Key findings of the 2022 IAHPC Assisted Dying Practices and Euthanasia Survey

Methodology

All 1,050 IAHPC members were invited by email to participate in an online survey in Survey Monkey between August 10 and October 31, 2022. Participants were given the option to reply to an English or a Spanish version of the survey. The survey was divided into five sections: 1) legal status of assisted dying practices in their country and state, 2) their degree of involvement in palliative care, 3) personal opinion, 4) current practice, and 5) sociodemographic data. Questions were based on a scoping review. Three reminders were sent. Participation was voluntary and anonymous. IAHPC offered members who participated and were willing to share their names, a three-month extension of their annual membership by way of thanks. Responses of those members who chose this option were anonymized and separated from their identifying information for the analysis.

Definitions

As several terms, definitions, and statements are used to describe assisted dying practices, the IAHPC applied the following definitions for consistency and for the purposes of the survey. 

Euthanasia: An act by a person, usually a physician or other health care provider, actively and intentionally to end another person's life by some clinical medical means, such as a lethal injection, at that person's explicit request. 

Physician-assisted suicide (PAS) and physician-assisted dying (PAD): An act by a physician or other health care provider to intentionally help a person to end their life by providing a lethal dose of medication that the person can self-administer. The explicit intention is to end the person’s life following their voluntary and competent request.

Assisted dying practices: An umbrella term that includes all the above.

Palliative sedation: The monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family, and health care providers. 

Voluntary stopping of eating and drinking (VSED): A deliberate, self-initiated attempt to hasten death in the setting of suffering refractory to optimal palliative interventions or prolonged dying that a person finds intolerable.  

Results

A total of 263 responses were submitted (response rate=25%) from participants in 66 countries. Most participants were: between 45 and 64 years old (52.9%), physicians (65.4%) with a subspecialty (50.6%), working 75% to 100% of the time in palliative care (51.7%), with an average professional experience of 14 years (SD 19.8) ranging from 0 to 40 years.
56.2% self-reported as Christian, of which 45% were Roman Catholic.

Main Findings

On the current status of assisted dying practices

Most participants report residence in a country where both euthanasia and physician-assisted suicide are listed as criminal offences in the penal code (n=152, 57.8%).

In your country, is physician-assisted suicide currently:

In your country, is euthanasia currently: 

On public debate about assisted dying practices

On whether there is a current public debate about assisted dying practices in the country

55% of respondents reported an ongoing public debate in their country of residence about euthanasia, about physician-assisted suicide, or both:

Regardless of current legal status, is there currently public debate about assisted dying practices in your country?

On how debates on assisted dying practices affect the development of palliative care in the country

When categorized by region, responses to the first statement, “They help palliative care development by bringing it up as a topic in the discussions,“ appear as follows:

When categorized by region, responses to the statement, “They hinder palliative care development by removing focus from palliative care,“ appear as follows:

On the provision and legalization of assisted dying practices

On the question if provision of assisted dying practices is part of palliative care

On the legalization of physician-assisted suicide and euthanasia

• 49% support the availability of physician-assisted suicide. Of these, 56% think that it should be available only for specific situations (exceptional cases), with narrowly defined safety criteria.
• 47.5% support the availability of euthanasia. Of these, 55% think that it should be available only for specific situations (exceptional cases), with narrowly defined safety criteria.
• 45% stated that assisted dying or euthanasia should not be available at all. 
• 5.7% and 7.6% were not sure about legalizing assisted dying or euthanasia, respectively.

On the level of agreement with different statements

• 71.1% agreed that, “Health care workers should be allowed to opt out of practicing euthanasia/physician-assisted suicide if they have a conscientious objection.”
• 53.2% agreed that, “With adequate palliative care, social support, and pastoral services, there is no need for euthanasia/physician-assisted suicide.”
• 40% agreed that, “A health professional should face criminal or administrative consequences for performing euthanasia if it’s illegal in the country.”
• 39.2% agreed that, “Euthanasia is wrong and should never be practiced regardless of the legal status and what the patient or the professional feels/believes in.” 
• 39.2% agreed that, “Physician-assisted suicide is not necessary, as there are alternative options such as palliative sedation and VSED.”
• 38.8% agreed that, “A health professional should face criminal or administrative consequences for assisting in a suicide if it’s illegal in the country.”
• 33.8% agreed that, “Physician-assisted suicide is wrong and should never be practiced regardless of its legal status and what the patient or the professional feels/believes in.”
• 25.5% agreed that, “Patients should have a right to choose euthanasia and receive it for any reasons the patients may choose. It should be legalized and made available in countries where they are not.”    
• 18.6% agreed that, “Health insurance should cover the cost of providing euthanasia/assisted death and/or it should be publicly funded.”    
• 17.5% agreed that, “Regardless of its legal status, many cases of physician-assisted suicide are underreported.”    
• 14.1% agreed that, “Regardless of its legal status, many cases of euthanasia go underreported.”    
• 7.2% agreed that, “I have conflicting opinions on assisted dying practices and cannot make up my mind.”

On whether they agree with the IAHPC Position Statement on Euthanasia and Physician-Assisted Suicide* 

*IAHPC Position Statement: IAHPC believes that no country or state should consider the legalization of euthanasia or PAS until it ensures universal access to palliative care services and to appropriate medications, including opioids for pain and dyspnea.

On assisted dying for themselves, and patients' wishes

On whether they would personally consider euthanasia/medically-assisted death for themselves

Wishes expressed for hastened death, euthanasia, or assisted suicide

Of those who stated that they have patients with palliative care needs (n=250) we asked how frequently, during one year, their patients express a wish for the following (regardless of the legal status in their country):

• 28 professionals (10.6%) work at a facility that allows assisted dying. All but three of those professionals work in facilities that allow health care workers to exercise their right of conscientious objection and opt out of the practice. 
• Seven professionals reported having been personally involved in assisted dying, four of them often (every month), and three infrequently (twice a year). Four of them feel comfortable and had no objections, two were neither comfortable nor uncomfortable, and one reported being uncomfortable.

Open Comments 

Participants were also given the option of providing comments in free format. The following are an indicative sample of the comments received. 

Palliative care may end the request for assisted dying

“I pray and hope that palliative care should be able to reach all patients who need it, so that people do not ask for euthanasia.” (Nurse from Uganda)

“I have experienced instances very rarely of a patient asking to be helped to die. These patients come to us in severe, excruciating pain. After we have treated their pain successfully and we ask them if they still want to die, they vehemently say they do not want to die any more. When pain is controlled, patients get hope and are motivated to do something with their life. They want to work on unfinished business; this varies from wanting to reconcile with family or friends to building a house for a wife or children.” (Nurse from Uganda)

“Palliative care is free and everyone needs to die in dignity receiving quality of life by trained palliative care health providers. [G]ood, accessible, affordable, acceptable, and quality palliation is the way to go, with no euthanasia.” (Nurse from Kenya)

Palliative care cannot always alleviate all suffering

“Palliative care is not the answer for all kinds of suffering. Willingness to die is a complex situation, the response must be an individualized PROCESS, not just euthanasia or palliative care.” (Physician from Spain)

 “Palliative care, offered in all domains, is sometimes not enough. There are domains of pain which are not answered except in allowing death in the manner and timing of the patient.” (Physician from the United States)

“Palliative care does not always have the complete answer to relieve suffering, and we must be humble when people decide hastened death.” (Physician from Colombia)

Political and religious aspects

“Pro-euthanasia defenders consider themselves as freedom fighters and they seem to me the worst face of ultraliberalism.” (Physician from Spain)

“I think we should allow God himself to end someone's life.” (Nurse from Uganda)

“Religious doctrines affect my stand on the subject matter a great deal.” (Pharmacist from Ghana)

“I am concerned that the position regarding end of life has been ‘Christianized’ in North America.” (Physician from the United States)

Against

“My stand is that ‘assisted dying practices’ should not be practiced in any country.” (Nurse from Ethiopia)

“In countries that legalized euthanasia, our descendants will probably witness the famous public apology from the government in 2100, 50 years after the unavoidable abuses, gross mistakes, scandals and lawsuits about to happen with the end of life of the Baby Boomers.” (Allied health professional from Canada)

“Life has an absolute value; a dignified death is not synonymous with euthanasia or assisted suicide. Dignity and quality of life are intrinsic aspects of the human being and palliative care is holistic care that is not limited to the physical but transcends the spiritual.” (Physician from Cuba)

Need to discuss

“I find such resistance to this discussion not only in my local environment, but in the palliative care field generally.” (Social worker from Zimbabwe)

“We should at least start discussing, instead of no discussion.” (Social worker from Hong Kong)

“I believe that a broad debate involving all sectors of society is necessary in order to make progress on this issue.” (Physician from Mexico)

Autonomy

“I believe that patients have the right to decide for themselves but, as a provider, I should be given the chance to refuse when I strongly feel against a procedure.” (Nurse from the United States)

“I agree that quality palliative care be provided before any Medical Aid in Dying is pursued, but if not effective, a person should have the right to end their suffering with the help from the medical profession. They shouldn't be made to suffer needlessly because we're uncomfortable with this therapy.” (Nurse from the United States)

“This is about how a society values their elderly, their sick, their dying...and balancing ethical principle of autonomy with the other key pillars...with the emphasis always on listening, respecting and protection of those suffering.” (Physician from the United Kingdom)