Sm. Sci. Med. Vol. 39, No. 5, pp.

64-654, 1994
Copyright 0 1994 Elsevier Science Ltd
Pergamon 0277-9536(93)EW66-N Printed in Great Britain. All rights reserved
0277-9536/94 $7.00 + 0.00

EUTHANASIA: WHY PEOPLE WANT TO DIE EARLIER

CLIVE SEALE’ and JULIA ADDINGTON-HALL*

‘Department of Sociology, Goldsmith’s College, University of London, Lewisham Way, London
SE146NW, U.K. and ‘Department of Epidemiology and Public Health, University College London,
66-72 Cower Street, London WClE6EA, U.K.

Abstract-The results from two surveys in England of relatives and others who knew people in samples
drawn from death certificates are reported. The main focus is on a sample of 3696 people dying in 1990
in 20 health authorities, with supporting analysis from an earlier national sample of 639 people dying in
1987.
The incidence of people saying they wanted to die sooner, and of requests for euthanasia are reported.
Excluding a proportion who did not wish to express a view, or did not know the answer, about a quarter
of both respondents and the people who died expressed the view that an earlier death would be, or would
have been, preferable. 3.6% of people in the 1990 study were said to have asked for euthanasia at some
point in the last year of life. The extent to which such views were determined by the experience of pain,
other distressing symptoms, dependency and social and cultural factors such as religious belief and social
class is explored. The finding that dependency was important in causing the feeling that an earlier death
would have been better, as well as requests for euthanasia, is related to the public debate about euthanasia,
which often contains the assertion that fear of pain is a dominant factor. Pain was found to be a significant
factor in death from cancer, but not as important for other causes of death. Social class, place of residence
of the deceased, and strength and type of religious faith were found to be largely insignificant in influencing
feelings about an earlier death and requests for euthanasia.

Key wordsAeath, euthanasia, hospice, cancer

INTRODUCTION against euthanasia in different hypothetical situations

In recent years there have been periodical upsurges of
[3]. Reports of single instances of euthanasia are
public and medical concern about euthanasia.
also occasionally presented [4]. This paper reports an
Currently, the position of the British Medical Associ-
empirical contribution to this debate, describing
ation is summarised as follows:
the circumstances in which a representative sample
of adults died, using the accounts given by relatives
The law should not be changed and the deliberate taking of
and others after the death. The analysis reported
a human life should remain a crime. This rejection of a
change in the law to permit doctors to intervene to end a here assesses the influences on both respondents’
person’s life is not just a subordination of individual wellbe- views and the reported views of the dying people
ing to social policy. It is, instead, an affirmation of the themselves about the desirability of an earlier death.
supreme value of the individual, no matter how worthless In addition, the causes of requests for euthanasia are
and hopeless that individual may feel [I].
reported.
Doubts about the wisdom of this position are
Focus of investigation
sometimes brought about by reports of particularly
harrowing cases, such as that in 1992 of Dr Nigel Cox This paper will assess the type of suffering that is
in the United Kingdom. Dr Cox was convicted of most likely to influence the desire to die earlier. An
attempted murder for administering a potentially analytic distinction is made between symptom
lethal injection to his patient who was suffering distress and dependency, as well as between different
unbearable pain. In this action he was following both groups of symptoms. This is important in assessing
the patient’s and the family’s wishes. In view of public the claims of opponents of euthanasia that good care
concern over this conviction, Richard Smith, editor is an adequate substitute, a topic that is explored
of the British Medical Journal wrote that: more fully in a subsequent paper.
In addition this paper will test the proposition that
It is time for the British to think deeply about euthanasia
there is an urgency to the need for a (royal) commission as the desire to die earlier, and requests for euthanasia,
one effect of (the Cox) case is likely to be that patients will be are more common in urban dwellers, the younger
terrified of talking to doctors about the possibility of their dying, those in higher social classes and the non
deaths being hastened. And dying alone afraid of talking to
religious. By implication, the alternative proposition
your carers may be much worse than being dead [2].
that these factors are unlikely to be important when
Much of the literature on this topic is written as people are very close to death (either themselves, or
moral philosophy, rehearsing the arguments for and through having experienced bereavement) will be

SSM W/SD
647
648 CLIVE SEALEand JULIA ADDINGTON-HALL

tested. Thus the relative importance of cultural The table shows that about a quarter of respon-
factors as against suffering will be assessed. dents who answered the question felt that it would
have been better if the person had died earlier, and
METHODS that a similar proportion of the dying people were
said to have felt this. A much smaller proportion were
This paper reports results from a survey of the said to have asked for euthanasia.
relatives and others who knew 3696 people dying in In addition to the exclusion of sudden deaths, a
1990 in 20 district health authorities in England. This proportion of respondents either did not know the
survey repeated the method of an earlier study of 639 answer to the question, or preferred to couch their
deaths in 1987 based on a nationally representative answer in terms other than those offered. The re-
sample [5]. Results from this earlier study are sponse bias introduced by all of these exclusions was
reported here in so far as they support or differ from investigated in both data sets for the question
the results from the larger study. concerning respondents’ views. In both surveys
Data were gathered by means of structured responders to the questions were more likely than
interviews with people in the community who best those who did not reply to it to be reporting for
knew the circumstances of the last year of life. people who suffered dependency and distress (as
Response rates for the two studies were 69% (1990) measured by the variables described in the section
and 80% (1987). The 1990 study sampled deaths from that follows), who were older, who suffered from
cancer disproportionately, so in the analysis of the cancer and who did not suffer from heart disease. In
whole sample these were weighted by a factor of 0.27 the 1990 survey respondents describing the deaths of
to conform to the proportion of deaths due to cancer women and of people who did not live in inner city
in the districts (26%). This gives an overall weighted areas were more likely to respond to the question. In
sample of 2192. The effect of this on significance both surveys responders were more likely to be sons
levels is conservative. Weighting is not used where or daughters of the deceased and less likely to be
cancer deaths are considered separately. spouses than non responders. The strength or type of
religious faith of either the deceased or the respon-
MEASURES dent was not associated with replying to the question,
nor was the social class of the deceased. Response
Dependent aariables bias to the questions about the deceaseds’ views in the
In both studies respondents were asked ‘Looking 1990 survey followed the same pattern [6].
back now, and taking (the deceased’s) illness into
Independent variubles
account, do you think s/he died at the best time-or
would it have been better if s/he had died earlier or In addition to background variables such as age,
later? In the 1990 study respondents were also asked gender and so on, and individual questions which will
‘What about (the deceased)? Did s/he ever say that bc described as results are reported, some composite
they wanted to die sooner?’ and ‘(If yes) did s/he ever scales of symptom distress and dependency were
say that s/he wanted euthanasia? created. Respondents were asked to report on the
The questions were not asked for people who died presence of 15 symptoms of illness, and to rate them,
suddenly with no illness or warning or time for care, if present at all in the last year of life, on a three point
and in a few cases where the respondent could not scale ranging from ‘very’ (scoring 3) to ‘fairly’
have been expected to know the answer (e.g. where a (scoring 2) to ‘not very distressing’ (scoring I). A
coroner was the only person who could be found to factor analysis of these symptoms (excluding pain
be interviewed). The frequencies for the responses to which is treated separately in the analysis) revealed
these questions are given in Table 1. four factors in both data sets, which were used to
create four different composite measures of symptom
distress. In addition. dependency on others for activi-
Table I. Views about dying earlier, and requests for euthanasia
(percentages, with 1990 data weighted)
ties of daily living was assessed by seven items, where
respondents also reported on the duration of depen-
Respondents’
views Deceaseds’ reported wishes dency, ranging on a six point scale from ‘less than a
1987 1990 I990 week’ to ‘more than a year’ before death or final
Best time 62 57 To die earlier 24 admission to a hospital or hospice. These dependency
Better earlier 24 28 Asked for euthanasia 3.6
14
items were shown to be unidimensional by factor
Better later I5
analysis in both data sets, and were combined to give
Valid N (= 100%) 434 1720 1907” a dependency score. Components of symptom dis-
Don’t know/
other answer I7 I3 D/K 8 tress and dependency scores are given in Tables 2
Missing I5 8 Miss. 5 and 3.
In the analysis that follows, these scales were
N(= 100%) 639 2192 2192
converted to give a three point scale (None, medium
“26 people who said that the person had wanted to die sooner said
they did not know whether the person had asked for euthanasia. and high). Here, a zero means that no symptoms or
giving a base of 1881 for the euthanasia figure. dependency were reported, and the cut-off points for
 Euthanasia: why people want to die earlier 649

Table 2. Components of four symptom distress scores

Appetite Control Mental Breath
Sickness/Vomiting Loss of bladder Mental Trouble with
control confusion breathing
Dry mouth Loss of Depression or Persistent
bowel control feeling miserable cough
Loss of appetite Unpleasant Sleeplessness
smell
Difficulty swallowing Bedsore
Constipation
Reliability (alpha)
1987 = 0.7246 0.6454 0.4783 0.4850
1990 = 0.6558 0.5881 0.5208 0.5123
Range=&15 &I2 &9 I%6
Cut-off for high score = 3 3 3 3

‘high’ levels are given in the tables, other scores The table shows that very distressing pain was
falling into the ‘medium’ category. judged to be more common in cancer than other
causes of death, and a high level of distress on the
composite appetite measure was also reported for
RESULTS
cancer. The other symptom distress measures were
Distress and dependency: the role of suffering only marginally higher in cancer, but overall, the
table suggests that cancer is a cause of death that
The argument for euthanasia arises from the
involves higher levels of both physical and mental
perception that illness near the end of life involves
distress than other causes of death. Ischaemic heart
intolerable levels of suffering, such that the quality of
disease, on the other hand, causes comparatively low
peoples’ lives deteriorates to the point where it is no
levels of symptom distress. People dying from stroke
longer worth living. Respondents were asked to
(CVA) were somewhat less likely to suffer from very
describe the dying person’s quality of life as either
distressing pain, as well as scoring low on breath
‘good, fair or poor’ during their final year. The degree
(Breathlessness and coughing). As might be expected,
to which this was associated with views about dying
those dying from respiratory disease scored particu-
earlier and requests for euthanasia is shown in
larly highly on breath and people dying from mental
Table 4. The table shows a moderate association
conditions, including Alzheimers, scored particularly
between reported quality of life and all the measures
highly on mental. People dying from mental
of the desire to die earlier. However, the question
conditions and Alzheimer’s were also the most
about quality of life occurred directly after the
dependent. Respiratory disease and stroke involved
question about whether it would have been better to
dependency levels that were slightly above average;
die earlier. It might reasonably be argued that this
ischaemic heart disease was below average, and
might have biased respondents’ assessments of
cancer about average [7].
quality of life. Much earlier in the interview, before
If symptom distress leads to a desire to die earlier,
any question of wishes to die earlier had arisen,
one might expect such wishes to be more likely for
respondents were asked to describe the symptoms
people dying from cancer. If dependency is a causal
and dependency which the dying people experienced.
factor, one might also expect such wishes to be more
The results show, firstly, that there is variation in
likely for those dying from mental conditions and
these in the last year of life: some people suffer more
Alzheimers, although due to mental confusion this
than others, and different causes of death involve
would be a view more likely to be expressed by the
different types of distress and dependency. This is
shown in Table 5.
Table 4. Reported quality of life, views about dying earlier, and
requests for euthanasia (percentages with base number in paren-
Table 3. Components of dependency score theses; 1990 data weighted)
Dependency 1987 1990 1990
Respondents’ Respondents’ Deceased’s
Get in and out of bath or shower
views views views
Dress/undress (inc. shoes/fastenings)
Go to toilet (cope on own while there)
Better Better Wanted Wanted
Wash (and shave)
earlier earlier sooner euthanasia
Cut own toenails
% % % %
Make a hot drmk
Need help at night Good 12 (154) 12.5 (637) I3 (716) 1.0(712)
Reliability (Alpha) Fair I4 (132) 23(519) 23 (580) 3.3 (573)
Poor 48 (124) SO(5lO) 39 (553) 6.7 (546)
1987 = 0.9253
All 23 (410) 27 (1665) 24(1848) 3.5(1831)
1990 = 0.9296
Cramer’9
Range = &42 v= 0.38 0.35 0.25 0.13
Cut-off for high score = 18 P= < 0.00005 <0.00005 < 0.00005 < 0.00005
650 CLIVE SEALEand JULIAADDINGTON-HALL

Table 5. Cause of death by distress and dependency (percent saying It was at the highest level; 1990 data
only)
Type of Other Mental
distress Cancer IHD CVA circulatory Respiratory /Alzheimers Other
Pain 53 36 28 36 35 39 36
Appetite 83 42 45 4x 61 4x 57
Control 4s I7 38 26 41 39 37.5
Mental 63 45 41 46 58 70.5 57
Breath 35 72 I4 27 53 IX 2:
Dependency 38 22 42 31 49 79 47

Total (100%) 2074 564 237 207 242 64 278

respondent than the person themselves. People dying direct link between aspects of distress and depen-
from ischaemic heart disease should be the least likely dency and views about dying earlier will now be
to express this view. The results shown in Table 6 test explored. This is important in assessing what can be
these ideas. Table 6 shows that, in death from cancer, done by those who give care to relieve suffering,
respondents were no more likely than average to say should one of the aims of this be to obviate the wish
that it would have been better if the person had died to die sooner. If pain, for example, is an important
earlier, in spite of this cause of death involving high determinant, the argument that pain relief can reduce
levels of suffering [S]. This sentiment was most likely the likelihood of a wish to die sooner gains strength.
to be expressed for people dying from respiratory Table 7 shows how the experience of pain affected
disease and, in particular, mental conditions. As this.
expected, ischaemic heart disease is the least likely to Pain is only weakly associated with views about an
be associated with respondents who felt an earlier earlier death, as expressed both by respondents and
death would have been better. IHD is also signifi- as reported by the dying people themselves. Very
cantly less likely to be associated with requests for distressing pain appears to be associated with more
euthanasia from those who died. requests from the dying for euthanasia, but this is not
An examination of the dying person’s reported statistically significant.
views about dying sooner shows few differences, with In fact other forms of distress and dependency
the only exception being those dying from respiratory show somewhat stronger associations with the desire
disease. In contrast to respondents’ views, it is death to die sooner and requests for euthanasia, as Table 8
from cancer that is most likely to have led to requests shows.
for euthanasia. Dying from mental conditions is not The measures of symptom distress are, for the most
associated with a high incidence of such requests, and part, significantly associated with both respondents’
this is in contrast to the views of respondents. This views and those of the dying people, with the
contrast might be expected in a group likely to be exception of breath (in the 1987 survey appetite was
suffering from mental confusion. also not significant). The associations for control and
Different diseases, then, are associated with mental are somewhat stronger than the others.
different patterns of distress and dependency, and Dependency is also associated with these views.
are also associated with differences in views about Reports of requests by the dying for euthanasia rise
dying earlier and requests for euthanasia. The as levels of distress and dependency rise.
As the different types of distress and dependency
were interrelated, multivariate analysis was used to
Table 6. Cause of death, by views about dying earlier and reported
requests for euthanasia (percentages; base numbers are given in assess which aspects of suffering had the strongest
brackets: 1990 data o&1 independent relationship with wishes to die earlier [9].
Respondents’ Deceased’s This was done separately for cancer and other causes
views views
of death and the results are shown in Table 9. Results
Better Wanted Wanted
earlier SOD”IX euthansia
Table 7. Pain and views about dymg earlier (I990 weighted data;
CCl”CCX 28 (1821) 23(1980) 5.2** (1952) percentages, with base numbers in parentheses)
IHD l4** (396) 23 (443) 1.8’(441)
Respondents’ Deceased’s
CVA 33 (195) 22 (217) 3.7 (216)
views views
Other circulatory 26(152) 23 (175) 2.9 (173)
Respiratory 40** (197) 30’ (222) 2.7 (219)
Better Wanted Wanted
Mental” 48” (54) 22 (58) I .8 (57)
Level of pain earlier Sooner euthanasia
Other ,
32 (2101 I
27 (232)
~ I
4.3 (230)
~ I

None 23 (341) 17 (402) 2.6 (400)

*P < 0.05; l*P < 0.01; Significance tesls comparing each cause of
Not very
death with all others.
distressing 25 (183) 2s (193) 2.8 (193)
‘Includes Alzheimers.
Fairly 24 (409) 25 (454) 2.8 (449)
% the 1987 survey, CVA was significantly more likely to be
Very 32 (688) 29 (743) 5.0 (734)
associated with respondents who felt a” earlier death would have
All 27 (1621) 25(1793) 3.7 (1775)
been better (P <0.05). Differences for IHD and respiratory
PC 0.01 0.001 not significant
death were not significant. Numbers were too low to test for
Cramer’s Y = 0.09 0.1 I 0.06
‘mental’ causes.
 Euthanasia: why people want to die earlier 651

Table 8. Views about dying earlier and requests for euthanasia by level and type of suffering (1990
weighted data)
Appetite Control Mental Breath &pendency
Respondents’ views: % better if deceased had died ealier
None 13 (216) 14 (663) I I (253) 27.5 (691) 12.5 (404)
Medium 22 (267) 27.5 (247) 19 (373) 28 (409) 22 (421)
High 30.5 (820) 37 (533) 34 (848) 28 (548) 38 (539)
All 26(1304) 25 (1443) 26 (1474) 28 (1648) 25.5 (1364)
P< 0.00005 0.00005 0.00005 not significant 0.00005
Cramer’s
v= 0.15 0.24 0.21 0 0.25

Deceaseds’ views: % wanting to die ~mner

None 13 (250) 16.5 (760) 7 (299) 22.5 (762) I2 (468)
Medium 18 (299) 29 (266) 13(415) 23 (473) 24 (462)
High 30 (896) 32 (574) 34(913) 28 (590) 31 (585)
All 25(1445) 24 (1601) 24 ( 1626) 24(1824) 23(1515)
P< 0.00005 0.00005 0.00005 not significant 0.00005
Cramer’s
v= 0.16 0.17 0.28 0.06 0.19

Deceaseds’ views: % wanting euthanasia

None 0.8 (250) I .7 (753) I .2 (298) 2.5 (756) I .7 (465)
Medium 0.9 (299) 4.5 (264) I.1 (414) 3.9 (466) 2.8 (457)
High 5.7 (882) 5.7 (568) 5.3 (901) 5.2 (584) 5.9 (581)
All 3.8 (1431) 3.6(1585) 3.5(1614) 3.7 (1806) 3.7(1503)
P< 0.00005 0.001 0.00005 0.05 0.001
Cramer’s
v= 0.12 0.1 0.11 0.06 0.1

are expressed as odds ratios, which can be interpreted one can say that of those dying from cancer in 1990,
as the increase in the odds of a person who has a high a high level of pain (the number in the top left hand
score for a particular measure of distress, compared comer of the first sub-table) increased the odds of
to a person who does not, scoring on the dependent respondents saying that it would have been better if
variable (wanting to die sooner, for example). Thus they had died earlier by a factor of 2.8.
Table 9 shows that the presence of symptoms in the
control and mental groups significantly increase the
Table 9. Logistic regression showing the relative independent
influence of high levels of symptom distress and dependency on views odds of respondents saying that it would have been
about dying earlier, and on reported requests for euthanasia (1990 better if the person had di.ed earlier. High levels of
datab)
dependency also significantly increase the odds. Pain
High level Cancer Non cancer
significantly increases the odds for cancer patients.
Of: Odds Odds
Symptoms in the appetite and breath groups were not
Respondents’ views
Pain 2.8” 1.5 significantly associated with respondents’ views.
Appetite 1.2 1.1 Considering the reported views of the person who
Control 1.7** 2.0’
died, a somewhat similar pattern is found, although
Mental 3.2** 2.5’
Breath 1.0 I .o there are important exceptions. Mental increases the
Dependency 2.2” 3.9” odds of a person being said to have wanted to die
N= 934 604
sooner particularly strongly in the case of non-cancer
Deceaseds’ reported views deaths. As this symptom group includes depression,
Sooner Euthanasia Sooner Euthanasia the expression of this feeling could be seen as a part
Pain 2.8” 1.1 1.2
Appetite a - 1.4 1.5 and parcel of such a mental state. High levels of
Control 1.6’ - 1.4 4.1 dependency increase the odds of wanting to die
Mental 2.4* - 5.5** 2.6
- sooner for people not dying from cancer and the
Breath 1.0 I.1 1.5
Dependency 1.4 - 2.6** 1.3 presence of pain increases the odds of this for those
N= 1002 992 672 668 dying from cancer. The numbers reported as having
*P < 0.05. asked for euthanasia are small, and this is why even
l*P < 0.01.
quite high odds ratios fail to reach significance.
‘Could not be computed due to high standard error.
Where a dash is shown goodness of fit for the model did not reach
an adequate significance level. Social and cultural influences
The reference category for odds ratios is the absence of symptoms
or dependency. Thus only comparisons between high levels of A series of analyses was done to assess the hypoth-
distress and dependency and the reference category are reported esis that social and cultural factors such as social
here.
bFor respondents’ wishes in 1987 goodness of fit for cancer deaths class, strength and type of religious faith, and urban
did not reach an adequate significance level. For deaths from rather than rural residence influence peoples’ willing-
other causes 1990 significance levels for odds were replicated ness to express a desire for an earlier death, or ask for
(conrrol odds = 3.8 (P < 0.05); mental odds = 4.7 (P < 0.05))
except in the case of dependency where the odds ratio (2.7) failed euthanasia. Respondents were asked to assess both
to reach significance. themselves and the deceased as having a ‘strong,’
652 CLIVE SEALE and JULIA ADDINGTON-HALL

Table 10. The influence of social and cultural factors on views about wanting to die sooner may be a necessary precondi-
dying earlier, and requests for euthanasia (percentages with base
numbers in parentheses) tion for requests for euthanasia, but does not in itself
1987 1990 (weighted) 1990 (weighted) constitute such a request. Respondents were asked to
Respondents’ Respondents‘ Deceased’s report on the dying peoples’ requests for euthanasia.
views views wews but not on whether they themselves would have
Better Better Wanted Wanted supported this. The numbers of people reported as
earlier earlier sooner euthanasia requesting euthanasia were too low for some
Social class of deceased analyses, even with the fairly large data set available
I II IIInm 29(133) 28 (520) 23 (5Xx) 3.5 (577) for 1990.
IIIm IV V 23 (265) 25 (782) 24 (842) 3.5 (838)
Religion * Secondly, the study did not involve interviews with
strong 15’(105) 25 (422) 25 (567) 3.5(560) dying people themselves. There are well known prob-
SOfIle 28* (200) 27 (780) 23 (892) 3.6 (884)
None 34’ (50) 31 (237) 27 (370) 4.6 (366)
lems in interviewing dying people; one has first to
Place of residence know that people are dying, for example, and this
Inner city 35’ (81) 24 (409) 23 (454) 3.2 (453) tends to restrict studies to those dying with cancer.
Other citv 221 (I301 28 (894) 25 (993) 3.5(981)
County ’ 21* i223j 31 <417j 24 {46Oj 4.3 ;455j However, this limitation probably means that reports
of the incidence of requests for euthanasia are likely
*P < 0.05.
aRefers to religion of the deceased for deceased’s views. rehgmn of to be underestimates. This is because many respon-
respondent for respondents’ VIPWI. dents will not have known about every such request
by the dying people during the year before death.

‘some,’ or ‘no’ religious faith, as well as to report on Cultural injiuences

the type of faith. In practice, analyses of the type of
The increasing proportion of elderly people in the
faith were restricted to Catholic, Church of England
population. with associated disability and distress,
and other Protestants, as numbers reporting other
and the role played by modern medical technique in
types of faith were too low for analysis. The de-
preserving life. combine to fuel public moral concern
ceased’s social class was measured on the Registrar
about euthanasia. The view that medical intervention
General’s scale, as recorded at death registration.
at the end of life should not be excessive has often
Results are given in Table 10. The table shows only
been conceded in medical circles [IO] on the grounds
two significant associations, for strength of faith and
that there may be a point for some elderly or very ill
place of residence in the 1987 survey. In view of the
people where life is no longer worth living. As well as
importance of religious views in the public debate
the passive euthanasia of withholding treatment,
about euthanasia, further analysis was conducted to
active euthanasia may then be conceivable [1 I].
discover any influence of type of faith on views about
However, the argument for allowing euthanasia as
dying earlier and requests for euthanasia. The results
a matter of social policy can also be understood as
of this are presented in Table Il. Significance tests
reflecting the emergence of the modern sense of self
(x ‘) were done for each category of religious faith,
in public discourse. Armstrong has suggested that the
compared to ‘None’. There were no significant
call for euthanasia in modern conditions gives ‘the
differences.
patient the right to speech and a claim thereby to be
human’ [ 121. The modern sense of self is influenced by
DISCUSSION ideas about psychological fulfilment. achievable by
exercising choice, asserting autonomy and maintain-
Two considerations should be borne in mind in
ing control over the direction of one’s own life [13].
assessing the significance of these results. Firstly,
In the Netherlands, where active euthanasia under
medical control is permitted, Fenigsen [I41 has
Table I I. The influence type of religious faith on wishes to die earlier, identified the success of the pro-euthanasia
and reauests for euthanasia movement as having depended on certain features of
1987 1990 (weighted) 1990 (weighted) Dutch public life: a value placed on freedom of
Respondents’ Respondents‘ Deceased’s
views
thought in a context of democratic liberalism, an
views views
encouragement given to the overthrow of taboos and
Better Better Wanted Wanted opposition to authoritarian behaviour (which in-
Faith’ earlier earlier scloner euthanasia
volves a degree of antimedical feeling), and a strong
None 34 (50) 31 (237) 27 (370) 4.6 (366)
AI/
secular consciousness. It has been observed [15] that
Catholic 21 (43) 25 (147) 22(184) 2.2(183) the discourse of consumerism and the language of
C. of E. 26 (202) 27 (827) 25 (1000) 3.9 (989) rights is particularly strong in the U.S.A., thereby
Protestant I9 (32) 28 (132) 22(182) 3.4(180)
Strong faith on/~
making that country more liable than Britain to
Catholic I5 (26) 24 (89) I9 (97) 3.7 (95)b accede to a social policy that allows active
C. of E. lQ49) 25 (224) 27 (294) 4.6 (291) euthanasia.
Protestant l5(13)b 3 I (75) 25 (128) l.3(127jb
Evidence suggests that the call for euthanasia is
‘Refers to religion of the deceased for deceased’s views, religion of
respondent for respondents’ views. associated with modern, urban cultural conditions.
bNumbers too low for valid test of significance. Devins [16] in the U.S.A. found that urban dwellers
 Euthanasia: why people want to die earlier 653

were more likely to support euthanasia, as did been close, it appears that religious considerations
Jorgensen and Neubecker [17], also in the U.S.A. The and cultural influences fade into insignificance in the
latter study also found that whites, males and face of the overwhelming physical and emotional
nonreligious people were more likely to be in favour. experience of suffering.
Kalish [ 181 found that Catholics were less likely to
support euthaasia, younger people more likely. Lam Suffering
[19] who surveyed members of EXIT, the British Recognition of the role of suffering in understand-
voluntary euthanasia society, found a disproportion- ing the experience of illness has been urged by Stacey
ate number of non-religious people from higher social [22], who is concerned about an over-emphasis on
classes. cultural factors, and on the extent to which disease is
The prominence of AIDS campaigners in calls for socially constructed, in recent medical sociology. In
legalising euthanasia and providing for ‘living wills’ this context, it is relevant to consider the assumptions
(these may express the wish for euthanasia should about the role of suffering made by proponents and
mental faculties deteriorate), can be understood in opponents of euthanasia.
part as culturally determined. The living will is a Opposition to active euthanasia comes from
gesture against future dependency and suffering [20]. several sources. On the one hand, there are specifi-
AIDS campaigners represent urban, young, male and cally religious objections [23]. On the other hand are
probably non-religious groups. Fenigsen [14] claims the more secular arguments of many in the hospice
that 11.2% of Dutch AIDS patients die by active movement, who propose an alternative solution to
euthanasia-a much higher proportion than other terminal suffering, based on the argument that good
disease groups. symptom control and emotional support obviate the
Maas et nf. [21] investigated three classes of desire to die earlier.
medical decisions concerning the end of life in large The hospice position has been outlined by Cicely
samples of deaths in the Netherlands. They estimate Saunders. In an editorial in Palliative Medicine she
that 1.8% of all deaths in the country were caused by argues that:
administering lethal drugs at the patient’s request
‘Kill me,’ a definite request for medically assisted suicide,
(active euthanasia); 17.5% of all deaths involved such
though heard more often than it was 30 years ago, is still
high dosages of opioids for symptom relief that in the extremely uncommon. It may be voiced because of long
opinion of the doctor they might have shortened life. unrelieved pain and is likely to fade away once this has been
In a further 17.5% of all deaths a decision not to treat addressed as in almost all cases it can be (A)ttitudes
change when a positive attitude and effective (pain) relief are
(where treatment would probably have prolonged
introduced [24].
life) was made. Active euthanasia was more common
amongst younger, male, urban dwellers. The other However, proponents of euthanasia refer to factors
two classes of decision, though, were more common other than unpleasant physical symptoms. Thus
in women and in the elderly. Active euthanasia and Hurwitt, chairman of the Voluntary Euthanasia
the administration of high dosages of opioids were Society, has pointed out “the indignity (not merely
more common in cancer. the pain) of incurable illness” is at stake in the case
In spite of these indications in the literature that for euthanasia [25].
ideological and cultural factors play a part in The hospice movement is, perhaps, on firmer
influencing the public debate about euthanasia, on ground when speaking of pain and other symptom
the whole the results (see Tables 10 and 11) did not relief than the problem of extreme dependency.
confirm these as important influences on views about Saunders [24] recognises that images of unrelieved
dying earlier or requests for euthanasia. City terminal cancer pain have become less prominent in
dwellers, those from higher social classes, and people calls for euthanasia in recent years. In their place
from a particular faith, or who held particularly have come fears of “extreme old age, brain failure
strongly to a faith, were not consistently more or less and helplessness.” While she notes that “we cannot
likely to say they wanted to die earlier, or want take all this away,” she feels that “we can ease and
euthanasia. Social class and urban residence are only share it,” and at a practical level doctors can avoid
proxies for measures of cultural difference; it might be the prolongation of such life by rejecting an
that if more direct measurement of attitudes on a “automatic commitment” to the preservation of life
wide range of topics had been done, significant at all costs. In another article rejecting euthanasia [26]
associations would have been found. However, the she argues that the deterioration of faculties, in
absence of consistent association with the religious particular “chronic brain failure” is rarer than many
variables is more surprising, given the religious affili- believe. The formation of “small community voiun-
ations of many who participate in the public debate tary organisations to help the elderly” is cited as a
about euthanasia. (It should be noted, however, that method to help with the problem of dependency. The
the results from the two data sets were contradictory results of the study reported here show that certain
on the matter of the strength of the respondents’ forms of distress and dependency are more likely to
faith.) When nearing one’s own death, or recalling the lead to desires to die sooner, and to requests for
death of a particular person to whom one may have euthanasia, than others. The importance of depen-
654 CLIVE SEALE and JIJLIA ADLXNGTO~-H~LI.

dency, and of the symptoms particularly associated results this is indicated either in the text or in footnotes.
Note that the 1987 survey only contained one of the
with very old age, such as loss of bladder and bowel
three dependent variables (concerning respondents’ own
control and mental confusion, are demonstrated in views). A full description of the methods used in the
Tables 8 and 9. Different causes of death involve 1987 study is contained in: Cartwright A. and Seale C.
different patterns of distress and dependency, with The Natural History qf a Survey. Kings Fund, London,
cancer tending to be very distressing, but with 1990: The 1990 survey is described in Addington-Hall J.
and McCarthy M. Regional study of care for the dying:
relatively low levels of dependency, and ischaemic
funding, methodology and sample characteristics.
heart disease involving relatively low levels of both Submitted for publicatron.
(Table 5). Those dying with mental conditions experi- 6 In all cases where a difference is reported in this
ence relatively high levels of dependency. as well as paragraph, this involves a significance level based on
chi-square at or below the 5% level.
certain types of distress. These patterns are then
7 These findings about variation in distress and depen-
reflected in both respondents’ and the dying peoples’ dency by cause of death support those given in Seale C.
views (Table 6). Pain is an important factor in desires F. Death from cancer and death from other causes: the
to die earlier for those with terminal cancer. relevance of the hospice approach. Palliariue Med. 5,
However, for those not dying from cancer, pain is not I2 19, 1991; where it was found that cancer involved
particularly intense levels of symptom distress, but that
as important a factor as dependency in causing this long term dependency was not characteristic, this being
state of mind (Table 9). more likely in deaths from other causes.
These findings have important implications for the x Cancer is the cause of death in a relatively young group
public debate about euthanasia. particularly in of people. and is therefore more likely than other causes
of death to have been reported on by a spouse rather
relation to the position of the hospice movement. If
than a child or other person. The independent influence
good care is to obviate the desire to die sooner, it of the type of respondent will be reported in another
needs to address the problem of dependency as well paper. but suffice to say that spouses tended to be less
as provide the symptom control in which hospice likely to wish that the person had died earlier. It is likely
practitioners have developed such impressive exper- that this is why the relationship between cancer and
respondents’ views is suppressed in Table 6.
tise. Some environments are more suitable than 9 The data were checked for multicollinearity; a
others in helping disabled people lead independent correlation matrix for the distress and dependency
lives, but there are inevitably limits to this. The issue variables showed no correlations above 0.5.
of dependency in the elderly is a broad one, and may Smith T. Consensus on overtreating cancer. Br. Med. J.
297, 438, 1988.
not be as amenable to remedy as certain symptoms
Euthanasia: an act of mercy or of murder’? The Guardian
have proved to be. Education Supplement. October 6th. pp. 223. 1992.
Armstrong D. Silence and truth in death and dying. Sot.
Acknowl~dRemmrs~The 1987 survey was carried out with .Sc,i. Med. 24, 651 -657, 1987.
financial support from the Medical Research Council in For an extended discussion of the role of psychology in
collaboration with Ann Cartwright. The 1990 survey was creating this sense of self see Rose N. Gocw-ning the
supported by the North East Thames Regional Health Socrl Routledge. London, 1989.
Authority, Bloomsbury and Islington District Health I4 Fenigsen R. The case against Dutch euthanasia. HUSI-
Authority, and other participating Health Authorities. and ing.~ Centrc Rep-r Special supplement, pp. 22-30, 1989
was done in collaboration with Mark McCarthy. The 1s Jennett B. Decisions to limit treatment. The Lancer
comments of Mark McCarthy, Michael Wadsworth, Sara 7x7 7X8 1987.
Arber and Madeleine Simms on earlier drafts of this paper 16 Devins G. M. Contributions of health and demographic
are gratefully acknowledged. The writing of this paper was status to death anxiety and attitudes towards voluntary
made possible by a grant from the Leverhulme Trust. passive euthanasia. Omega 11, 2933302. 1980.-81.
17 Jorgenson D. E. Neubecker R. C. Euthanasia: a na-
tional survey of attitudes toward voluntary termination
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