End-of-life decisions : studies of attitudes and reasoning

The overall aim of this thesis is to study attitudes towards and reasoning for and against end-of-life decisions among physicians and the general public in Sweden. The end-of-life decisions in focus are refraining from life-sustaining treatment, continuous deep sedation, physician-assisted suicide and euthanasia. The thesis consists of four studies.

STUDY I. Aim: To study attitudes and reasoning towards physician-assisted suicide. Methods: A postal questionnaire distributed to 1,206 individuals in the general public. Results: Response rate 51%. Of these, 73%, replied in favour of physician-assisted suicide, 12% against and 15% were undecided. A majority believed that their trust in the medical services would either increase or not be influenced at all if physician-assisted suicide were to be allowed. Conclusion: No evidence was found for the assumption that trust in the medical services would be jeopardised if physician-assisted suicide were to be legalised.

STUDY II. Aim: To study attitudes and reasoning towards the withdrawal of lifesustaining treatment on a competent patient’s request. Methods: A vignette-based postal questionnaire distributed to 1,200 physicians and 1,202 individuals in the general public. Results: Response rate 57% (physicians) and 48% (general public). A majority in both groups prioritised arguments in favour of terminating life-sustaining treatment on a patient’s request and classified the act as defensible in all vignettes. Conclusion: There seems to be a widespread consensus regarding competent patients’ right to refrain from life-sustaining treatment.

STUDY III. Aim: To investigate attitudes towards physician-assisted suicide and euthanasia, and to explore whether continuous deep sedation is considered an acceptable course of action. Methods A vignette-based postal questionnaire distributed to 1,200 physicians and 1,201 individuals in the general public. Results: Response rate 56% (physicians) and 52% (general public). Among physicians, 22% favoured granting a request for physician-assisted suicide expressed by a non-terminally ill patient with Huntington’s disease; 21% accepted continuous deep sedation as an alternative. Among the general public, 59% declared themselves in favour of physician-assisted suicide; 60% accepted continuous deep sedation as an alternative. Conclusion: A significant proportion of Swedish physicians and the general public seem to be more liberal in their views on continuous deep sedation than current guidelines permit.

STUDY IV. Aim and methods: A moral philosophical investigation of Daniel Sulmasy’s ‘reinvented’ version of the rule of double effect, the aim being to determine the moral relevance of the intention/foresight distinction and this distinction’s alleged implication for the moral difference between continuous deep sedation and euthanasia. Conclusion: The reinvented rule of double effect is an improvement compared to the traditional version, but it will not stand closer scrutiny. The range of proper applicability has narrowed significantly and, more importantly, Sulmasy fails to establish that there is a morally relevant distinction between intended and foreseen effects.

List of scientific papers

I. Lindblad A., Löfmark R., Lynöe N. (2009). Would physician-assisted suicide jeopardize trust in the medical services? An empirical study of attitudes among the general public in Sweden. Scandinavian Journal of Public Health. 37:260-4.
https://doi.org/10.1177/1403494808098918

II. Lindblad A., Juth N., Fürst CJ., Lynöe N. (2010). When enough is enough; terminating life-sustaining treatment at the patient’s request: a survey of attitudes among Swedish physicians and the general public. Journal of Medical Ethics. 36: 284-9.
https://doi.org/10.1136/jme.2009.034967

III. Lindblad A., Juth N., Fürst CJ., Lynöe N. (2010). Continuous deep sedation, physician-assisted suicide and euthanasia in Huntington’s disorder: A study of attitudes among physicians and the general public in Sweden. International Journal of Palliative Nursing. 16: 527-33.
https://pubmed.ncbi.nlm.nih.gov/21135785

IV. Lindblad A., Lynöe N., Juth N. (2012). End-of -life decisions and the reinvented rule of double effect: A critical analysis. Bioethics. 2012 Oct 1.
https://doi.org/10.1111/bioe.12001