confidence intervals) Years from 1983 Religiosity (church attendance) Once a week Less often than once Never Varies Religious denomination Roman catholic
1.017*** (1.00 e1.02)
no religion (base) 0.089*** (0.03 e0.25) 0.216*** (0.08 e0.58) 0.254*** (0.09 e0.69) 0.366 (0.03e4.11)
0.181*** (0.07 0.203*** (0.07 0.102*** (0.03 0.198*** (0.08 0.101*** (0.03 0.277*** (0.20 e0.50) e0.59) e0.33) e0.48) e0.34) e0.39) 0.578 (0.21e1.62) 1.021 (0.37e2.84) 0.602 (0.20e1.77) 0.679 (0.31e1.49) 0.545 (0.20e1.52) 0.958 (0.71e1.30) 0.569 (0.20e1.62) 1.547 (0.58e4.11) 0.597 (0.22e1.58) 0.939 (0.45e1.98) 1.480 (0.59e3.69) 1.25 (0.95e1.65) 0.369 (0.06e2.12) 0.449 (0.09e2.25) 0.086** (0.01 e2.82)
Other Christian
no religion (base) 1.364 (0.50e3.73) 0.694 (0.25e1.96) 0.311*** (0.17 e0.58) 2.994** (1.16 1.261 (0.46e3.45) 0.884 (0.52e1.51) e7.74) 2.114 (0.79e5.63) 0.934 (0.34e2.60) 0.596* (0.34e1.06)
Non-Christian
e
Church of England
Pooled
e
1.325 (0.13 e13.81)
3.618 (0.23 e56.35)
0.867 (0.41e1.85)
0.392** (0.18 0.476** (0.26 0.471 (0.18e1.21) 0.358*** (0.27 e0.86) e0.86) e0.48) 0.681 (0.36e1.29) 0.855 (0.54e1.35) 1.079 (0.46e2.55) 0.715*** (0.56 e0.92) 0.555 (0.26e1.19) 0.605* (0.36e1.00) 0.851 (0.37e1.93) 0.518*** (0.40 e0.68) 0.377* (0.14e1.05) 0.399 (0.08e1.94) 0.249*** (0.12 0.238** (0.07 0.228*** (0.14 e0.52) e0.86) e0.36) 19.10*** 8.99*** 18.45*** 17.44*** 9.379***
Constant term 6.35*** 10.39*** Collective significance of the covariates: Wald test F-statistics Years from 1983 Religiosity (church attend.) 35.1*** 35.4*** Religious denomination 16.7*** 6.7* Education level e e Age category 1.2 19.4*** Gender (male) 9.3*** 0.0 Household income quintiles 0.2 2.4 Marital status 6.6* 3.0 Satisfaction with NHS 1.4 1.9 Even wrong laws obeyed e e Would break a law 0.2 2.9
63.0*** 18.3*** 3.2 8.1** 1.6 3.9 1.4 2.5 2.8 e
36.4*** 6.2 3.9 1.4 0.0 3.5 2.0 3.0 3.3 e
36.8*** 18.3*** 10.6** 2.1 0.5 0.6 4.0 5.2* 0.5 e
40.6*** 8.2* 5.4 2.3 1.2 0.8 0.7 e 1.6 e
21.04*** 208.83*** 83.18*** e 22.86** 5.35 1.33 5.28 e e e
Number of observations Likelihood ratio test (Chi2) P-value (Chi2)
1120 142.3 <0.001
864 92 <0.001
1527 117.1 <0.001
696 100.3 <0.001
7142 545.4 <0.001
1466 96.09 <0.001
1373 114.5 <0.001
***p < 0.01, **p < 0.05, *p < 0.1.
2012. The increase appears to have been step-wise rather than smooth. The increase in support coincided with what might be referred to as an increase in secularisation (see Table 1 and Supplement 1): the share of those who report having no religion in response to religious denomination query grew steadily from 31% in 1983 to 45.4% in 2012. Similarly, religiosity, proxied by the frequency of church attendance decreased. The share of those with the strongest religious identity (attending church once a week) decreased slightly: from 13% in 1983 to 10% in 2012, among less frequent attendants the percentage fell from 30.6 in 1983 to 23.7% in 2012, whilst the percentage of those who state that they never attend or have “no religion” increased from 55.7% to 65.03%. Notably, the highest rate of support with a relatively steady increase over time is observed in the least religious group, i.e. those who do not attend religious service (Supplement 1). For the most religious people, i.e. attending religious service once a week, the support varied by year and fell overall from 53.2% in 1983 to 48.0% in 2012. The multivariate regressions are presented in Table 2. The pooled regression demonstrates that there is a trend of increasing support over time, when other variables are controlled. Religiosity is the most important predictor of the attitudes in all years. Those who attend church regularly (once a week) are 5e11 times less likely to be supportive of a change in the law regarding euthanasia than those who never attended. Religious denomination is also seen to impact on the attitudes towards PAS. Non-Christians, whose
numbers grew in recent years (2005e2012), are about 4 times less likely to support legalisation of euthanasia than those with noreligion. Roman Catholics are more than twice as likely to oppose legalisation, although this relation is at the verge of significance in some of the years. For both religion and religiosity, there does not appear to be any definite trend in the magnitude of the effects over time. None of the other covariates demonstrated a consistent effect on the attitudes towards euthanasia across the six years of the study. 4. Discussion Our analysis, based on a nationally representative survey, shows an increase in support for legalisation of euthanasia in Britain over time e from 75.8% in 1984 to 83.8% in 2012. While the change of 8 percentage points may not seem dramatic, it remains statistically significant. It should be remembered too that the high initial support might have limited the potential for further increases over time. The increase in support coincides with an increase in the degree of secularisation recorded in the survey as measured by the percentage reporting no religious affiliation and the percentage reporting non- and infrequent attendance at religious services. The most substantial changes in the support for euthanasia legalisation over time happened among the least religious groups, while in the group of most religious people little change in attitudes are evident. These findings echo the descriptive work of others using the BSAS
A. Danyliv, C. O'Neill / Social Science & Medicine 128 (2015) 52e56
data (Clements, 2014) though our study tested these relations statistically accounting for the potential effects of the other covariates. The strength of religious affiliation together with religious denomination are not only statistically significant determinants of attitudes but are consistently the most important determinants of attitudes among the observable factors in defining attitudes towards euthanasia involving a physician. The findings echo those of others internationally in respect of involvement by physicians in hastening death (Anderson and Caddell, 1993; Bachman et al., 1996; Baume et al., 1995; Caddell and Newton, 1995; Jorgenson and Neubecker, 1980; Kalish, 1963; Suarez-Almazor et al., 1997; Sullivan et al., 1998; Ward, 1980). Given the trend, the role of religion and the evidence of increasing secularisation in our analysis, it may be tempting to infer that at some point a change in the law around hastening death in Britain is inevitable. The repeated legal challenges in the UK (UK Supreme Court, 2014) and the recent private members Bill in the UK House of Lords are consistent with this narrative. However, several important facts should be born in mind. First, trends in secularisation as well as the increase in support are not particularly dramatic over time. Moreover, increases in numbers of those classified here as “non-Christians” are associated with groups more likely to oppose legalisation of euthanasia. In other words, it would be dangerous to assume that current trends that support a change in legislation are immutable. Second, the position of doctors' groups, contrast starkly to the general publics' attitudes (Watt, 2014; Jaques, 2012; Wolfe et al., 1999). Given the envisaged role of doctors in hastening death, their opposition may hold greater sway in debates on the subject than others and/or on the impact of changes in the law on actual practices. Third, the current legal position in England and Wales which is prohibitive of hastening death by assisted suicide or euthanasia but provides for discretion in particular cases of assisted dying allows a perhaps more nuanced approach to the issue than legislation might otherwise provide. This pragmatic approach may serve to reduce if not remove the appetite for a change in the law. There is a need for explicit distinction between euthanasia and assisted suicide in public debates and surveys. The two currently seem to be conflated in the public mind, though they are distinct in terms of the psychological threshold that must be crossed before an individual requests their death to be hastened. The perhaps worrisome trends in hastened deaths the Netherlands and USA (Finlay and George, 2011; Twycross, 2014) seem to reflect concerns regarding euthanasia, but not for assisted suicide (Gamondi et al., 2014), though the interpretation of these statistics are debated (Onwuteaka-Philipsen et al., 2012). This debate further underscores the importance of separating these two ways of hastening death in public discourse.
5. Conclusion Our analyses have shown that consistently the most significant observable determinant of opposition to legalisation of euthanasia is religious beliefs and the strength of those beliefs as evidenced by frequency of religious service attendance. It is unsurprising therefore that support for legalisation of euthanasia has increased in Britain over the past 30 years coinciding with an increase in secularisation. It does not follow, however, that trends in public support are immutable nor that a change in the law would improve on the current approach in England and Wales that bans euthanasia and seeks to strike a balance between compassion and safeguards against abuse in respect of assisted suicide.
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Supplement 1. Dynamics of proportion supporting legalisation physician hastening death
Year
Support legalisation
p-value for difference in proportion from year:
n
1983
%
1984
Whole sample 1983 1262 (77.0%) 1984 1168 (75.8%) 0.443 1989 1018 (79.0%) 0.177 0.040 1994 801 (83.8%) p<0.01 p<0.01 2005 1434 (81.9%) p<0.01 p<0.01 2012 774 (83.9%) p<0.01 p<0.01 By religiosity (religious service attendance): Do not attend church 1983 759 (82.5%) 1984 696 (82.4%) 0.941 1989 582 (87.8%) 0.004 0.004 1994 503 (89.3%) p<0.01 p<0.01 2005 995 (88.0%) p<0.01 p<0.01 2012 534 (90.5%) p<0.01 p<0.01 Once a week 1983 109 (53.2%) 1984 85 (45.2%) 0.115 1989 73 (42.7%) 0.043 0.631 1994 52 (50.5%) 0.656 0.389 2005 78 (49.1%) 0.436 0.475 2012 47 (48.0%) 0.396 0.658 Less than once 1983 389 (77.0%) 1984 383 (76.0%) 0.697 1989 345 (79.5%) 0.362 0.200 1994 245 (84.8%) 0.009 0.003 2005 357 (78.8%) 0.508 0.299 2012 193 (82.1%) 0.115 0.061 By religious denomination: No religion 1983 435 (85.0%) 1984 426 (86.1%) 0.620 1989 398 (88.3%) 0.136 0.316 1994 350 (90.9%) 0.008 0.027 2005 593 (89.4%) 0.021 0.080 2012 369 (90.7%) 0.009 0.033 Any religion 1983 827 (73.3%) 1984 742 (70.9%) 0.216 1989 620 (74.1%) 0.706 0.131 1994 451 (79.0%) 0.011 p<0.01 2005 841 (77.3%) 0.030 0.001 2012 405 (78.5%) 0.025 0.001
1989
1994
2005
0.005 0.049 0.004
0.215 0.967
0.204
0.394 0.904 0.123
0.407 0.511
0.113
0.210 0.246 0.403
0.821 0.720
0.864
0.073 0.802 0.412
0.043 0.416
0.302
0.211 0.533 0.251
0.446 0.905
0.520
0.034 0.101 0.066
0.432 0.842
0.593
The p-values provided in bold are <0.05, i.e. representing presence of a significant difference at 0.05 level.
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Attitudes towards legalising physician provided euthanasia in Britain: The role of religion over time* Andriy Danyliv, Ciaran O'Neill* J.E. Cairnes School of Business and Economics, National University of Ireland Galway, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 30 December 2014
Hastening the death of another whether through assisted suicide or euthanasia is the subject of intense debate in the UK and elsewhere. In this paper we use a nationally representative survey of public attitudes e the British Social Attitudes survey e to examine changes in attitudes to the legalisation of physician provided euthanasia (PPE) over almost 30 years (1983e2012) and the role of religious beliefs and religiosity in attitudes over time. Compatible questions about attitudes to euthanasia were available in the six years of 1983, 1984, 1989, 1994, 2005, and 2012. We study the trends in the support for legalisation through these time points and the relationship between attitudes, religious denomination and religiosity, controlling for a series of covariates. In total, 8099 individuals provided answers to the question about PPE in the six years of the study. The support for legalisation rose from around 76.95% in 1983 to 83.86% in 2012. This coincided with an increase in secularisation exhibited in the survey: the percentage of people with no religious affiliation increasing from 31% to 45.4% and those who do not attend a religious institution (e.g. church) increasing from 55.7% to 65.03%. The multivariate analysis demonstrates that religious affiliation and religiosity as measured by religious institution attendance frequency are the main contributors to attitudes towards euthanasia, and that the main increase in support happened among the group with least religious affiliation. Other socio-demographic characteristics do not seem to alter these attitudes systematically across the years. Our study demonstrates an increase in the support of euthanasia legalisation in Britain in the last 30 years coincided with increased secularisation. It does not follow, however, that trends in public support are immutable nor that a change in the law would improve on the current pragmatic approach toward hastening death by a physician adopted in England and Wales in terms of the balance between compassion and safeguards against abuse offered. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Britain Euthanasia Religion Religiosity Public attitudes
1. Introduction Both physician assisted suicide and euthanasia share the common effect of hastening death. In assisted suicide the individual with the assistance of a physician acts to hasten their own death while in euthanasia e with physician involvement e the physician acts to hasten the death of the individual. Assisted suicide has been legalised in five states of the USA (Washington, Oregon, Vermont, New Mexico and Montana) as well as Luxembourg, the
*
Ciaran O'Neill was funded under a HRB Research Leader Award RL/2013/16. * Corresponding author. E-mail address: [email protected] (C. O'Neill).
http://dx.doi.org/10.1016/j.socscimed.2014.12.030 0277-9536/© 2014 Elsevier Ltd. All rights reserved.
Netherlands, Germany, and Switzerland. Euthanasia has been legalised in Belgium (though not mentioned explicitly in legislation), the Netherlands and Luxembourg. Despite its legalisation in several jurisdictions, hastening death, remains the subject of intense debate in these and other jurisdictions (Hendry et al., 2013; Steck et al., 2013) as does interpretation of trends in their rates in those jurisdictions where it has been legalised (Gamondi et al., 2014; Onwuteaka-Philipsen et al., 2012). In the UK, there is an ongoing debate on the issue of legalising assisted suicide, though less attention is devoted to euthanasia. The current legal position with respect to assisted suicide might be described as pragmatic. In England, Wales, and Northern Ireland, for example, individuals who assist in the death/suicide of another could face prosecution under 1961 Suicide Act. However, in 2010,
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the Director of Public Prosecutions issued guidelines detailing provisions under which a prosecution would not be pursued (Crown Prosecution Service, 2010) in England and Wales. Since 2002 of over 90 cases examined none has resulted in a prosecution in England and Wales (Curtice and Field, 2010). Attempts to provide clarity around the legal position of those assisting others to end their lives through a private member's Bill in the UK's House of Lords in July 2014, provoked intense debate. A number of studies have demonstrated public support for legalisation of assisted suicide/dying and/or euthanasia across a number of countries including the UK (Albanese, 1996; Caddell and Newton, 1995; Dietz, 1997; McLean and Britton, 1996; Seale and Addington-Hall, 1994, 1995a, 1995b; Wise, 1996; O'Neill et al., 2003). These attitudes vary depending on for whom legal protection is sought e whether family members or physicians (O'Neill et al., 2003) e as well as on whose opinions are sought and on the precise wording of the question posed (Clements, 2014). A body of literature has demonstrated the importance of religious beliefs in attitudes to these subjects both in terms of the strength of the religious affiliation e religiosity (Bachman et al., 1996; Baume et al., 1995; Jorgenson and Neubecker, 1980; Kalish, 1963; O'Neill et al., 2003; Suarez-Almazor et al., 1997; Ward, 1980), and in terms of the religious denomination with which one is affiliated (Anderson and Caddell, 1993; Caddell and Newton, 1995; O'Neill et al., 2003). Interestingly studies have shown that a majority of doctors in the UK oppose legalisation of physician assisted suicide and euthanasia and that their religiosity appears to affect their attitudes (McCormack et al., 2012), a finding echoed elsewhere (Gielen et al., 2009). Given the recent debate in the UK on legalisation of assisted suicide/dying it is perhaps timely to review public attitudes to the subject. In this paper we use a nationally representative survey of public attitudes in Britain e the British Social Attitudes survey e to examine attitudes to the legalisation of the physician hastening the death. Specifically, we study (i) if these attitudes changed over almost 30 years (1983e2012) and (ii) the role of religious beliefs and religiosity in attitudes and the role of religion and religiosity in attitudes over time.
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frequency of church (religious institution) attendance, this being split into groups of frequent users (once a week), less frequent users (less often than once a week), occasional attendants (varies), and those who do not attend religious services or state having no religion. A series of socio-demographic factors were included in the analysis: education, age, sex, household income (quintiles), and marital status. We assume that the attitudes towards euthanasia might be correlated with respondent's satisfaction with the health care system as an indicator of unmet need (Largey and O'Neill, 1996; Seale and Addington-Hall, 1995b), and hence, control for this relation. Again following O'Neill et al. (2003) we sought to capture an individual's autonomy of opinion regarding attitudes to the law by incorporating their stated willingness to ignore a law they disagreed with. Difference in proportion tests of respondents supporting legalisation in the whole sample and in the sample partitioned by religiosity and religious denomination over time were undertaken; these are presented in the Supplement 1. A series of multivariate logistic regressions for each time point were also undertaken to assess the impact of the covariates on the binary indicator: support for the legalisation of euthanasia in each year. These results are reported in Table 2. To study specifically the presence of an annual trend, adjusted for the effects of other covariates, a pooled logistic regression with the number of years since 1983 as a covariate was also estimated and reported in Table 2. Sampling weighting factors provided in BSAS data were applied in the analyses. Changes to questions across years necessitated changes to the precise format of regression models. Hence, where information on certain characteristics were not available in certain years these were omitted (e.g. education level for 1983 and 1984, satisfaction with NHS for 2012). The level of (dis)obedience to law is proxied by different questions in 1983/84, i.e. “Would you break a law under certain circumstances if you are strongly opposed to it?”, and 1989e2012, i.e. “The law should always be obeyed even if one feels that it is wrong/unjust”. In the pooled regression, the covariates that were not available for all six years were omitted as they would have been collinear with the year effect if introduced. 3. Results
2. Methods In this study, we use British Social Attitudes Survey data available since 1983 (National Centre for Social Research, 1983e2012). As our study involved secondary analysis of an anonymised publicly available dataset, no ethical approval was necessary. Compatible questions about attitudes to legalisation of hastening death were available in the years of 1983, 1984, 1989, 1994, 2005, and 2012. The respondents were asked: “Suppose a person has a painful incurable disease. Do you think that doctors should be allowed by law to end the patient's life, if patient requests it?” with the options to answer “yes” or “no”, or “don't know”. While we interpret the data as reflective of attitudes to euthanasia we concede the possibility of confusion on the part of the respondents with assisted suicide in the responses provided. We study the trends in the support for legalisation of euthanasia through the time points and the relationship between attitudes, religious denomination and religiosity, controlling for a series of covariates identical to those used by O'Neill et al. (2003) in a cross sectional analysis of 1994 data. Religious denomination was aggregated into five groups, based on the numbers present in the sample: those with no religious affiliation, Roman Catholics, Church of England, other Christians, and non-Christians. The latter group is small though its size has substantially increased in the sample over the study period. We include a proxy factor for the strength of religious beliefs e
In the six years of the study, 8099 individuals provided answers to the question about euthanasia: 1640 in 1983, 1541 in 1984, 1288 in 1989, 956 in 1994, 1751 in 2005, and 923 in 2012 (see Table 1). The lowest support is observed in 1983 and 1984, i.e. 76.95% and 75.95% respectively, support growing to 83.86% in
Table 1 Summary statistics.
Supportive of PAS No Yes Religiosity (church attendance) No religion Never Once a week Less often than once Varies Religious denomination No religion Roman Catholic Church of England Other Christian Non-Christian
1983
1984
1989
1994
2005
2012
1640 23.05% 76.95% 1747
1541 24.21% 75.79% 1667
1288 20.96% 79.04% 2982
956 16.21% 83.79% 3455
1751 18.10% 81.90% 4241
923 16.14% 83.86% 3246
31.14% 24.56% 13.17% 30.62% 0.52% 1754 31.01% 9.69% 40.36% 17.10% 1.82%
31.73% 23.58% 12.78% 31.37% 0.54% 1667 31.73% 11.40% 40.73% 14.46% 1.68%
5.40% 48.42% 13.01% 32.49% 0.67% 3024 34.29% 11.11% 37.10% 15.77% 1.72%
8.08% 50.71% 12.50% 28.25% 0.46% 3461 37.99% 9.48% 34.44% 15.49% 2.60%
11.04% 52.82% 9.88% 25.61% 0.66% 4243 39.24% 9.33% 28.40% 18.74% 4.29%
16.94% 48.09% 10.29% 23.69% 0.99% 3229 45.40% 9.01% 23.66% 17.25% 4.68%
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Table 2 Results of a weighted logit regression analysis of attitudes to physician assisted suicide. 1983
1984
1989
1994
2005
2012
Odds ratios for religion and religiosity (95% confidence intervals) Years from 1983 Religiosity (church attendance) Once a week Less often than once Never Varies Religious denomination Roman catholic
1.017*** (1.00 e1.02)
no religion (base) 0.089*** (0.03 e0.25) 0.216*** (0.08 e0.58) 0.254*** (0.09 e0.69) 0.366 (0.03e4.11)
0.181*** (0.07 0.203*** (0.07 0.102*** (0.03 0.198*** (0.08 0.101*** (0.03 0.277*** (0.20 e0.50) e0.59) e0.33) e0.48) e0.34) e0.39) 0.578 (0.21e1.62) 1.021 (0.37e2.84) 0.602 (0.20e1.77) 0.679 (0.31e1.49) 0.545 (0.20e1.52) 0.958 (0.71e1.30) 0.569 (0.20e1.62) 1.547 (0.58e4.11) 0.597 (0.22e1.58) 0.939 (0.45e1.98) 1.480 (0.59e3.69) 1.25 (0.95e1.65) 0.369 (0.06e2.12) 0.449 (0.09e2.25) 0.086** (0.01 e2.82)
Other Christian
no religion (base) 1.364 (0.50e3.73) 0.694 (0.25e1.96) 0.311*** (0.17 e0.58) 2.994** (1.16 1.261 (0.46e3.45) 0.884 (0.52e1.51) e7.74) 2.114 (0.79e5.63) 0.934 (0.34e2.60) 0.596* (0.34e1.06)
Non-Christian
e
Church of England
Pooled
e
1.325 (0.13 e13.81)
3.618 (0.23 e56.35)
0.867 (0.41e1.85)
0.392** (0.18 0.476** (0.26 0.471 (0.18e1.21) 0.358*** (0.27 e0.86) e0.86) e0.48) 0.681 (0.36e1.29) 0.855 (0.54e1.35) 1.079 (0.46e2.55) 0.715*** (0.56 e0.92) 0.555 (0.26e1.19) 0.605* (0.36e1.00) 0.851 (0.37e1.93) 0.518*** (0.40 e0.68) 0.377* (0.14e1.05) 0.399 (0.08e1.94) 0.249*** (0.12 0.238** (0.07 0.228*** (0.14 e0.52) e0.86) e0.36) 19.10*** 8.99*** 18.45*** 17.44*** 9.379***
Constant term 6.35*** 10.39*** Collective significance of the covariates: Wald test F-statistics Years from 1983 Religiosity (church attend.) 35.1*** 35.4*** Religious denomination 16.7*** 6.7* Education level e e Age category 1.2 19.4*** Gender (male) 9.3*** 0.0 Household income quintiles 0.2 2.4 Marital status 6.6* 3.0 Satisfaction with NHS 1.4 1.9 Even wrong laws obeyed e e Would break a law 0.2 2.9
63.0*** 18.3*** 3.2 8.1** 1.6 3.9 1.4 2.5 2.8 e
36.4*** 6.2 3.9 1.4 0.0 3.5 2.0 3.0 3.3 e
36.8*** 18.3*** 10.6** 2.1 0.5 0.6 4.0 5.2* 0.5 e
40.6*** 8.2* 5.4 2.3 1.2 0.8 0.7 e 1.6 e
21.04*** 208.83*** 83.18*** e 22.86** 5.35 1.33 5.28 e e e
Number of observations Likelihood ratio test (Chi2) P-value (Chi2)
1120 142.3 <0.001
864 92 <0.001
1527 117.1 <0.001
696 100.3 <0.001
7142 545.4 <0.001
1466 96.09 <0.001
1373 114.5 <0.001
***p < 0.01, **p < 0.05, *p < 0.1.
2012. The increase appears to have been step-wise rather than smooth. The increase in support coincided with what might be referred to as an increase in secularisation (see Table 1 and Supplement 1): the share of those who report having no religion in response to religious denomination query grew steadily from 31% in 1983 to 45.4% in 2012. Similarly, religiosity, proxied by the frequency of church attendance decreased. The share of those with the strongest religious identity (attending church once a week) decreased slightly: from 13% in 1983 to 10% in 2012, among less frequent attendants the percentage fell from 30.6 in 1983 to 23.7% in 2012, whilst the percentage of those who state that they never attend or have “no religion” increased from 55.7% to 65.03%. Notably, the highest rate of support with a relatively steady increase over time is observed in the least religious group, i.e. those who do not attend religious service (Supplement 1). For the most religious people, i.e. attending religious service once a week, the support varied by year and fell overall from 53.2% in 1983 to 48.0% in 2012. The multivariate regressions are presented in Table 2. The pooled regression demonstrates that there is a trend of increasing support over time, when other variables are controlled. Religiosity is the most important predictor of the attitudes in all years. Those who attend church regularly (once a week) are 5e11 times less likely to be supportive of a change in the law regarding euthanasia than those who never attended. Religious denomination is also seen to impact on the attitudes towards PAS. Non-Christians, whose
numbers grew in recent years (2005e2012), are about 4 times less likely to support legalisation of euthanasia than those with noreligion. Roman Catholics are more than twice as likely to oppose legalisation, although this relation is at the verge of significance in some of the years. For both religion and religiosity, there does not appear to be any definite trend in the magnitude of the effects over time. None of the other covariates demonstrated a consistent effect on the attitudes towards euthanasia across the six years of the study. 4. Discussion Our analysis, based on a nationally representative survey, shows an increase in support for legalisation of euthanasia in Britain over time e from 75.8% in 1984 to 83.8% in 2012. While the change of 8 percentage points may not seem dramatic, it remains statistically significant. It should be remembered too that the high initial support might have limited the potential for further increases over time. The increase in support coincides with an increase in the degree of secularisation recorded in the survey as measured by the percentage reporting no religious affiliation and the percentage reporting non- and infrequent attendance at religious services. The most substantial changes in the support for euthanasia legalisation over time happened among the least religious groups, while in the group of most religious people little change in attitudes are evident. These findings echo the descriptive work of others using the BSAS
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data (Clements, 2014) though our study tested these relations statistically accounting for the potential effects of the other covariates. The strength of religious affiliation together with religious denomination are not only statistically significant determinants of attitudes but are consistently the most important determinants of attitudes among the observable factors in defining attitudes towards euthanasia involving a physician. The findings echo those of others internationally in respect of involvement by physicians in hastening death (Anderson and Caddell, 1993; Bachman et al., 1996; Baume et al., 1995; Caddell and Newton, 1995; Jorgenson and Neubecker, 1980; Kalish, 1963; Suarez-Almazor et al., 1997; Sullivan et al., 1998; Ward, 1980). Given the trend, the role of religion and the evidence of increasing secularisation in our analysis, it may be tempting to infer that at some point a change in the law around hastening death in Britain is inevitable. The repeated legal challenges in the UK (UK Supreme Court, 2014) and the recent private members Bill in the UK House of Lords are consistent with this narrative. However, several important facts should be born in mind. First, trends in secularisation as well as the increase in support are not particularly dramatic over time. Moreover, increases in numbers of those classified here as “non-Christians” are associated with groups more likely to oppose legalisation of euthanasia. In other words, it would be dangerous to assume that current trends that support a change in legislation are immutable. Second, the position of doctors' groups, contrast starkly to the general publics' attitudes (Watt, 2014; Jaques, 2012; Wolfe et al., 1999). Given the envisaged role of doctors in hastening death, their opposition may hold greater sway in debates on the subject than others and/or on the impact of changes in the law on actual practices. Third, the current legal position in England and Wales which is prohibitive of hastening death by assisted suicide or euthanasia but provides for discretion in particular cases of assisted dying allows a perhaps more nuanced approach to the issue than legislation might otherwise provide. This pragmatic approach may serve to reduce if not remove the appetite for a change in the law. There is a need for explicit distinction between euthanasia and assisted suicide in public debates and surveys. The two currently seem to be conflated in the public mind, though they are distinct in terms of the psychological threshold that must be crossed before an individual requests their death to be hastened. The perhaps worrisome trends in hastened deaths the Netherlands and USA (Finlay and George, 2011; Twycross, 2014) seem to reflect concerns regarding euthanasia, but not for assisted suicide (Gamondi et al., 2014), though the interpretation of these statistics are debated (Onwuteaka-Philipsen et al., 2012). This debate further underscores the importance of separating these two ways of hastening death in public discourse.
5. Conclusion Our analyses have shown that consistently the most significant observable determinant of opposition to legalisation of euthanasia is religious beliefs and the strength of those beliefs as evidenced by frequency of religious service attendance. It is unsurprising therefore that support for legalisation of euthanasia has increased in Britain over the past 30 years coinciding with an increase in secularisation. It does not follow, however, that trends in public support are immutable nor that a change in the law would improve on the current approach in England and Wales that bans euthanasia and seeks to strike a balance between compassion and safeguards against abuse in respect of assisted suicide.
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Supplement 1. Dynamics of proportion supporting legalisation physician hastening death
Year
Support legalisation
p-value for difference in proportion from year:
n
1983
%
1984
Whole sample 1983 1262 (77.0%) 1984 1168 (75.8%) 0.443 1989 1018 (79.0%) 0.177 0.040 1994 801 (83.8%) p<0.01 p<0.01 2005 1434 (81.9%) p<0.01 p<0.01 2012 774 (83.9%) p<0.01 p<0.01 By religiosity (religious service attendance): Do not attend church 1983 759 (82.5%) 1984 696 (82.4%) 0.941 1989 582 (87.8%) 0.004 0.004 1994 503 (89.3%) p<0.01 p<0.01 2005 995 (88.0%) p<0.01 p<0.01 2012 534 (90.5%) p<0.01 p<0.01 Once a week 1983 109 (53.2%) 1984 85 (45.2%) 0.115 1989 73 (42.7%) 0.043 0.631 1994 52 (50.5%) 0.656 0.389 2005 78 (49.1%) 0.436 0.475 2012 47 (48.0%) 0.396 0.658 Less than once 1983 389 (77.0%) 1984 383 (76.0%) 0.697 1989 345 (79.5%) 0.362 0.200 1994 245 (84.8%) 0.009 0.003 2005 357 (78.8%) 0.508 0.299 2012 193 (82.1%) 0.115 0.061 By religious denomination: No religion 1983 435 (85.0%) 1984 426 (86.1%) 0.620 1989 398 (88.3%) 0.136 0.316 1994 350 (90.9%) 0.008 0.027 2005 593 (89.4%) 0.021 0.080 2012 369 (90.7%) 0.009 0.033 Any religion 1983 827 (73.3%) 1984 742 (70.9%) 0.216 1989 620 (74.1%) 0.706 0.131 1994 451 (79.0%) 0.011 p<0.01 2005 841 (77.3%) 0.030 0.001 2012 405 (78.5%) 0.025 0.001
1989
1994
2005
0.005 0.049 0.004
0.215 0.967
0.204
0.394 0.904 0.123
0.407 0.511
0.113
0.210 0.246 0.403
0.821 0.720
0.864
0.073 0.802 0.412
0.043 0.416
0.302
0.211 0.533 0.251
0.446 0.905
0.520
0.034 0.101 0.066
0.432 0.842
0.593
The p-values provided in bold are <0.05, i.e. representing presence of a significant difference at 0.05 level.
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