CENTER FOR PENAL AND CRIMINOLOGICAL RESEARCH
FINDINGS OF THE RESEARCH FOR EUTHANASIA
Euthanasia is indeed one of the most controversial issues of our time and this is because it lies at the edge between two equally critical priorities. On the one hand is the human right to decide about which way he prefers to live or to die and on the other the interest or the obligation of the social community to protect the utmost privilege of life towards anybody who makes an attempt against it or to abolish it.
Moreover issue of euthanasia has subtle boundaries and shades which usually are shadowed by prejudices and lead, although it should not, to extremist attitudes. In this discussion there are usually scholars involved from different fields with different knowledge and experience or if they conduct research with different methodology such as doctors, lawyers, theologists and philosophers with the result that contradictions appear which are unbridgeable. However in the last years it must be acknowledgment that because of certain shattering cases of euthanasia or even independently from them, an attempt is being made for a more sober and multidisciplinary, although not cross disciplinary, approach of the issue so that commonly accepted steering directions have been imprinted and a way for a more constructive dialogue has now been opened. Apart from the ambiguous Recommendation 1418/1999 of the Council of Europe “for the protection of human rights and the dignity of incurable patients and those who are terminally ill” and the relevant provisions (esp. art. 2 para. 1, 6 and 9 of the Convention for biomedicine- Act 2619/1998) the central axis of this evolution unquestionably art. 29 of the Code of Medical Deontology (Act 3418/2005) which is based in the oath of Hippocrates and attempts very carefully to harmonise and compose the contradicting views. However an important parameter in this evolution is one to be aware of the real scale of the issue of euthanasia in Greek society and especially the attitude of educated members of this society towards euthanasia. With this research we believe that the Center for Penal and Criminological Research will contribute to academic dialogue interesting information for the reconsideration of the issue of euthanasia in the modern Greek society.
Methodology of research
1. The research with title “The modern issue of euthanasia” was conducted between the years 2005-2006 by the Center for Penal and Criminological Research, University of Athens under the academic supervision of the Head of the above Center Professor Nestor Courakis. Calliope Spinellis Professor Emeritus of Criminology at the University of Athens and Deputy Head of the Center played a leading role throughout the conduct of this research.
For the collection of data regarding the attitude of specialists and the public towards the issue of euthanasia we used questionnaires, anonymously and self-controlled which were initially drafted by the heads of the Research Group and it was further discussed by the Plenary Session of the Group. These questionnaires were given to be completed in January 2006 to students of the Faculty of Law at the University of Athens but also to other people 100 in total and then the final draft was formed. It is noted that there is no mention of the word “euthanasia” in the questionnaire in order to complete the same without emotional charge or prejudice. The subject-matter of this research was to explore the attitude of those questioned and the degree of the personal knowledge towards the different forms of euthanasia and towards the whole issue.
This research was funded by the Special Account for Research Funds of the University of Athens with funds which were given as a reward to the undergraduate and postgraduate students of the Research Group and for the purchase of consumable items.
The completion of questionnaires took place from February to May 2006. The majority of those questioned were working at the time in public, municipal and private hospitals. Private doctors were also questioned individually, individuals from different professions and students from the broader area of the capital (in total 593 questionnaires) and selectively from towns of the countryside (Herakleion and Chania in Crete, Syros, Corinthos, Patra and Kalamata: 321 questionnaires) without having at this stage of the research data for the population of agricultural areas. In total 914 questionnaires were distributed.
More specifically, questionnaires were distributed, in the broader area of Attica in seven big hospitals, one private clinic and doctors- inspectors of a big public insurance organisation. Questionnaires were also given to undergraduates of the College for Nurses in Patra, postgraduate students of the LLM in Criminal Law, Faculty of Law in Athens and different professionals (psychologists, sociologists etc).
Finally regarding the countryside, questionnaires were distributed to nine big hospitals and doctors of one of the branches of the public insurance organisation and to many private doctors of different specialisations without being certain that those referred to as “rural doctors” really practise medicine permanently for years in the countryside or simply do their traineeship or specialisation there.
2. From the 914 questionnaires submitted for completion 903 were answered (N=903) although in certain cases certain questions remained unanswered and therefore the questionnaires display missing items. For that reason the percentages recorded have been calculated on the total of those who answered every question and not on the total collected 903 questionnaires. Their completion took place by people who were gathered in one room in the presence of the researchers of the Group who were prepared to provide clarification when this was required. In a few cases, the researchers left the questionnaires to those questioned people who were not always prompt at returning them completed and in this way the small “mortality” of the sample is interpreted (903 from 914 questionnaires or 1,2%). The average age of the people who answered approaches, with a deviation of +/- 5,1 41 years while men are slightly outnumbered (55,5% of the questioned of the two genders) and on purpose the doctors are substantially outnumbered. More specifically, almost 8 out of 10 who answered the Questionnaire were doctors (78,6% or 703 from the 903 and especially 522 doctors in Athens and 181 in the countryside). It is remarkable that in Athens (broader area of Athens) it was observed that in the sample of doctors the numbers of women doctors were higher (64,9% women and 35,1% men) although in the countryside this sample of doctors seemed to be more equally distributed (50,8% women and 49,2% men) (in both these cases the sample of questioned doctors cannot be considered as a fully representative sample). As for the broader population, that is to say “public opinion” because of the limited financial potential, the selected sample does not fulfill all the conditions of representation and the answers simply have a indicative character. It is noted that this sample includes nurses, teachers, teachers of secondary education, theologists, philologists, priests, lawyers, psychologists, students, social workers, economists, physiotherapists, agriculturalists, biologists, traders, public and private employees. Substantial differences were usually observed, in the answers of the broader population and doctors and where this happens as an exception it is noted in the following analysis. It is finally noted that in the framework of this research, those who have a close relationship to patients in hospitals, clinics or/and private practices even nurses are labelled as doctors.
In the opening paragraph of the questionnaire an attempt was made to clarify the terms used. It was mentioned that “when a mention is made for a medical action to an incurable patient it means that for this patient there is a diagnosis that he suffers from a non curable disease or he/she had been in a non reversible condition for at least one year and that this medical action takes place with the proved previous consent of the patient even if he/she is at the specific moment of the action in coma. In the questions regarding these patients there is no mention of continuous and unbearable pain as it is to the contrary provided in certain legislation given that in the last years medicine has the means to treat pain successfully. The even more serious problem of such patients is that because of their incurable disease they lose their dignity and autonomy. In addition, as “medical actions” are defined i.e. those related to the mechanical support of the patient, dialysis, bowel feeding, blood transfusion etc” (underlined in the questionnaire).
3. The final draft of the questionnaire included 22 closed questions distributed in two main sections:
In the first section (q. 1-10) the questions sought to discover the degree of agreement or disagreement of those questioned with the practices of euthanasia if certain conditions are in place as a matter of course. The first ten questions refer to the above and therefore relate to the possible ways that doctors (and nurses) can contribute for the expedition of the fatal. There are four possible answers to these questions that is to say that there was a four degree scale agreement-disagreement with answers such “agree, strongly agree, strongly disagree and disagree”.
In the second part (q. 11-22) the questions have a more pragmatic complexion i.e. they aim to discover the extension of the practices of euthanasia in our country and the personal choices of those questioned to this issue. More specifically this part includes: a) questions as to whether the questioned have become aware of cases of euthanasia (q. 11-13),b) questions to estimate whether in our country it is considered frequent and possible to attempt euthanasia. The possibilities of the questions were in these questions structured in a four degree scale of frequency-rarity in a form of “very frequent, frequent, rather rare, rare” [phenomenon] (q. 14-16), c) hypothetical questions regarding euthanasia for the personal choice of those questioned either for himself or for his relative as well as for the possible methods of terminating his life which the questioned would choose in these cases (q. 17-19) and d) summary questions in order to diagnose the final attitude of those questioned towards euthanasia and its legislative treatment (q. 20-22).
It would be useful to note that for the answers of the questionnaire the four degree scale was chosen either the unequivocal answers “Yes”, “No” and “Pro” “Against” instead of the traditional scale Lickert (3, 5 or 7 possibilities for answers) and this is because firstly it was aimed that with this research a clear response of those questioned would arise to the complex issue of euthanasia. For the same reason the answers which did not express a stable perception such as “strongly agree” and “strongly disagree” were bound for the presentation of the results (but not in the analytical tables which are displayed in an annex) with the closest in meaning answer i.e. with the “agree” and “disagree” respectively in order to give a more clear and accomplished picture of the attitude of those questioned. It must be noted that except from the first question where no remarkable difference between the percentages of “disagree” and “strongly disagree” in all other answers of this type the “strongly disagree” is substantially predominant to the “disagree” as a total and in all subcategories (see Tables) (i.e. in q. 2 in the total of the answers the “strongly disagree” accumulates the 46,1% and the “agree” only the 14,0%, in q. 3 the respective percentages are 48,9% and 15,8%, in q. 4 30,9% against 11,8% etc). We believe that this is indicative of the ambivalence and the cautiousness which dominate most of the people towards the especially complex issue of euthanasia.
• Almost six out of ten of those questioned (58,3%) considered that they would request the assisted suicide if the condition of their health was considered irreversible. In such case they would request the dispensation of a substance of medication which would lead to the fatality (27,1%) and less the restriction (20,1%) or the interruption of their medication (11,1%) (q.18). If they were in a coma and could not decide by themselves most of them (51,5%) would wish the decision for the assisted suicide to be made by the doctors together with their close relatives while almost a ¼ of those questioned (23%) would wish anybody to make such a decision on their behalf (q. 19).
• Almost one out of five of those questioned (21,3%) were aware of the interference of the doctor for the euthanasia, mainly passive euthanasia (77,4% of the positive answers) while slightly less (14,4%) were aware of the second case (q.11, 11a, 12, 12a). In addition, more than half of those questioned (52,7%) were aware of a person who had expressed a wish that if he/she suffered from an incurable disease the doctor should interfere so that the fatality would come (q.13). Despite the above most of those questioned considered on a general level that the phenomenon of euthanasia is “rare” (34,1%) or “rather rare” (54,1%) in our country even after a request by the patient to facilitate the fatality (q. 14).
• The same questioned persons declared by a percentage of 63% that in no case they would undertake the initiative to disconnect the mechanical support of an incurable patient (q.17). They also did not exclude the possibility, and indeed by such remarkable percentages, to perform medical interference in order to assist suicide of an incurable patient after the request of the patient’s relatives for the additional reason of obtaining a financial benefit (25,9%) (“very frequent” or “frequent” phenomenon) or even the doctor himself/herself (13,7%) (“possible” or “highly possible” case) (q. 15 and 16).
• Those questioned in the general “summary” question as to what extent they were for or against the maintenance of life by every mean of an incurable patient who persistently and deliberately requested the termination of his life appear to be completely divided: 50,8% for the maintenance of life against 49,2%. A preference for euthanasia appears to arise when the patient is in a coma and cannot continue his life with dignity and autonomy. Against the maintenance of life: 55,46% pro and 44,7% against (q.22).
• In a portion of questions these divided views were clarified to a remarkable degree according to specific cases of euthanasia. Thus, a performance of euthanasia for avoiding unbearable and continuous pain appears to be tolerated by 54,3& of those questioned (q.1b) even with the dispensation of medication which will definitely lead to the fatality. This percentage becomes higher (87,4%) when the assisted suicide as a consequence of combating pain appears to be only possible (indirect euthanasia) (q.1a). Respectively euthanasia after the request of the patient (art. 300 Criminal Code) either with the dispensation of substances or medication (50,5%) or even more with the omission of dispensation of medication (57,1%) (q.4,5) concentrates a borderline percentage of approval.
• Those questioned appear to reject and disapprove of the cases of early euthanasia for incurable patients infants or toddlers up to 3 years old (the percentage of disapproval here comes up to 71,3%) (q.7), euthanasia after the request of close relatives of a patient who is in a coma (percentage of disapproval 57,8% for the passive and active euthanasia) (q. 8,9) and the euthanasia by dispensation of substances to the relatives who will give it to the patient in order to assist suicide (negative attitude: 87,7%) (q.10). The attitude of those questioned towards passive euthanasia also appears to be negative when it is conducted even with the consent of the patient but independently from the existence or not of unbearable and continuous pain (60,1% opposition to euthanasia with the interruption of medication and 64,7% with the omission of a dispensation of medication) (q.2,3). Finally those questioned the case of a patient requesting the doctor to dispense him/her substances or medication which will lead to the fatality (q.6) declared their opposition by a percentage slightly over half (55,6%).
• While those questioned exhibit this justified to an extent hesitance and reservation towards euthanasia to the point that their views were almost divided, the picture changes when they are asked the question of the possibility of a legislative provision in order for the law to allow (under certain conditions and with safety valves such as the consent of the patient) the possibility of termination of life of an incurable patient. The accordant opinions especially for the passive euthanasia reached 61,3% while slightly lower are the percentages for the active euthanasia (47,4%) and even lower for the participation of the doctor in the suicidal of the patient with medication dispensed and taken by the patient (30,4%) (q.20).
From the answers given in the above research it is therefore concluded that there is a need for reconsideration of the present legislative framework in Greece in order that the issue of euthanasia should be placed on a more modern and well-founded legal base with a main axis of the question for a possible revocation or not of the criminal element of the actions or omissions performed by doctors to an incurable patient or even to people who are in a coma for the assisted suicide. Within the framework of reconsideration of such a provision, the precondition of a proved previously expressed uninfluenced consent, if not request, of the patient is necessary for euthanasia (for instance by a deed from a Notary Public at a different time as is provided in other jurisdictions). More specifically it would be worthwhile to explore the possibility of passive euthanasia within the framework of such a provision when the patient –having already expressed his consent- he/she is already a “vegetable” or, when he/she suffers from unbearable and continuous pain and requests that the doctors will not dispense medication to him considering that dignity and autonomy are missing from his life. More generally when on the face of this terminally ill person the value of human as a Human is affected (see to this direction art.29 Code of Medical Deontology- Act 3418/2005).
On the other hand, in such a provision, the necessary safety valves must be provided in order to protect the incurable patient from abusing actions against him. Further, it is considered essential, according to the conclusions of the research, to completely exclude from such a provision, cases of dispensing medication to the patient in order to take it by himself/herself or actions which come and, decisions taken only by patients and early euthanasia to infants and young children (perhaps here the interference should only be allowed during prenatal tests which should be recommended to parents in certain cases).
It is obvious that the above remarks provide another trigger for cross academic dialogue conducted in recent years in our country concerning the issue of euthanasia in order to define clearly the admissible terms of such interference by doctors and to prevent the phenomena of abuse by people who even when well-intentioned, consider that they may offer assisted suicide in incurable patients. Final legislative proposals for the process of amendment of the Criminal Code could therefore be expressed only after consultation with the competent authorities (for instance National Committee of Bioethics, Expert Committee of Bioethics of the Church of Greece, Association for Research of Medical law and Bioethics, Network of Aristoteleion University of Thessaloniki “Modern Medical Action, Biomedicine and Law”, Institute of Biological Research of E.I.E. etc) and after considering the respective legislative changes in foreign countries in relation to their effectiveness in the rational treatment of the issue of euthanasia.