Changes in opinions on intentional or unintentional hastening of death from graduation to 6 years as a physician—a follow-up cohort study

Introduction

Palliative care aims to improve the quality of life of patients and families with physical, psychosocial, or spiritual suffering due to severe illness (1-3). Palliative care aims neither to hasten nor postpone death (1,2). Assisted death refers to either physician-assisted suicide (PAS) or euthanasia, both of which are intended to cause patient’s death. In PAS a lethal medication, prescribed by a physician, is voluntarily self-administered by a patient (4), while a physician administers a lethal amount of drugs to a patient under euthanasia (4,5). However, the term hastened death lacks a specific definition and may refer to different situations (4).

In addition to assisted death, there is a dilemma about whether to accept the possibility of unintentionally hastening death when the intention is to manage suffering. In a broad context, this ethical dilemma is called the doctrine of double effect (6). It refers to a phenomenon, in which an act intended to do good may justify a foreseeable risk of harm, in this case, unintentional hastening of death. The foreseeable harm is morally justifiable because the intended good is considered to be morally more important than the harm caused (6,7). Relieving patients’ suffering with high doses of opioids at the end-of-life, regardless of the potential but unproven and unintentional life-shortening effects, is sometimes used as an example of the doctrine of double effect (8). This phenomenon is seen in a study where more than half of physicians from Australia and Europe reported to have intensified pain medication while considering the possibility of hastening death (9).

Euthanasia has been allowed in the Netherlands and Belgium since 2002, and it has since been approved or decriminalized in Luxembourg, Colombia, Canada, the states of Victoria and Western Australia in Australia, New Zealand, Spain, Portugal, Ecuador, Cuba, and Uruguay (10-14). In addition, PAS has been legalized in 10 states in the United States of America (11) and is now legal in all Australian states, except the Northern Territory (15). PAS has been decriminalized in Colombia, Germany, and Switzerland (10,11). In Finland, patients cannot obtain euthanasia upon request (16), and it is not legal for a physician to perform PAS or euthanasia (17). A citizens’ initiative, launched in 2023, calling for the legalization of euthanasia has been referred to the Finnish Parliamentary Committee on Social Affairs and Health for review. No decision has yet been made on the matter (18). Several surveys from the USA, Canada, and Europe report lower acceptance of euthanasia and PAS among physicians than among the public (19). Studies on Finnish physicians have shown that their acceptance of euthanasia has increased during the past decades (20-23).

Physicians face ethical dilemmas in decision-making during end-of-life care and struggle with the possibility of hastening death while relieving suffering. Decision-making in end-of-life care is complex and sometimes challenging for all physicians. However, the accumulation of life and work experience can aid in decision-making (24,25), although the ethical principles of decision-making and the opinions or attitudes behind them may have been adopted already before and during the years of medical school (26).

The complex and demanding issues of euthanasia, PAS and occasionally even unintentional hastening of death are topics of ongoing discussion among physicians. Changes in physicians’ attitudes towards hastened death and the factors influencing their decision-making during the early working years as a physician are important objects to study. Through research, it is possible to improve ethical aspects in undergraduate and postgraduate medical education and to enrich the ongoing discussion on hastened death. The aims of our study were to evaluate whether attitudes behind decision-making and acceptance of hastened death among physicians change after 6 years from graduation through working experience. We present this article in accordance with the STROBE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-128/rc).

Methods

Participants

A survey with a questionnaire including seven hypothetical patient scenarios was administered to all Finnish medical students (n=639) as part of their scheduled teaching sessions during their last year at medical school in 2015 or 2016 depending on the graduation day. The questionnaire was returned either personally in sealed envelope or by mail. A valid response was received from 402 (63%) students (24,26).

At the end of 2021, the same questionnaire was mailed to these same responders, who now had 6 years of experience as physicians. Contact information was obtained from the registry of the Finnish Medical Association, which had the information for 396 (99%) of the target subjects. Reminders were sent twice to non-responders. A cover letter including an introduction to the study and an assurance of anonymity and voluntariness was mailed together with the questionnaire. A valid response was received from 227 (57%) participants in 2021.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Regional Ethics Committee of Tampere University Hospital, Finland (R15101) and informed consent was obtained from all individual participants. The study was conducted in accordance with Finnish laws and regulations.

Questionnaire

The responders answered seven distinct hypothetical patient scenarios concerning decision-making in different end-of-life situations. Out of the seven hypothetical scenarios, the selected scenario—the only one that assessed attitudes towards the possibility of hastening death and the doctrine of double effect (27)—is presented below. The responders’ opinions on several factors including attitudes towards euthanasia and assisted suicide were assessed on visual analogue scale (VAS) from “definitely agree” (0 mm) to “definitely disagree” (100 mm). The responders’ personal life values, such as the importance of family, health, religion and a clean environment, were assessed using a four-point Likert scale ranging from “not at all important” [1] to “very important” [4]. In addition, the background factors of the responders were inquired. All of the case scenarios and statements of this Finnish-language questionnaire used in this study have been previously used and validated with Finnish physicians (28-32).

Patient scenario

In this study, we used one patient scenario: a 60-year-old male patient suffering from prostatic cancer with metastases. Metastases in the thoracic spine led to total paraparesis 1 month earlier. There is no hope for a cure. The patient is well aware of the situation. He has totally lost his will to live. When you are together with him alone, he asks for a sufficient dose of morphine to “get away”. You have denied the overdose, explaining that it is against your ethical principles. During the following days, you notice that the patient asks you to double his morphine dose because of unbearable pain. You suppose that increasing the dose in such a way would lead to the patient’s death. Your decision is which of the following: a) to raise the dose because the patient has the right to sufficient pain relief in this end-of-life (terminal) care situation; b) to try to help the patient in other ways, such as with antidepressants, thus continuing with morphine dosing according to given guidelines; c) I can’t say; or d) provide an alternative response in free text.

Statistical analysis

The answers to the case scenario were combined into two options: “Accepted increasing morphine dose (a)” and “Did not accept increasing morphine dose (b, c or d)”.

Life values measured with a 4-step Likert-type scale were converted into a 2-step scale: 1–2 “Not important” and 3–4 “Important”.

Continuous variables were considered non-normally distributed and were tested with the Mann-Whitney U test or Wilcoxon’s test when appropriate. Paired two-scale variables were tested with McNemar’s test. Two-sided P values less than 0.05 were considered statistically significant.

A forward stepwise logistic regression was used to create a model explaining the decision to increase the morphine dose in 2015 and 2021. All background factors, life values and attitudes were included in the model. The P value limit for significance was set at 0.10 for entry and 0.15 for removal from the model. The number of physicians accepting morphine dose escalation was relatively small, which might lead to overfitting in the regression analysis. However, there were no signs of that.

Data analysis was executed using IBM SPSS Statistics for Windows, version 29.0.1.0.

Results

A total of 227 participants provided a valid response to the questionnaire (response rate 57%) and were included in this study. The responders’ characteristics are presented in Table 1. The majority of the responders were women (60%). Being married and having children was more common in 2021 than in 2015. In both years, approximately two out of three participants had taken part in end-of-life care during the previous 2 years. Responders’ own advance directives were uncommon in both years. To control the possible response bias, we compared non-responders from 2021 and responders from both years. No statistically significant differences were found considering their background factors, answers to the patient case, or statements measured using the VAS scale in 2015.

The acceptance of increasing the morphine dose in the patient scenario is shown in Figure 1. Among the responders, 74% maintained their opinion on the patient scenario unchanged between the study years. The majority of the responders did not accept increasing the morphine dose in both years, but the percentage of responders who accepted this increased from 25% in 2015 to 31% in 2021 (P=0.06). The direction of the change in opinion towards increasing morphine in 2015 and 2021 is shown in Figure 2.

Figure 1 Responders’ acceptance of increasing the morphine dose in 2015 and in 2021 (P=0.06). Data are missing from one responder in 2021.

Figure 2 Responders’ decision to increase the morphine dose in 2015 and 2021. Data are missing from one responder in 2021.

The attitudes of the responders in the years 2015 and 2021 are shown in Table 2. Statistically significant changes in attitudes were found for six of the fourteen statements, but most of the attitudes showed only minor changes in the VAS score. Compared with answers in 2015, in 2021 the responders were more likely to oppose that people should pay for the cost of self-inflicted diseases and were less pleased with their salary. Attitudes towards the reprehensibility of euthanasia and assisted suicide did not significantly change between 2015 and 2021. Withdrawal of life-sustaining treatments was considered less reprehensible in 2021 than in 2015.

The responders’ views on the importance of the asked life values are presented in Table 3. The majority of the values were considered important nearly as often in 2015 as in 2021. However, length of life and a clean environment were regarded as significantly more important in 2021 than in 2015, whereas the proportion of responders considering faith in God as important significantly decreased. The most important life values in both years were health, family, and a clean environment.

The differences in attitudes between participants who accepted and did not accept increasing the morphine dose in the patient scenario are shown in Table 4. Lower reprehensibility towards euthanasia and assisted suicide was associated with a greater willingness to increase the morphine dose in both years, although this difference decreased in 2021.

Table 5 shows a logistic regression analysis of factors explaining the willingness to increase the morphine dose in both study years. In 2015, not considering assisted suicide to be reprehensible and not finding advance directives helpful in decision-making were associated with a willingness to increase the morphine dose. In 2021, being a man, being single, emphasizing faith in God, not considering assisted suicide to be reprehensible, and not feeling burned out was statistically significantly associated with a willingness to increase the morphine dose.

Discussion

Our results revealed that the acceptance of the possibility of hastening death by increasing the morphine dose did not significantly change among the cohort of physicians during the first 6 years after graduation from medical school. Attitudes towards the reprehensibility of PAS and euthanasia, as well as life values did not change significantly either. Hence, it seems that the majority of the participants’ attitudes and life values had already been adopted before graduation. However, there was a slight tendency for willingness to increase the morphine dose to a potentially lethal level to relieve suffering in the hypothetical patient scenario reflecting the doctrine of double effect. This willingness was associated with less reprehensibility towards assisted suicide together with several background factors. Young Finnish physicians express divergent opinions concerning the complex and demanding issue of hastening death unintentionally or intentionally, which highlights the need for continuous open discussion and ethical education for the medical profession, starting from medical school.

In our study, the majority of physicians did not agree to increase the morphine dose to a potentially lethal level, and this did not show a significant change after 6 years of graduation. Nevertheless, a statistically nonsignificant trend towards more accepting views was seen. In contrast to our findings, a survey performed in six European countries and Australia in 2008 revealed that in Australia, Belgium, Denmark, and the Netherlands, a large majority of physicians (83–95%) had intensified pain medication while considering the possibility of hastening death. These percentages were lower in Italy (57%), Sweden (64%), and Switzerland (71%) (9). Our study population, however, represented only young physicians with a relatively narrow age range, which must be taken into account when comparing our results to previous studies on physicians in general. Nevertheless, a British study conducted among medical students in 2018 revealed that older students are slightly more likely to agree with death-hastening acts than younger students (33).

The reasons behind the acceptance of administering a morphine dose that was associated with a risk for hastened death in our study can be diverse. The primary aim of our case scenario was to present the ethical dilemma associated with the doctrine of double effect. Accordingly, we do suggest that one reason for increasing morphine dosing was physicians’ consideration that the thorough treatment of patients’ symptoms justified the risk of unintentionally hastening death. Secondly, multiple studies suggest that opioids do not hasten death, even at relatively high doses (34-36). Therefore, the tendency to increase the morphine dose in our study might have been related to the knowledge and clinical experience with morphine dosing during end-of-life care and not to the acceptance of hastening death. Thirdly, a true willingness to hasten death at the request of a patient in the case scenario cannot be ruled out in our survey study. Thus, the reasons behind the increase in the morphine dose may be multifactorial, but we suggest that this is also the case in clinical reality, where the physicians struggle with ethically complex decisions. In addition, it has been shown previously that patients’ wish to die might arise from physical, psychological, social, and existential suffering, rather than genuine desire to die (37-39). Further research is needed to expand our understanding of these complex decisions.

Reprehensibility towards euthanasia was modest and did not significantly change after graduation in our study. A Finnish study performed in 2022 states that ambivalence towards euthanasia among physicians has decreased in recent years (23). At the same time, public discussion on the legalization of euthanasia has continued in Finland, as a citizens’ initiative to legalize euthanasia is currently reviewed by the Finnish Parliamentary Committee of Social Affairs and Health (18). The reported acceptance toward euthanasia among medical students has been highly variable, ranging from 18% to 97% in different studies depending, among other things, on the study cohort, country, culture and religion of the responders (40-42). However, younger physicians, in general, are shown to be more likely to be in favor of euthanasia than older physicians (22,43,44). In contrast to previous reports and the increasing general acceptance of euthanasia in recent years, our study showed a relatively stable and adverse attitude towards euthanasia among the responders.

The responders’ attitudes in this study towards assisted suicide remained unchanged, but it was seen as less reprehensible than euthanasia. In the United States, Canada, and Europe, the support for legalizing PAS varies between physicians from 36% to 54% (19). Previous findings are in line with our research, as support for the use of PAS has been found to be greater than support for euthanasia (20,40,45). It seems that opinions on euthanasia and PAS are formed before medical school graduation and may not change significantly during the first years as a physician. Moreover, the stability of opinions with increasing experience suggests that attitudes and decision-making perspectives on these complex issues are shaped before graduation. Thus, teaching ethical decision-making during medical studies is important to enable physicians to respect patient autonomy, understand the complex ethical factors underlying their decision-making, and ultimately make better-informed decisions for their patients.

Withdrawal of life-sustaining treatments was more likely to be accepted than euthanasia and PAS by physicians (20,40,46). In a previous Finnish study, higher willingness to withdraw and withhold life-prolonging therapies was associated with age, medical education, and clinical experience (24). In our study, the reprehensibility of withdrawing life-sustaining treatments decreased 6 years after graduation and was considered clearly less reprehensible than both euthanasia and PAS. In Finland, withholding and withdrawing life-sustaining treatments, when they are considered futile, is legal and a common clinical practice and an important part of good palliative care (16,17,47). Hence, our results probably reflect the increasing knowledge of the basics in clinical decision-making and, therefore, it is highly understandable that withdrawing unbeneficial or harmful treatments is considered less reprehensible than euthanasia and PAS.

It seems that there are no major changes in important life values during the first 6 years as a physician. The same values as in our study, especially health, family and clean environments, were considered important in a Finnish study performed in 2018, but studies on the life values that are important to physicians are limited (20). The life values of our responders probably reflect the values commonly adopted in Finnish society, and again, these basic values seem to have already been adopted in early adulthood.

In our study, the willingness to increase the morphine dose was higher among men than among women after 6 years of graduation. Our results are in line with those of a Canadian study performed in 2019 showing that male physicians are more willing to prescribe lethal drugs and are more supportive of hastening death (46). In contrast to our findings, a Dutch study performed in 2020 indicated that women in the general public were more prone to accept euthanasia (48), whereas other studies have shown no gender difference (49). Gender has not been a significant factor in attitudes towards hastening death in studies concerning medical students (50,51). The impact of gender on the acceptance of hastening death seems to be multifactorial and might be dependent on the study cohort and on how the research question is framed. We must again note that the exact intention behind the willingness to increase the morphine dose remains unknown in our study, even though the possibility of hastening death is presented in the case scenario.

The importance of religion decreased during the first 6 years as a physician in our study cohort, and this might have influenced the overall attitudes toward hastening death. However, faith in God was also independently associated with a greater tendency to increase the morphine dose. Our results differ from those of previous studies. A study performed in 2018 among British medical students revealed that students with religious backgrounds tend to oppose death-hastening acts more than non-religious students (33). In another study from Canada, residents who were not strictly practicing religion were more likely to be willing to participate in acts that hasten death (46). Additionally, a 2022 study found near-universal opposition to euthanasia and PAS among representatives of various religious groups (52). Religious backgrounds have also been associated with lower acceptance of euthanasia and PAS among physicians and medical students (19,42,45,48,53). The findings of our and previous studies reflect that religion may guide physicians’ opinions on hastened death and decisions during end-of-life to multiple directions. The basic life values may impact physicians’ practices even when they have not consciously considered them to be influential in decision-making.

The limitations of our study need to be discussed. Even though the response rate in our study can be considered good (57%), when compared with the other studies (9,20,24), the possibility of response bias cannot be ruled out. To control the possibility of response bias, we analyzed background factors and answers in 2015 between responders and non-responders in 2021 and found no significant differences. Our study population can be considered to be a representative sample of Finnish physicians, reflecting the ratio of female physicians and specialties (54). However, the age distribution in our study was homogeneous due to the study design, which limited our ability to evaluate age as an influential factor. The number of responders in the study is limited, which may have contributed to some of the results not being statistically significant. On the other hand, the likelihood of type I errors in some analyses cannot be ruled out, as we conducted a large number of analyses. However, P values considered statistically significant were mostly <0.001. In our questionnaire, we did not explain terms such as euthanasia or PAS in detail, which is a significant limitation of our study. The terms are used interchangeably in medical discussions; therefore, some of the responders may have confused them. These terms should be clearly explained in future studies. Our patient scenario is hypothetical, and the responders did not have the opportunity to explain their answers. Although answering hypothetical scenarios may differ from decisions made in real life, we still assume that the responses reflect the responders’ attitudes and decision-making in clinical practice. It is possible that the location of the patient case in the questionnaire, the presentation and wording of the case and the framing of the question influenced the responders’ interpretation of the question and their responses. For example, the perception that hastened death is against the responders’ ethical values may not be true for every physician. The last questionnaire was conducted in 2021, and some legal changes globally have occurred. However, in Finland, the legal status of PAS and euthanasia has not changed during our study period. Finally, we argue that this kind of scenario would be impossible to study in real life and that we might need more years after graduation to see possible changes in physicians’ end-of-life decisions in these kinds of complex situations.

Conclusions

The willingness to increase the morphine dose to a potentially lethal level remained stable in a cohort of Finnish physicians 6 years after graduation. More than two-thirds of the participants still opposed this although a slight nonsignificant trend for increased willingness was found. Attitudes toward euthanasia, PAS and acceptance of hastened death through double effect appear to develop before graduation and tend to remain divided during the early years as a physician. Our results add to the existing literature on various aspects of hastened death and provide context to the ongoing ethical discussions on this demanding issue among physicians and medical students.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at: https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-128/rc

Data Sharing Statement: Available at: https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-128/dss

Peer Review File: Available at: https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-128/prf

Funding: This study was supported by the Signe and Ane Gyllenberg Foundation.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-128/coif). R.P.P. has received a personal research grant from the Signe and Ane Gyllenberg Foundation. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Regional Ethics Committee of Tampere University Hospital, Finland (R15101) and informed consent was obtained from all individual participants. The study was conducted in accordance with Finnish laws and regulations.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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