Public attitudes toward euthanasia and suicide for terminally ill persons: 1977 and 1996
DeCesare, Michael A
Public Attitudes Toward Euthanasia and Suicide for Terminally III Persons: 1977 and 1996*
ABSTRACT: This study replicates Singh’s (1979) “classic” examination of correlates of euthanasia and suicide attitudes. The purposes of the current study were to assess (1) changes in public attitudes toward these voluntary termination of life practices, and (2) changes in the effects on attitudes of selected independent variables. I found Americans’ approval of both euthanasia and suicide in 1996 to be higher than that in 1977. The increase in the approval of suicide, however, far outstripped that of euthanasia. Results of OLS regressions indicated that race, religious commitment, religious attendance, political identification, and suicide approval were statistically significant predictors of euthanasia approval. Only religious attendance and euthanasia approval were statistically significant predictors of suicide approval in both 1977 and 1996. The findings regarding euthanasia approval support those of Singh (1979); those regarding suicide approval do not. Triangulation of methods in future research is necessary to illuminate other aspects of these multifaceted issues.
At a time when voluntary termination of life practices were largely legislative rather than public issues, B. K. Singh (1979) used 1977 General Social Survey (GSS) data to explore selected correlates of public attitudes toward euthanasia and suicide for terminally ill persons. The article has since been called the “classic” in the field (Monte, 1991). Since its publication, the United States has witnessed several important events in the larger rightto-life movement, including the Nancy Cruzan case which went to the U.S. Supreme Court, the first publicly acknowledged physician-assisted suicide by Dr. Jack Kevorkian in 1990, and the 1997 legalization of the practice in Oregon. These and other events have forced Americans to reconsider euthanasia and suicide for terminally ill persons as two of the most important bioethical, legislative, and moral issues we face presently and in the future. Indeed, Glick (1992) correctly predicted nearly a decade ago that “[t]he right to die will be on the political agenda into the next century” (p. ix). It is clearly necessary to evaluate the extent of any change in public opinion toward these issues.
Past research has included a plethora of potential correlates of euthanasia and suicide approval. Researchers have found that approval of euthanasia decreases with age (Finlay, 1985; Hamil-Luker and Smith, 1998; Huber, Cox, and Edelen, 1992; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; Klopfer and Price, 1978; MacDonald, 1998; Ostheimer, 1980; Rao et al., 1988; Singh, 1979; Ward, 1980), as does approval of suicide for the terminally ill (Johnson et al., 1980; Sawyer and Sobal, 1987; Singh, 1979). Whites are generally more accepting of both euthanasia (Finlay, 1985; Hamil-Luker and Smith, 1998; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; MacDonald, 1998; Rao et al., 1988; Seidlitz et al., 1995; Singh, 1979; Ward, 1980) and suicide (Johnson et al., 1980; Sawyer and Sobal, 1987; Singh, 1979) than blacks, and males are more approving than females of euthanasia (Finlay, 1985; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; MacDonald, 1998; Seidlitz et al., 1995; Singh, 1979; Ward, 1980) and suicide (Johnson et al., 1980; Sawyer and Sobal, 1987; Singh, 1979).
Those with a higher income are more likely to approve of euthanasia than those with a lower income (Huber et al., 1992; Jorgenson and Neubecker, 1980-1981; Ostheimer, 1980; Ostheimer and Ritt, 1976; Rao et al., 1988; Seidlitz et al., 1995; Ward, 1980); the former group is also more likely to approve of suicide (Sawyer and Sobal, 1987; Singh, 1979). Acceptance of both euthanasia (Adams et al., 1978; Caddell and Newton, 1995; Finlay, 1985; Huber et al., 1992; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; Ostheimer, 1980; Ostheimer and Ritt, 1976; Rao et al., 1988; Singh, 1979; Ward, 1980) and suicide (Caddell and Newton, 1995; Johnson et al., 1980; Sawyer and Sobal, 1987; Singh, 1979) also increase with education.
Euthanasia approval appears to be highest among Jews and atheists (or those with “no religion”) and lowest among Catholics and Protestants (Caddell and Newton, 1995; Finlay, 1985; Huber et al., 1992; Jorgenson and Neubecker, 1980– 1981; Monte, 1991; Ostheimer, 1980; Ostheimer and Moore, 1981; Ostheimer and Ritt, 1976; Rao et al., 1988; Ward, 1980); the same pattern holds for approval of suicide (Caddell and Newton, 1995; Johnson et al., 1980; Monte, 1991; Sawyer and Sobal, 1987). Those who attend religious services more frequently or are more involved in religious activities show a lower degree of approval of both euthanasia (Adams et al., 1978; Finlay, 1985; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; Rao et al., 1988; Singh, 1979) and suicide (Johnson et al., 1980; Sawyer and Sobal, 1987; Singh, 1979). Previous studies have uncovered a moderate negative correlation between the strength of religious convictions and both euthanasia attitudes (Ho and Penney, 1991; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; Rao et al., 1988; Singh, 1979; Ward, 1980) and suicide attitudes (Caddell and Newton, 1995; Johnson et al., 1980; Sawyer and Sobal, 1987; Singh, 1979).
Several studies have found a weak correlation between political views and euthanasia attitudes (Jorgenson and Neubecker, 1980-1981; Rao et al., 1988; Ward, 1980). All three previous studies that included freedom of expression analyzed it as a summed measure of three variables: freedom of speech for atheists, communists, and militarists. Both Finlay (1985) and Singh (1979) found that those who approve of freedom of expression are more likely to approve of euthanasia; Singh (1979) concluded the same about approval of suicide.
Though Rao et al. (1988) discovered a negative significant relationship between community size and euthanasia attitudes, Adams et al. (1978) and Ostheimer and Ritt (1976) found no association between the two variables. Rao et al. (1988) also found the South to have high percentages of euthanasia approval; Finlay (1985) found that geographic region to be low, while finding the West to be consistently high. Generally, Ostheimer’s and Ritt’s (1976) and Singh’s (1979) findings support Finlay’s, though Adams et al. (1978) found the West to have the lowest percentage of euthanasia approval, and the East, the highest.1
The focus of the present research is to examine Americans’ attitudes toward euthanasia and suicide for terminally ill persons in 1996.2 Are Americans’ attitudes in 1996 significantly different from those in 1977? To what extent are they different, and in what direction? Are the variables of predictive importance in 1977 still influential in 1996? In an attempt to answer these questions, the current study is a replication of B. K. Singh’s (1979) “classic” study mentioned above.
MATERIALS AND METHODS
The data used in this research were collected as part of the larger 1996 General Social Survey (GSS) administered by the National Opinion Research Center (NORC). The data used by Singh (1979) were collected as part of the larger 1977 GSS. The GSS is conducted annually, using an independently drawn random sample of English-speaking people 18 years of age or older, living in noninstitutional settings within the United States. The respondents are personally interviewed for approximately 90 minutes by the professionally trained staff of the NORC (Davis and Smith, 1992).
The 1996 GSS sample consisted of 2,904 respondents. However, in keeping with Singh’s (1979) methodology, two exclusions reduced the sample size to 1,714.3 First, respondents other than black or white were excluded. Also, a respondent must have answered the questions on both euthanasia and suicide to be included in the analysis. The 1977 GSS sample used by Singh (1979) consisted of 1,530 respondents, and the above exclusions reduced that sample to 1,398.
As in Singh (1979), the chi-square test set at a 0.05 alpha level was used to test the significance of the associations between variables. The bivariate relationships are presented in Tables 1-4. Singh (1979) conducted ordinary least squares (OLS) regression analyses that did not include dummy variables; these are replicated-using 1996 data-in Model 1. OLS regressions were then run using dummy variables where appropriate; this is Model 2. The results of all of the OLS regressions (Models 1 and 2 for each of the dependent variables) are displayed in Tables 5 and 6.4
The two dependent variables from the GSS used both in the current study and in Singh’s (1979) study measure attitudes toward euthanasia and suicide for terminally ill persons. Respectively, the specific questions read: “When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his family request it?”; “Do you think a person has the right to end his or her own life if this person has an incurable disease?” Respondents answered either Yes or No to these questions.5 It should be noted that the questions are similar in that they both address a person with an incurable disease. The only difference between them is that a doctor ends the patient’s life in the hypothetical situation posed in the euthanasia question, while the patient ends his or her own life in the suicide question.
As in Singh’s (1979) study, the 14 independent variables used in this research were separated into five broad categories: sociodemographic, socioeconomic, religious, ideological, and geographic. The four sociodemographic variables analyzed were age, race, sex, and size of place of residence. Socioeconomic dimensions included education and income. Three indicators of religious behavior were religious affiliation,6 frequency of attendance at religious services, and strength of religious convictions.
Ideological dimensions included political identification, approval of euthanasia, approval of suicide, and approval of freedom of expression, which was a summed scale of attitudes toward freedom of speech for atheists, militants, and communists. Respondents who would permit freedom for all three were considered permitting total freedom of expression, and those who disapproved of freedom for all three were considered permitting no freedom of expression. Those who approved of freedom of speech for one or two but not all three constituted the middle category. Regional differences were also considered. Recoding of variables was done in accordance with Singh’s (1979) recodes.
Table I shows the levels of approval among GSS respondents in 1977 and in 1996, and the magnitude of the change between 1977 and 1996 for both euthanasia and suicide. The great majority of the respondents in 1977 (62.4 percent) and in 1996 (70.4 percent) expressed approval of a doctor assisting an incurably ill patient to terminate his or her life, while less than the majority (39.6 percent) to more than the majority (65.8 percent) approved of an incurably ill person ending his or her own life. The substantial increase (26.2 percent) in the approval of suicide between 1977 and 1996 was an unexpected result, especially when compared to the much smaller increase (8 percent) in the approval of euthanasia.
A comparison shows a greater percentage of approval in 1996 than 1977 for both dependent variables regardless of geographic region or size of place of residence. Those who live in New England, the Pacific region, and the Mountain region showed the highest approval percentages for both euthanasia and suicide in both years. Singh (1979) did not report whether the attributes of geographic region were statistically significant with respect to the two dependent variables; the relationship was significant at the 0.05 level for both dependent variables in 1996. As in Singh (1979), a greater proportion of metropolitan than non-metropolitan respondents approved of both euthanasia and suicide for the terminally ill.
Table 2 shows a greater percentage of approval in 1996 than 1977 for both euthanasia and suicide, regardless of age, sex, race, education, and family income. Consistent patterns between Singh’s (1979) findings and the current findings include the following: approval of both euthanasia and suicide decreased as age increased, a larger proportion of males and whites expressed approval of both, and approval of both euthanasia and suicide increased as education increased and as income increased.
Table 3 shows a greater percentage of approval in 1996 than 1977 for both euthanasia and suicide, regardless of religious affiliation, religious commitment, and religious attendance. Again, there are consistent results between Singh’s (1979) study and the present study, including the following: a greater proportion of non– Catholic than Catholic respondents expressed approval of both euthanasia and suicide, and approval of both euthanasia and suicide increased as religious commitment weakened, and as religious attendance decreased.
Though Singh (1979) did not analyze religious affiliation by its NORC categories (Protestant, Catholic, Jewish, No religion, Other), it was analyzed in the current study as a dummy variable. The present findings indicate that Protestants and Catholics showed the lowest rates of approval, whereas Jews and atheists (“No religion”) showed the highest rates of approval. It is clear that in order to fully understand the relationships between religious affiliation and both euthanasia and suicide attitudes, religious affiliation cannot simply be considered as Catholic versus non-Catholic, because the inclusion of Protestant respondents in a “nonCatholic” category cancels out the other religious preferences (Jewish, None, Other) that are included in the same category. Religious affiliation must be analyzed in the future by its NORC categories as Ostheimer and Moore (1981) concluded, or even more precisely, by the “historically distinct Protestant religious identities” (such as evangelical, fundamentalist, and liberal) as Hamil-Luker and Smith (1998:388) suggested.
A greater percentage of approval exists in 1996 than in 1977 for both dependent variables, regardless of political views and freedom of expression approval. These results are displayed in Table 4. The current study found a lower level of approval of euthanasia than Singh (1979) among those respondents who expressed disapproval of suicide. Consistent patterns between Singh’s (1979) findings and the current findings include the following: approval of both euthanasia and suicide increased as approval of freedom of expression increased; a greater proportion of liberal than moderate or conservative respondents expressed approval of both euthanasia and suicide; and a greater proportion of those who approved of euthanasia expressed approval of suicide, and vice versa.
The OLS regressions on each of the independent variables were based on all 1,714 observations. The 1996 replication of Singh’s regression model (Model 1 here) accounted for almost 40 percent of the variation in attitude toward euthanasia, while Model 2 (which included dummy variables) explained about 42 percent of the variation in euthanasia attitudes. Few of the independent variables were statistically significant at the 0.05 level, and only three-race, “high” religious attendance, and attitude toward suicide for terminally ill persons-had beta weights of 0.10 or higher.
The independent variables included in the 1996 replicated regression on approval of suicide for terminally ill persons (Model 1) accounted for 39 percent of the variation in that variable, while Model 2 explained about 41 percent of the variation. Again, few of the independent variables were statistically significant at the 0.05 level, and only two– “high” religious attendance and attitude toward euthanasia for terminally ill persons -had beta weights larger than 0.10. When compared to Singh’s (1979) findings, the present results show a significant drop in the effects of most of the variables-the most notable of which are the religious variables-included in the regression models. Attitude toward euthanasia has become more important, however, in explaining attitude toward suicide, and vice versa.
SUMMARY AND DISCUSSION
Americans’ attitudes toward euthanasia and suicide in 1996 were found to be more approving than those found in previous studies (Caddell and Newton, 1995; Finlay, 1985; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; Rao et al., 1988; Seidlitz et al., 1995; Singh, 1979; Ward, 1980). A substantial amount of previous research supports the current finding that approval rates continue to increase (Brigham and Pfeifer, 1996; Glick, 1992; Hamil-Luker and Smith, 1998; Huber et al., 1992; Jorgenson and Neubecker, 1980-1981; Monte, 1991; Ostheimer, 1980; Rao et al., 1988; Singh, 1979).
While the approval of euthanasia in 1996 has increased slightly (8 percent) compared to 1977, the approval of suicide has increased by more than 26 percentage points. It is suggested here that this result may reflect two broader, well– documented societal trends: a decline in public confidence in medicine, and an increase in the strength of public belief in individual autonomy. Americans’ confidence in medicine and the medical field has been declining for at least four decades. Originally in 1983, and again in the 1987 revised edition of Confidence Gap: Business, Labor, and Government in the Public Mind, Lipset and Schneider discuss “the prolonged loss of confidence in American institutions since 1965” (p. 5), including the institution of medicine. Focusing specifically on the medical profession, Humphry and Clement (1998:35) cite Robert Samuelson’s The Good Life and Its Discontents (1995:51) in claiming that confidence in medicine has steadily decreased, falling from 73 percent in 1966 to 43 percent in 1975, to 35 percent in 1985, to 23 percent in 1994. Hoefler (1994) argued several years ago that “trust [in medicine] has eroded and that this erosion in confidence is beginning to manifest itself as right-to-die activism” (p. 67).
Concomitant to the decline in public confidence in medicine has been an increase in the strength of public belief in individual autonomy. Hamil-Luker and Smith (1998) attribute this trend to increased secularization and a decrease in the amount of control religious authority exerts over people’s lives. Humphry and Clement (1998) claim that the increasing “commitment to freedom of thought and action” (p. 27) grew out of the global rebellions of the 1960s: “[T]he rights culture of the 1960s strengthened the values of individualism, participation, self– determination, and autonomy” (p. 29). Hoefler (1994) makes a similar argument about the phenomena he refers to as the “emergence of a rights culture” (p. 95) in America over the last four decades. He claims “the right to die can be understood … as a natural extension of rights Americans already expect to enjoy” (p. 95).
Perhaps the observed increase in approval of euthanasia is so much smaller than the increase in approval of suicide because in the former scenario, the effect of Americans’ distrust of doctors tempers the effect of their belief in the importance of individual autonomy. (Again, in the hypothetical scenario posed in the euthanasia question, a doctor is present at the patient’s death.) The absence of a medical professional in the hypothetical suicide scenario, on the other hand, renders the effect of the public’s distrust of medicine irrelevant, and the effect of their emphasis on autonomy thus becomes more evident, driving up the approval percentage of suicide. Again, however, once a doctor is introduced into the hypothetical situation, as in the euthanasia question, the two trends seem to work in opposition, almost canceling out the relative effects of one another, and thus ultimately creating little change in the approval percentage of euthanasia.
In each category of each variable but two (black and Jewish respondents), approval percentages for euthanasia were higher than those for suicide in 1996. Glick (1992) also claims that people are less supportive of suicide than they are of euthanasia. Caddell and Newton (1995) reached a similar conclusion: “[w]hen discussing the possibility of euthanasia performed by a physician or suicide, Americans favor the participation of a physician” (p. 1679). Apparently, while the majority of the American public approves of both types of death, we are more approving of the type of death in which a doctor is present.
Despite Sawyer and Sobal’s (1987) contention that nearly half of American adults consider suicide to be an acceptable solution to particular life problems, there may still be a stigma attached to the concept of suicide which results in higher disapproval percentages. People may believe that suicide is a cowardly act committed in an effort to escape from one’s life, while euthanasia is a heroic act committed in order to end one’s pain and suffering. Perhaps also present here are issues of security and safety. Terminally ill people may feel more safe and secure by including a doctor in the act of terminating their lives. Benson (1999) argues that the consistently lower percentages of approval of suicide may be attributed to “an instinctive aversion to and religious proscriptions against suicide or fear that the suffering patient might act too rashly” (pp. 266-67). Regardless of the causal factors behind this finding, it suggests that if voluntary termination of life treatments were to be legalized, federal and state governments may partially appease the issue’s opponents by making a doctor’s presence mandatory in all such cases.
The above two general findings, however, suggest a paradox: While on the one hand the American public’s trust in the medical profession to make end-of-life decisions for individuals has decreased, and the public’s belief in individual autonomy has increased, people still seem to trust medical professionals more than individuals to carry out end-of-life decisions (though the gap is smaller in 1996 than in 1977). This dichotomy has important implications for both patients and doctors. While the public distrusts doctors more than ever before, if given the choice, we would still prefer them to be involved in the voluntary termination of life. Whether the American Medical Association makes an effort to address this contradiction remains to be seen.
The results of the OLS regressions indicate that race, religious commitment and attendance, political identification, and suicide approval were statistically significant predictors of euthanasia approval. These findings, for the most part, support those of Singh (1979). However, only religious attendance and euthanasia approval were statistically significant predictors of suicide approval in both 1977 and 1996. Overall, in 1996, very few variables have any significant, substantive effect on attitudes toward euthanasia or suicide. Basic demographic variables appear to no longer explain people’s attitudes toward these specific end-of-life issues. Monte (1991) reached a similar conclusion, though he found (in opposition to the current findings) that religious affiliation remains an important predictor variable. It will be up to future researchers to more accurately delineate the specific characteristics that influence people’s attitudes toward euthanasia and suicide.
Perhaps a more effective future approach than that taken here to studying attitudes toward euthanasia and suicide would be a small-scale panel study. Such a research design would serve two purposes: it would help to illuminate the relationship between specific events in the right-to-die movement and public opinion, and perhaps more importantly, it would allow for the examination of attitudes of specific individuals as they change over time. Studying the change over time in attitudes of the same individuals would make it possible for the researcher to specify both the condition of, and dynamics behind, that change.
Euthanasia and suicide are clearly multifaceted issues; each case of euthanasia and suicide is different from every other case. Obviously, it is extremely difficult for survey questions to tap into every facet of the issues. Therefore, the researcher concludes that there is a need for more frequent use of triangulation in euthanasia and suicide research. Quantitative survey research can be combined with intensive in-depth interviewing, for instance. Future triangulation also will aid researchers in resolving the contradictory results that have plagued past euthanasia and suicide research. Only by triangulating evidence will it be possible to illuminate more of the many dimensions of an issue that promises to persist well into the future.
I wish to thank Robert Zussman, the late Andy Anderson, Sarah Babb, and two anonymous reviewers for their invaluable comments on, and criticisms of, earlier drafts of this paper.
*This paper is part of the author’s Master’s thesis, which was written at Southern Connecticut State University under the direction of Joseph A. Polka.
1 It is useful to note, in order to assess both how comparable and how robust my results are, that several of the studies I have cited here analyzed GSS data. These include Caddell and Newton (1995), Finlay (1985), Hamil-Luker and Smith (1998), Johnson et al. (1980), Jorgenson and Neubecker (1980-1981), MacDonald (1998), Monte (1991), Ostheimer and Moore (1981), Rao et al. (1988), Sawyer and Sobal (1987), Singh (1979), and Ward (1980).
2 The year 1996 was chosen as the comparison year for this study simply because it was the most recent dataset available to the researcher.
3 This represents approximately a 41 percent sample loss. However, an investigation of the characteristics of those individuals who were excluded showed no significant differences on any of the variables under consideration when compared to those who were included in the analysis.
4 Singh (1979) conducted OLS regressions despite the fact that logistic regression is the appropriate method to use with dichotomous dependent variables, as are the dependent variables in this case. I therefore also conducted a logistic regression on each of the dependent variables and found that the statistically significant regressors were the same, and significant at the same levels, as those in the respective OLS regressions.
5 Entire studies (see, e.g., Huber et al., 1992) have been devoted to the semantics involved in this issue. With this in mind, we must precisely define what we mean by the terms “euthanasia” and “suicide.” The consensus in the literature is that the first GSS question listed above refers to voluntary euthanasia or euthanasia (Finlay, 1985; Ho and Penney, 1991; Johnson et al., 1980; Jorgenson and Neubecker, 1980-1981; MacDonald. 1998; Monte, 1991; Ostheimer, 1980; Singh, 1979; Ward, 1980), while the second question refers to suicide (Finlay, 1985; Johnson et al., 1980; Monde, 1991; Singh, 1979). These conventions are also used here.
6 Singh (1979) recoded religious affiliation into two categories, Catholic and non-Catholic, and found that the variable had little effect on either euthanasia or suicide attitudes. Ostheimer and Moore (1981), intrigued by Singh’s unconventional finding, analyzed religious affiliation by its NORC categories of Catholic, Jewish,
Protestant, No religion, and Other. While Singh’s recode had masked distinctions between the categories, Ostheimer’s and Moore’s analysis indicated that religious affiliation was an important predictor of euthanasia attitudes. In order to address this discrepancy, I replicated both analyses using the 1996 data.
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Michael A. DeCesare
University of Massachusetts, Department of Sociology, Thompson Hall 536, 200 Hicks Way, Amherst, MA 01003, e-mail: email@example.com
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