In this survey of attitudes toward critical interventions at the end of life of terminally ill patients, the most interesting finding was that most of the participants in each of the four study groups — patients, family caregivers, oncologists and members of the general public — showed a positive attitude toward the withdrawal of futile life-sustaining treatment and the practice of active pain control.
These findings suggest that recent debates about death with dignity and a generalized desire to counter “bad” ways of dying have influenced opinion.4,22,23
In the absence of effective palliation, it is no surprise that patients and others would choose a route that avoids the prolongation of suffering. Palliative care was introduced to Korea recently but is still rare, and practical services are provided mainly by oncologists or family physicians in inpatient care units.
Overall, the attitudes of the group representing the general public were similar to those of the cancer patients. This similarity might be explained by the general public’s empathy for patients with terminal illness. Whereas the patients and the members of the general public appeared to support patient autonomy and hastening of the dying process, the oncologists and family caregivers who participated in the survey had more negative attitudes. Their attitudes might be influenced by uncertainty about the prognosis, religious beliefs, fear of pressure on vulnerable patients and legal circumstances.5
In Korea, where advance directives are not legally binding, the withholding or withdrawal of futile life-sustaining treatment according to a patient’s wishes is controversial, and it is not dealt with in medical training programs. In our study, however, oncologists were the group that was most accepting of the withdrawal of futile life-sustaining treatment and the practice of active pain control. These findings suggest that oncologists have an interest in improving end-of-life care, as is supported by physicians working in voluntary hospice services in the United Kingdom.24
In our survey, attitudes toward acceptance of euthanasia and physician-assisted suicide were associated with age, sex and religious belief. In most other studies, however, sex was not a major influential factor,14,15,20,25
and the effect of age was inconsistent.9,14,20
As people age, they are confronted with deteriorating health and the death of friends or family members; thus, they may be expected to support the easing of dying through withdrawal of life-sustaining treatment and physician-assisted suicide.5,9
These findings suggest that the shift in attitudes comes from the experiences of an aging population rather than from the younger generation’s “new ideas.”
We found that religious belief correlated significantly and negatively with acceptance of interventions used for terminally ill patients at the end-of-life. This observation supports previous findings that religion is a strong determinant of the attitudes of patients,11,14,17,20,26
and the general public.4,11,17
We found that participants with lower education levels were more supportive of active euthanasia and physician-assisted suicide than were more educated participants. It is interesting that religion and education correlated similarly with attitude toward euthanasia. These findings warrant further study for confirmation.
Although there has been concern in the United States that poor people would be more likely than those in higher income groups to choose a hastened death,21
we found no association between monthly income and attitude toward any of the life-ending interventions studied. In Korea, there are few uninsured people. National health insurance, together with medicare for low-income people, covers almost the whole population. Especially for cancer, coverage is high, and the patient’s out-of-pocket share was 10% in 2000 and decreased to 5% in 2010. That helps explain the lack of an association between income and support for physician-assisted suicide and euthanasia.28
In contrast, higher income was associated with approval of the withdrawal of futile life-sustaining treatment and the practice of active pain control. These findings suggest that the association between income and end-of-life interventions varies by type of intervention.
Surveys conducted in other countries have reported that 60%–90% of patients support euthanasia or physician-assisted suicide,8,14–17,20
as compared with only about 50% of patients in our study. The relatively higher proportion of negative attitudes in Korea toward the hastening of death of terminally ill patients could possibly be ascribed to different cultural attitudes toward personal autonomy. Earlier empirical studies, especially those from Western countries, generally showed an increase in public acceptance of euthanasia that might be explained by a rising belief in personal autonomy regarding end-of-life decisions and the individualism that has been increasing over the last two decades.4
It is understandable, then, that euthanasia is more acceptable in those parts of the world that traditionally favour personal autonomy (e.g., North America and Europe) and less acceptable in parts that favour more paternalistic or family-centred models of decision-making (e.g., Asia).
Our finding that oncologists were more negative than the other study groups toward euthanasia and physician-assisted suicide supports findings from the Netherlands, the United States15
and the United Kingdom.26
Moreover, oncologists in the United States and Europe are reluctant to accede to requests of terminally ill patients to help hasten death, probably because they will be held accountable for the deaths.5,9,21
Other reasons might be a belief that symptoms can be controlled without resorting to euthanasia or, perhaps, the honouring of the Hippocratic oath.
Our study has several limitations. First, we enrolled only cancer patients, their family caregivers and oncologists from university hospitals, so our results may not be generalizable to other treatment settings or to other terminal illnesses. The nature of cancer is such, however, that most patients are likely to face the end-of-life issues discussed here.
Second, we interviewed the patients, family caregivers and oncologists in person, whereas the members of the general public were surveyed by telephone. This difference may have lessened the validity of the comparisons. However, we used a model based on identical study designs and questionnaires for all participating groups in an attempt to overcome this shortcoming.
Third, although there was no obligation to participate in the survey, the response rates in the patient and family caregiver groups were very high. High response rates are not usual for surveys in Korea; however, in our study, the patients’ oncologists recommended participation, which may have caused the patients and their family caregivers to feel a sense of obligation. It may also have caused patients to provide answers that the survey seemed to want.
Fourth, although the questionnaire in our survey was designed on the basis of those used in previous studies of this issue,5,9,11,20,21
it was not validated separately.
Fifth, we did not analyze the attitudes of patients by their stage of cancer. Those who knew they were dying may have had different opinions from those hopeful in the face of a new diagnosis. Further study is needed for confirmation.
Finally, we did not include in the database any important variables — such as the participants’ own experiences with chronic or critical diseases, their experiences of caring for family members or loved ones, or their being cared for by family members. Including those variables in the multiple logistic regression analysis might have changed the results.
Our study suggests that, although the various participant groups shared the same attitude toward futile and ameliorative end-of-life care (the withdrawal of futile life-sustaining treatment and the use of active pain control), oncologists had a more negative attitude than those in the other groups toward the active ending of life (euthanasia and physician-assisted suicide).