- Noritoshi Tanida MD., PhD.
Department of Internal Medicine 4,
Hyogo College of Medicine,
1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan
Fax: +81-798-45-6661
Eubios Journal of Asian and International Bioethics 8 (1998), 138-41.

A questionnaire survey was conducted at the annual meeting of the Japanese Society for Hospice and Home Care to study attitudes toward euthanasia. Respondents were asked how they agreed with the doctor's decision regarding several forms of euthanasia in hypothetical clinical situations dealing with terminal and non-terminal patients. Their acceptance of euthanasia was correlated with respect to patient's autonomy. Results (n=248) showed 54% and 62% of respondents agreed with voluntary and non-voluntary passive euthanasia at the terminal stage, respectively. Indirect euthanasia was accepted by 71%. In voluntary active euthanasia, 21% agreed with the doctor's act. In non-voluntary active euthanasia, 13% and 37% agreed with the use of potassium chloride and sedative, respectively. In dealing with a quadriplegic patient, 18% and 37% agreed with voluntary active euthanasia with a sedative and voluntary passive euthanasia. Voluntary passive euthanasia in the terminal stage and voluntary active and passive euthanasia and mercy killing were more likely to be favoured by the respondents who respected patient's autonomy than those who did not.

Introduction

Pros and cons regarding certain forms of euthanasia have been a controversial issue around the world. Japan is not an exceptional country in this respect, particularly since the Tokai University and Keihoku Hospital euthanasia cases. The Tokai University Hospital case was the first euthanasia where a physician was prosecuted and was convicted of the murder of a patient in Japan (1). Here, the physician gave a potassium chloride injection to a comatose patient with multiple myeloma on request of his family. On April 11, 1995, this case was settled with a 2 years' imprisonment sentence (suspended for 2 years). In Keihoku Hospital, a physician gave a muscle relaxant to a dying patient without request of himself or his family (2). The physician first proclaimed that his act was active euthanasia. However, on facing fierce condemnation by nurses, colleagues and media as a murderer, he changed his claim to say that he intended to reduce convulsion, not euthanasia. He was questioned by police, but finally he was not prosecuted because the amount of muscle relaxant he gave to the patient was below the lethal dosage.

During the discussion on these issues, there was noticeable confusion regarding euthanasia. For example, a leading hospice physician and ethicist kept saying that the Tokai University case was not euthanasia (3,4). Judges in the trial court concluded that the family did not know the meaning of what they said and asked for (1). Similarly, other physicians and lawyers kept saying that the family did not ask for euthanasia (1,2). These claims were hard to understand, because the Tokai University case was indeed an act of non-voluntary active euthanasia (5) and the court document clearly noted the words of the family asking for hastening death of the patient (3,6). Thus, there was public pretence that there was no euthanasia or there were no people who asked for euthanasia in Japan. Such a cover-up behavior would suppress open discussion and lead to lack of understanding on euthanasia. Furthermore, sincere discussion is only attained based on truth and fact through basic research. Attitudes of Japanese people toward euthanasia have been surveyed several times by mass media and researchers. According to the recent surveys, 70% of laypeople (7), 20% of nurses (8) and 15% to 30% of doctors (8,9) thought that euthanasia was permissible. However, interpretation of these results was often difficult because the form of questionnaires allowed a majority of indecisive responses in these studies. And the term "euthanasia" is often meant in different ways by respondents (10). Therefore, the author set up hypothetical clinical situations involving certain forms of euthanasia and asked participants to answer these questions on how they agreed with the acts of euthanasia by the attending doctor. The word "euthanasia" was used as little as possible to minimize preconception or ambiguity in clinical situations. The forms of euthanasia in this article are characterized on the basis of the intention of the doctor (active or passive) and request by the patient (voluntary, non-voluntary and involuntary) (5). In addition, indirect euthanasia and physician-assisted suicide were included as part of euthanasia for discussion (11). Details of the results will be shown elsewhere (12). This report focuses on the overall result and the correlation with respect to the autonomy principle.

Methods

The Japanese Society for Hospice and Home Care (JSHHC) has existed since 1992 to promote hospice and home care for terminally ill patients. In June, 1997, a questionnaire survey regarding euthanasia was conducted among the participants in the annual meeting. Questionnaire sheets were delivered to 1,000 consecutive pre-registered participants and collected when they came to the meeting. Respondents were assured of anonymity.

Questions included such background profiles of respondents as age, gender, education, occupation, own history of serious illness and presence at close person's death. For assessment of the autonomy principle, 2 questions were raised: 1) who should decide introduction of life-sustaining artificial respiration? and 2) who should decide administration of antibiotics for end-stage pneumonia? An answer was chosen from one of 3 items, "patient", "family" or "doctor".

Hypothetical clinical situations and questions are shown in Table 1. Case 1 to 3 dealt with terminal patients and Case 4 dealt with non-terminal illness. Question 9 specified the situation using the word "mercy killing" deliberately. Respondents were asked how they agreed with the doctor's decision or the act of euthanasia. An answer was chosen from one of the 5 items, "agree strongly", "agree", "neutral", "disagree", "disagree strongly".

For summarizing the data, percentages were calculated based on the total respondents. Figures may not sum to 100%, because not all respondents answered every question. Categorical variables were tested by chi square test. Decision-making regarding antibiotics administration for end-stage pneumonia was selected as a dependent variable in logistic regression analysis regarding patient's autonomy. Reference categories of categorical variables were female, university graduates, non-health care workers, no history of serious illness or presence at close person's death. Answers to hypothetical clinical questions are treated as numerical variables in logistic regression analysis. Estimation of odds ratio were adjusted with age, gender, education, occupation, own history of serious illness and presence at close person's death. Thus, an odds ratio greater than 1.0 indicates that the respondents who respected patient's autonomy were more likely to favor the decision or act of euthanasia by the doctor in hypothetical clinical situations. All statistical tests were carried out at the 5% level of significance as appropriate using the SPSS6J package.

Table 1. Hypothetical clinical situations and questions

Case 1; an elderly patient is bed-ridden because of disability in nursing home. He suffered from repeated pneumonia, and he has caught pneumonia again. Antibiotics administration is considered to be effective to some extent.

The patient has asked the doctor not to use antibiotics, because he wants to die quietly. The doctor has accepted his wish. (Question 1)

The patient has fallen into unconsciousness without showing his wishes. The family asked the doctor not to use antibiotics. The doctor has accepted the family's wish. (Question 2)

Case 2; a patient with end-stage cancer suffers from severe pain and fatigue despite every measure. Her death is estimated to be near. She has repeatedly asked the attending doctor for peaceful death using drug. Her family approves of patient's wish.

The doctor administered potassium chloride and the patient died. (Question 3)

The doctor administered a sedative to keep the patient unconscious till death. (Question 4)

Case 3; a patient has fallen into irreversible coma without showing his wishes. His death is inevitable and near because of his disease. Knowing the situation, the family has repeatedly asked the attending doctor for hastening death using drug.

The doctor administered potassium chloride and the patient died. (Question 5)

The doctor administered a sedative, and the patient died. (Question 6)

Case 4; a young patient has been quadriplegic for 6 years. He has suffered from pneumonia repeatedly. He does not look like the superb athlete he used to be. At present the patient's condition is stable. He has been fed on nasogastric tube nutrition. He is not depressive according to psychiatrists.

He has repeatedly requested euthanasia to the doctor using a high dose of sedative. The doctor accepted his wish. (Question 7)

The patient has repeatedly asked the doctor to withdraw tube feeding. He has rejected water and electrolyte infusion as well. The doctor accepted his wish. (Question 8)

He has fallen into unconsciousness because of severe pneumonia without expressing his wishes. The family has asked the doctor for euthanasia. The doctor performed mercy killing with a high dose of sedative. (Question 9)

For each question, respondents were asked to rate the degree of agreement with the doctor's decision or act from "agree strongly", "agree", "neutral", "disagree", and "disagree strongly".

Table 2. Attitudes toward hypothetical clinical situations of euthanasia*

Agree Agree Neutral Disagree Disagree

strongly strongly

Case 1, elderly end-stage pneumonia

Q1;VPE 24(10) 109(44) 79(32) 28(11) 7(3)

Q2;non-V 23(9) 132(53) 68(27) 21(9) 4(2)

Case 2, a conscious end-stage cancer patient

Q3;VAE(KCl) 13(5) 39(16) 58(23) 80(32) 53(22)

Q4;ID 27(11) 148(60) 52(21) 15(6) 3(1)

Case 3, an unconscious end-stage cancer patient

Q5;non-VAE(KCl)

6(2) 26(11) 51(21) 101(41) 61(25)

Q6;non-VAE(sedative)

10(4) 81(33) 88(36) 51(21) 15(6)

Case 4, a quadriplegic patient

Q7;VAE(sedative) 7(3) 36(15) 82(33) 87(35) 31(13)

Q8;VPE 8(3) 83(34) 82(33) 58(23) 10(4)

Q9;mercy killing 9(4) 29(12) 78(32) 90(34) 34(14)

*Figures are numbers of respondents and percentages in parentheses. Abbreviations: VPE: voluntary passive euthanasia, VAE: voluntary active euthanasia, ID: indirect euthanasia, KCl: potassium chloride

Results

Backgrounds of Respondents: Numbers of respondents to this survey were 62 (25%) males and 146 (59%) females (40 not revealed, recovery rate 25%). Their age (mean±SD) was 43±9 years old. Occupations included 12 (5%) doctors, 115 (46%) nurses, 63 (25%) other health care workers, and 53 (21%) non-health care workers. 43 (17%) respondents experienced own serious illness and 200 (81%) did not. 159 (64%) respondents experienced a close person's death, while 83 (34%) did not.

With regard to introduction of life-sustaining artificial respiration, 15 (6%), 69 (28%) and 117 (47%) respondents thought that decision should be made by "doctor", "family", and "patient", respectively. Corresponding figures for administration of antibiotics for end-stage pneumonia were 95 (38%), 14 (6%) and 112 (45%) for "doctor", "family" and "patient", respectively.

Answers to Hypothetical Clinical Situations: Table 2 summarizes the answers of the respondents to the hypothetical clinical situations. In Case 1, which dealt with the act of voluntary passive euthanasia by a doctor, a total of 54% of the respondents answered "agree strongly" and "agree". The corresponding figure was 62%, when the family asked for it. The difference in responses of these 2 situations was statistically insignificant (chi square=4.85, P=0.30, df=4)

Case 2 dealt with voluntary active euthanasia and indirect euthanasia or sedation. The result showed a total of 21% answered "agree strongly" and "agree" with the doctor's decision using potassium chloride. The corresponding figures increased to 71% for indirect euthanasia or sedation. The difference in responses between the two situations was statistically significant (chi square=157.8, P<0.0001, df=4).

Case 3 simulated the Tokai University Euthanasia case, i.e., non-voluntary active euthanasia. The result showed that a total of 13% of the respondents "agreed strongly" and "agreed" with the doctor's decision, when potassium chloride was used. The corresponding figure was 37%, when a sedative was used. The difference in responses between use of potassium chloride and sedative was statistically significant (chi square=83.4, P<0.0001, df=4).

Case 4 dealt with a quadriplegic patient who might be expected to live longer but wanted to die. The result showed that a total of 18% of the respondents "agreed strongly" and "agreed" with the doctor's decision for voluntary active euthanasia with a sedative. The corresponding figure was 37%, when the doctor accepted voluntary passive euthanasia. The difference in responses between active euthanasia and passive euthanasia was statistically significant (chi square=35.1, P<0.0001, df=4). Response to mercy killing was similar to active euthanasia.

In these results, male respondents were more favorable to euthanasia than females. This finding was mainly due to a less favorable attitude of nurses toward euthanasia.

Influence of Autonomy Principle: Although involvement of family and doctor was different in preference of life-sustaining artificial respiration and antibiotics treatment for end-stage pneumonia, respondents who chose "patient" as a decision-maker were consistent in their attitudes. Thus, the patient's decision regarding antibiotics treatment was chosen as a measure of autonomy in logistic regression analysis (Table 3).

The respondents who respected the patient's decision were more likely to favor voluntary passive euthanasia (Q1) at the terminal stage. Active euthanasia and non-voluntary euthanasia did not correlate with patient's autonomy at the terminal stage (Q3, Q5, Q6), whereas patient's autonomy was correlated with voluntary active and passive euthanasia at the non-terminal stage (Q7, Q8) and in a form of mercy killing (Q9). Indirect euthanasia did not correlate with patient's autonomy (Q4).

Table 3: Influence of the autonomy principle on attitudes toward hypothetical clinical situations of euthanasia

Odds ratio (95% confidence)* p value

Case 1, elderly end-stage pneumonia

Q1; VPE 1.58 (1.20 - 6.97) 0.01

Q2; non-VPE 1.19 (0.64 - 3.59) 0.34

Case 2, a conscious end-stage cancer patient

Q3; VAE (KCl) 1.13 (0.68 - 2.58) 0.38

Q4; indirect euthanasia 1.16 (0.57 - 3.53) 0.44

Case 3, an unconscious end-stage cancer patient

Q5; non-VAE (KCl) 1.36 (0.96 - 4.29) 0.06

Q6; non-VAE (sedative) 1.12 (0.62 - 2.74) 0.47

Case 4, a quadriplegic patient

Q7; VAE (sedative) 1.46 (1.16 - 4.97) 0.01

Q8; VPE 1.59 (1.29 - 6.64) 0.009

Q9; mercy killing 1.49 (1.18 - 5.38) 0.01

*Odds ratios were adjusted with background profiles of respondents. Odds ratio greater than 1.0 indicates that respondents who respect patient's decision of antibiotics administration are more likely to favor euthanasia. Abbreviations: VPE: voluntary passive euthanasia, VAE: voluntary active euthanasia, KCl: potassium chloride

Discussion

Clinical practices involving ethical problems differ among countries with different tradition and culture. This may be particularly true in the end-of-life issues including euthanasia (13). For example, physician-assisted suicide has never been mentioned during discussion of euthanasia in Japan, which is in contrast with the current debates focusing on the issues of active euthanasia and physician-assisted suicide in Western countries (14,15). Passive euthanasia is often condemned by Japanese mass media (e.g., articles in Mainichi Shinbun, Jan 6 and 10, 1997), presumably because they believe that prolongation of life is the supreme aim of medicine. It is different from the situation in Western countries where passive euthanasia and indirect euthanasia have been accepted so far as these are part of palliative care derived from patient's autonomy (14,15).

The respondents of the present study were those who attended the meeting of the JSHHC. Participants of this meeting were likely to be those who were aware of terminal care. Furthermore, the JSHHC emphasizes the importance of informed consent or decision-making by patients themselves. It may explain the finding that there was a more favorable attitude toward truth telling among the respondents (12) compared with laypeople (7). Also, the recovery rate of the survey was not high, thus the results may not represent the general public or health care workers. In addition, this type of questionnaire survey which had no "case-by-case" answer has not been used before in Japan. Therefore, direct comparison of the present results with previous reports may not be appropriate. Nevertheless, this survey revealed some insights into the Japanese attitudes toward euthanasia.

The present results showed that a majority (around 60%) of respondents are favorable to passive euthanasia at the terminal stage. Indirect euthanasia was also accepted by over 70% of respondents. Thus, passive euthanasia and indirect euthanasia have been gaining acceptance as part of terminal care, although these figures are still lower than those in Western countries (16-18). It should be noted that these practices have been approved by the Japanese Academy of Science and Art (19).

On the other hand, the attitude toward active euthanasia was much less favoured than passive euthanasia. The respondents preferred a sedative over potassium chloride for active euthanasia. This was presumably because a sedative might be less traumatic for health care workers to inject to a patient than potassium chloride which was solely meant cardiac arrest. These results shows reluctance toward active euthanasia, despite the allowance of active euthanasia by the Bioethics Counsel of the Japanese Medical Association (20) and the court decision (1).

This survey revealed that patient's request was not an important determinant for the decision-making in passive euthanasia and indirect euthanasia at the terminal stage. Rather, respondents preferred non-voluntary over voluntary euthanasia in these clinical situations. Considering the preference of a sedative as drug in choice for euthanasia, voluntary active euthanasia was less favored at the non-terminal stage than at the terminal stage. These results indicated that clinical condition was an important factor and family's wishes were crucial for decision-making regarding terminal care in Japan. Such a practice which values family's request over patient's wishes has been well described previously (21).

With regard to the autonomy principle, the respondents who respected patient's autonomy were more likely to favor voluntary passive euthanasia regardless of clinical stages. Also, patient's autonomy was correlated with voluntary active euthanasia in the non-terminal stage but not in the terminal stage. The present respondents included a majority of health care workers who might be in a position prone to acquiring the idea of the autonomy principle. It may be the reason why the autonomy principle was accepted partly in the present study but not in the previous study where respondents were laypeople (22). Thus, the autonomy principle is acquiring a certain position in medical practice in Japan.

In addition, mercy killing was more likely to be favored by the respondents who respected patient's autonomy than those who did not. This acceptance of mercy killing is presumably derived from cultural or historical backgrounds in Japan (23). However, the correlation between the autonomy principle and mercy killing was unexpected, since these two ideas are in theory not linking directly. Additional study is necessary particularly as to what extent Japanese culture and tradition influence mercy killing and the autonomy principle.

Attitudes toward euthanasia differ over time as well as depending on their social, cultural and religious backgrounds even within the same country (24). Unwillingness of Japanese doctors to accept the idea of physician-assisted suicide may be one of the examples. Once a certain form of suicide was highly honorable act in Japan (23). Rulers often made suicide illegal, but these attempts were mostly unsuccessful. Now, assisting suicide is a criminal act in the Criminal Law. In addition, administration of drug, or toyo in Japanese, literally means giving drug through a hand of Buddha, which is a sacred act of doctors. Accordingly, physician-assisted suicide is out of thinking among Japanese doctors who never leave a patient in a position like "it is up to you to decide to swallow this drug or not".

Thus, current Japanese attitudes toward euthanasia show complex features caused by mixture of Japanese tradition and the recently introduced idea of the autonomy principle. Though the acceptance of euthanasia is thought to be derived from the ultimate right or final autonomy of patients (25,26), this concept has not been examined in Western countries yet. Further study on this subject including the correlation of the acceptance of euthanasia with the autonomy principle is essential for deeper understanding of these complex controversial end-of-life issues.

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