Euthanasia Education for Health Professionals in ...

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Euthanasia Education for Health Professionals in Turkey: students change their opinions Erdem Özkara, Murat Civaner, Sema Oglak and Atilla Senih Mayda Nurs Ethics 2004 11: 290 DOI: 10.1191/0969733004ne.696oa The online version of this article can be found at: http://nej.sagepub.com/content/11/3/290

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EU T H A N A SIA ED U C AT IO N FO R HE A LT H PR O FE SSIO N A L S IN TU R K E Y: ST U D E N T S C H A N G E T H E IR O P IN IO N S ¨ zkara, Murat Civaner, Sema Og Q lak and Atilla Senih Erdem O Mayda Key words: education; euthanasia; health sciences students; paramedics The purpose of this study was to investigate the impact of euthanasia education on the opinions of health sciences students. It was performed among 111 final year students at the College of Health Sciences, Dokuz Eylu ¨ l University, IR zmir, Turkey. These students train to become paramedical professionals and health technicians. Fifteen hours of educational training concerning ethical values and euthanasia was planned and the students’ opinions about euthanasia were sought before and after the course. Statistical analyses of the data were performed with the related samples t -test by means of the Epi-Info program. Significant changes were shown in the students’ opinions on people’s right to decide about their own life, euthanasia in unconscious patients, and reasons for their objection to euthanasia after completing the course. The results of this study suggest that education can significantly change a person’s approach to euthanasia.

Introduction Euthanasia is the practice of killing without pain a person who is suffering from a disease that cannot be cured.1 The concepts of both passive and active euthanasia are under discussion all over the world, especially in developed countries.2 ¡ 5 In 2001 the Netherlands Parliament drafted a new law about active voluntary euthanasia, which has now been legalized. However, active euthanasia has not been legalized in countries such as Germany and the UK.2 ¡ 5 Although euthanasia and assisted suicide are not clearly defined in the Turkish Penal Code, they are considered as murder (punishable by imprisonment of 24¡/30 years) and as persuasion and helping to commit suicide (punishable by imprisonment of 3 ¡/10 years). In the newly prepared criminal law draft, the paragraph about euthanasia is headed ‘murder on demand’, suggesting that, if a doctor terminates the ¨ zkara, Dokuz Eylu¨ l University, Address for correspondence: Assistant Professor Erdem O School of Medicine, Department of Forensic Medicine, 35300 IR zmir, Turkey. E-mail: [email protected] or [email protected]

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life of a patient who has unbearable pain and a terminal disease at the request of the patient, the doctor will be sentenced to imprisonment for one to three years. Euthanasia was banned by the declaration of patients’ rights made by the Turkish Ministry of Health.2,3 ,6 There have been studies about physicians, nurses, health care workers, lawyers and some other groups’ opinions on euthanasia in Turkey and in other countries.2 ,3 ,7¡9 In these studies the main objective was to investigate what health care workers, doctors and nurses think about euthanasia because they are the foremost medical staff and, additionally, they are in closer contact with patients than others. Medical and nursing students’ opinions have also been investigated,10 ¡1 5 but there have been a limited number of studies of the effects of education on their opinions.1 6 ,1 7 The present study was on students at the College of Health Sciences, Dokuz Eylu¨l University, who will be paramedical health care workers and health technicians when they graduate. Their opinions about euthanasia before commencing and after completing an undergraduate course on euthanasia were investigated. We hope that this study will contribute to data on euthanasia and elucidate how people’s approach to the issue changes with education.

Materials and methods This investigation was carried out with final year students at the College of Health Sciences, Dokuz Eylu¨l University between 20 February and 21 June 2002. There were 2375 students at 40 colleges of health sciences in Turkey during that time. High school graduates can attend these schools after succeeding in a central examination administered in all the cities of Turkey by the Turkish Higher Education Council, which is directly affiliated to the Presidency of the Turkish Republic. The colleges of health sciences offer a two-year vocational course. Graduates are employed as health technicians and work as paramedics.18 All 114 final year students who were studying ambulance and acute care, anaesthesia, medical laboratory technology, radiology and radiotherapy were asked to take part in the study. The Director of the school gave permission for us to conduct the study. We developed a questionnaire to determine what the students think about euthanasia and asked 10 students to pilot it in order to test whether it was understandable. We then amended the questionnaire in accordance with the results, which were not included in the statistical analysis. Students were not obliged to participate in the study; 111 of the total 114 students agreed to fill in the questionnaire, which they completed both before and after attending the course on ethical values and euthanasia under the supervision of the lecturer teaching the course. There was a four-month gap between the surveys. ‘Ethical values and euthanasia’ was a two-year module offered as part of the curriculum of the College of Health Sciences. One of the authors of this study taught the students 15 lessons of 45 minutes in one semester. Formal lectures, discussion and exercises were used. Case reports about euthanasia were presented. No dictionary or cliche´d description of euthanasia was given; instead, historical background and changes in the description of euthanasia were outlined and debate on the issue was emphasized in the lessons. The syllabus consisted of 45-minute lectures on the following subjects:

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Ethical values; Professional ethics; Patients’ rights; Informed consent; Aspects of medical malpractice; Genetics and ethics; Organ transplantation; What is euthanasia? The legal status of euthanasia; Opinions on euthanasia in Turkey and elsewhere; Patients and their relatives while deciding about euthanasia; Euthanasia and patients’ autonomy; Euthanasia and patients’ rights.

Two lectures took the form of case discussion. The data obtained from the first and second surveys were analysed statistically by means of the related samples t -test using the Epi-Info program.

Results Of the 111 students who took part in the study, 58.3% were female and 41.7% were male. Their mean age was 19.59/1.097 years. The results of the two surveys carried out both before and after completion of the course are summarized in Table 1. We found that students’ opinions changed over the four months of the course. . The number of students suggesting that no one could decide on euthanasia on behalf of an unconscious patient decreased. . The percentage of students who believed that everyone has the right to decide about his or her own life and health increased. . The percentage of students agreeing that a doctor who commits euthanasia should not be punished increased, and the percentage stating that doctors should be punished for carrying out euthanasia decreased significantly (P B/0.001). . Students’ opinions on the type of punishment for doctors who have performed euthanasia also changed. The percentage of students agreeing with the statement ‘doctors who have performed euthanasia should be accused of homicide and punished accordingly’ increased. . There was no significant increase in the number of students who supported euthanasia (P Í/0.05). . The reasons that students gave for their objections to euthanasia changed. The number who thought it was illegal increased. Before the educational programme, no student marked ‘illegality’ as a reason for his or her objection to euthanasia. However, after the lectures, 9% of the students objected to euthanasia because it was illegal. They may not have known that euthanasia was illegal before attending the course. Most of the students gave ‘religious thoughts’ as a reason for their objection to practising euthanasia and many of them also gave ‘it may be abused’ as a reason. Opinions that did not change after the educational programme were: . 46.6% and 52.4% of the students said ‘yes’ to the question ‘should euthanasia be legalized?’ before and after the educational programme respectively (P Í/0.05).


Euthanasia education for health professionals in Turkey Table 1

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Students’ approaches to euthanasia before and after the course: no. (%)

Opinion

Before course (%)

After course (%)

Does every person have the right to decide about his or her own life and health? Yes 99 (89.2) 109 (98.2) No 12 (10.8) 2 (1.8) Who should decide about euthanasia for an unconscious patient? No one 61 (55.0) 40 (36.0) Doctor 4 (3.6) 6 (5.4) Family 12 (10.8) 20 (18.0) Family and doctor 34 (30.6) 45 (40.5) Should committing euthanasia be considered as:a Committing homicide? 6 (7.1) 17 (29.3) Assisting suicide? 59 (69.4) 32 (55.2) Minor offence? 20 (23.5) 9 (15.5) Do you believe that euthanasia is used in our country even though it is not legal? Yes 67 (60.4) 99 (89.2) No 44 (39.6) 12 (10.8) Why do you object to euthanasia?b It is illegal 7 (9.1) ¡/ It is contradictory to my religious beliefs 31 (37.3) 30 (39.0) It is not ethically acceptable 15 (18.1) 12 (15.6) It may be abused 37 (44.6) 28 (36.4)

P- value B/0.01 B/0.05 B/0.01 Í/0.05 Í/0.05 Í/0.05 B/0.05 Í/0.05 Í/0.05 B/0.001 B/0.001 B/0.05 Í/0.05 Í/0.05 Í/0.05

n ¾/111, except: a Before the course 26 students, and after the course 53 students, stated that the doctor should not be punished b Before the course 28 students, and after the course 34 students, stated that they were not against euthanasia

. 88.1% and 87% of the participants defined euthanasia as ‘the practice of killing someone with a progressive, unbearable and fatal disease and with no hope of recovery despite modern medicine, and carried out painlessly after enduring prolonged pain, at a patient’s request with the assistance of a physician’ before and after the educational programme respectively (P Í/0.05). . 7.6% and 10.2% of the students answered ‘yes’ to the question ‘Have you ever faced a request for euthanasia’ before and after the educational programme respectively. . 81% and 86.6% of the participants found it useful to discuss euthanasia before and after the educational programme respectively.

Discussion and conclusion There is heated debate about the definition of euthanasia, especially in the USA, Australia, the Netherlands and some other European countries. Although some countries support the idea that euthanasia should be carried out only when patients suffer from fatal and painful diseases, others also support the view that patients with nonfatal chronic diseases should be able to receive euthanasia. However, committing euthanasia and assisting suicide in patients with nonfatal diseases has been criticized harshly from an ethical view point.2 ,3,1 9 ¡23 In our study, most of the students added some points to the definitions of euthanasia that have been discussed all over the


294 E O¨zkara et al. world. They described it as ‘the practice of killing someone with a progressive, unbearable and fatal disease and with no hope of recovery despite modern medicine, carried out painlessly after a long and painful illness, at the patient’s request with the assistance of a physician’. This description may have resulted from discussions in the lessons about the definitions and methods of euthanasia. Students demonstrated a broad knowledge of euthanasia rather than simply giving a dictionary definition. Studies carried out in Turkey have revealed that 91% of doctors and 85% of law students gave similar descriptions of euthanasia.24 ,2 5 Attitudes to euthanasia have been investigated among different social groups in many countries. Jorgenson and Neubecker 26 investigated 1525 adults’ attitudes to euthanasia and found that white people and men were more positive about euthanasia than black people and women. They noted that religious beliefs affected thoughts about euthanasia negatively, whereas changes in social class had a positive effect. In the present study the first reason given for objection to euthanasia was that people may misuse it and the second was that euthanasia and religious beliefs are in conflict. We think that, because of secularism in Turkey, religious reasons did not come first. In our study, although the percentage of students who were against euthanasia was high before the educational programme, it decreased after the programme (P Í/0.05). In other studies from Turkey, it has been reported that 63.5% of law students and 61% of doctors were against euthanasia.24 ,25 Studies from the other countries have revealed that 40% of medical students in Puerto Rico1 2 and 33% of medical students in the former Yugoslavia9 and Norway1 3 supported euthanasia. In a survey among nurses working in intensive care units in the USA, participants were asked to comment on sample cases. Almost all of them (99 ¡/100%) agreed with the actions of pain management and withholding or withdrawing life support, 83% disagreed with assisted suicide, and 95% disagreed with voluntary euthanasia.2 7 In this study 31% of the students confirmed after the course that they were not against euthanasia. The results of this study were consistent with results of studies with medical students and doctors, but they were inconsistent with those of nurses working in intensive care units in the USA. This may be because of the working conditions in intensive care units and the sample cases used in the surveys. We found that the percentage of students in favour of legalization of euthanasia did not change significantly after the educational programme (P¾/0.4229). Another study from Turkey showed that 65% of doctors and 52% of law students demanded legalization of euthanasia.24 ,2 5 In the former Yugoslavia 61% of lawyers were reported to support euthanasia.9 As in many other countries, active euthanasia is not legal in Turkey. However, the number of students believing that euthanasia is practised in Turkey, even though it is not legal, increased significantly after the course (P B/0.001). During the educational programme, the students were instructed in ways and means of carrying out euthanasia, given case reports and told about its possible misuse. A study from Turkey demonstrated that 65% of doctors surveyed believed that euthanasia was practised in Turkey even though it is not legal.2 4 The students’ attitudes to euthanasia changed significantly with education. Their opinions changed concerning who can decide about euthanasia, how a doctor practising euthanasia should be punished, whether they believed euthanasia was practised in Turkey or not, and the reasons they gave for their objection to euthanasia. The changes in their opinions may have been caused by the intensive course in


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euthanasia offered to them. This provided in-depth insight into euthanasia, causing the students to think that it was being performed in Turkey, so the reasons they gave for their objections to euthanasia changed. There have been few studies investigating the effects of education on opinions about euthanasia. Those that have been carried out emphasized that education is important for gaining insight into euthanasia and that curricula in medical schools should include courses on this issue, which should be as intensive as possible.16 ,17 Our finding that students’ opinions changed with education on this topic can be explained in two ways. First, health care workers may have false beliefs or information on euthanasia and consider it as murder or suicide. Secondly, the course on euthanasia may have caused these students to develop some sort of empathy with patients. After the course, there were changes in the answers to the questions about whether one has the right to decide about one’s own life and who should decide about euthanasia for an unconscious patient. The number of students in favour of the right to decide about one’s own life increased. However, the number of students believing that no one can decide about euthanasia for an unconscious patient decreased. The students learned about some aspects of euthanasia, such as its legal status in Turkey and elsewhere in the world, which caused them to change some of their opinions. On learning that euthanasia is not legal in Turkey, they rejected it because of its illegality. When they learned the nature of passive euthanasia, the number of students believing that euthanasia is practised in Turkey increased. Euthanasia should be discussed on various platforms and our citizens should be informed about it; 83.5% of the students involved in our study reported that it would be helpful to discuss euthanasia in Turkey. Likewise, in other studies, 87.9% of doctors and 86% of law students agreed on the usefulness of discussions on and informing people about euthanasia.24 ,25 A structured educational programme is a good opportunity for students to review their opinions, especially about the right to decide about their own life, and it is also a useful tool for teachers to discuss end-of-life issues. Education would help people to change their opinions on euthanasia. Euthanasia and related subjects are especially important in medical education, so the curricula of medical schools should include unprejudiced and complete discussion of euthanasia and other life-and-death issues. Specific training in palliative care is necessary for medical students and medical ethics curricula should focus on end-of-life issues, including euthanasia. Currently, euthanasia is not discussed by the public in Turkey. However, it is clear that, in a country where 18 ¡/27% of surveyed physicians had been asked to perform euthanasia and 39¡/65% believed that it is practised secretly,24 ,28 it is important that the subject should be discussed in scientific quarters. It is useful to teach physicians, other health professionals and patients about the various approaches to euthanasia because this will help to determine who needs education and to teach them what euthanasia is. The results of this study suggest that a course in euthanasia should be included in the curricula of medical schools, colleges of health sciences and nursing schools. This would help to prevent the abuse of euthanasia and encourage the enactment of regulations on the subject in the near future, not only in Turkey but also in other countries. The study also revealed that education in ethics and euthanasia changed students’ opinions about euthanasia and made them aware of the fact that passive euthanasia in particular was practised anyway.


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Acknowledgements The authors are grateful to Assistant Professor Leyla Dinç for her suggestions. Erdem O¨zkara, Murat Civaner and Sema OgQlak, Dokuz Eylu¨l, University, IRzmir, Turkey. Atilla Senih Mayda, Abant IRzzet Baysal University, Bolu, Turkey.

References 11 12 13 14 15 16

17

18

19 10

11

12

13 14 15 16

17

18

19 20

Wehmeier S, ed. Oxford advanced learner’s dictionary, sixth edition Oxford: Oxford University Press, 2000: 450. ¨ lme HakkW-O ¨ tanazi (Right to die¡/euthanasia). Istanbul: AyrWntW YayWnlarW, 1999: 135¡/ IR nceogQlu S. O 254 (in Turkish). ¨ zkara E. O ¨ tanazide Temel Kavramlar ve Gu¨ncel Tartis¸malar (Basic concepts and current O discussion about euthanasia). Ankara: Seçkin Press, 2001: 11 ¡/46 (in Turkish). Weber W. Netherlands legalise euthanasia. Lancet 2001; 357: 1189. Bernheim JL. Euthanasia in Europe. Lancet 2001; 357: 1038. The Patients’ Rights Written Regulations. Turkish Ministry of Health Ofcial Newspaper 1998 Aug 1; 23420. (TC SagQ lWk BakanlWgQW. Hasta HaklarW Yo¨netmeligQi. 1 AgQustos 1998. Resmi Gazete) (in Turkish). Dickinson GE, Lancaster CF, Clark D, Ahmedzai SH, Noble W. UK physicians’ attitudes toward active voluntary euthanasia and physician-assisted suicide. Death Stud 2002; 26; 479¡/ 90. Tanida N, Asai A, Ohnishi M et al. Voluntary active euthanasia and the nurse: a comparison of Japanese and Australian nurses. Nurs Ethics 2002; 9: 313¡/22. Radulovic S, Mojsilovic S. Attitudes of oncologists, family doctors, medical students and lawyers to euthanasia. Support Care Cancer 1998; 6: 410¡/15. Etzersdorfer E, Vijayakumar L, Schony W, Grausgruber A, Sonneck G. Attitudes towards suicide among medical students: comparison between Madras (India) and Vienna (Austria). Soc Psychiatry Psychiatr Epidemiol 1998; 33: 104¡/10. Caralis PV, Hammond JS. Attitudes of medical students, housestaff, and faculty physicians toward euthanasia and termination of life-sustaining treatment. Crit Care Med 1992; 20: 683¡/ 90. Ramirez Rivera J, Rodriguez R, Otero Igaravidez Y. Attitudes toward euthanasia, assisted suicide and termination of life-sustaining treatment of Puerto Rican medical students, medical residents, and faculty. Bol Asoc Med P R 2000; 92: 18¡/21. Schioldborg P. Students’ attitudes to active euthanasia. Tidsskr Nor Laegeforen 1999; 119: 2515¡/ 19. Ramirez-Rivera J, Ramos O. Euthanasia and relief of suffering: attitudes of medical students. Bol Asoc Med P R 1995; 87: 164¡/66. Grassi L, Asostini M, Rossin P, Masnani K. Medical students’ opinions of euthanasia and physician-assisted suicide in Italy. Arch Intern Med 2000; 160: 2226¡/27. Muller MT, Onwuteaka-Philipson RD, Kriegsman DM, van der Wal C. Voluntary active euthanasia and doctor-assisted suicide: knowledge and attitudes of Dutch medical students. Med Educ 1996; 30: 428¡/33. Hayes RP, Stomchemine AS, Kinlaw K, Dell ML, Loomis A. Changing attitudes about end-oflife decision making of medical students during third-year clinical clerkships. Psychosomatics 1999; 40: 205¡/11. ¨ gQrenci Seçme ve Yerles¸ tirme Sistemi-Yu¨kseko¨gQretim ProgramlarW ve KontenjanlarW KWlavuzu. O (Selection and placement of students in higher education institutions in Turkey: programmes guide). ¨ SYM Press: Ankara, 2002: 18 ¡/50 (in Turkish). O Battin M. Voluntary euthanasia and the risks of abuse: can we learn anything from the Netherlands? Law Med Health Care 1992; 20: 133¡/143. Gostin LO. Drawing a line between killing and letting die: the law, and law reform, on medically assisted dying. J Law Med Ethics 1993; 21: 94 ¡/101.


Euthanasia education for health professionals in Turkey 21 22 23 24

25

26 27 28

297

Decker C. Euthanasia in Holland . Retrieved September 26, 2002, from: http://www.euthana sia.org/dutch.html Salem T. Physician-assisted suicide: promoting autonomy or medicalizing suicide? Hastings Cent Rep 1999; 29(3): 30¡/36. Sulmasy PD. Killing and allowing to die: another look. J Law Med Ethics 1998; 26: 55 ¡/65. ¨ zkara E, O ¨ zdemir MH, DalgWç M, Karakus¸ A, Salaçin S, Yemis¸ cigil A. Hekimlerin o¨tanaziye O yaklas¸WmW (The opinions of doctors on the issue of euthanasia). Proceedings of the IV Forensic Sciences Congress; Istanbul 2000 May 10 ¡/13; 8 (in Turkish). ¨ zkara E, Yemis¸ cigil A, DalgWç M. Hukuk Faku¨ltesi O ¨ gQrencilerinin O ¨ tanaziye BakWs¸W (The O opinions of law school students on the issue of euthanasia). J Forensic Med (Turkey) 2001; 15: 46 ¡/52 (in Turkish). Jorgenson DE, Neubecker RC. Euthanasia: a national survey of attitudes toward voluntary termination of life. Omega (Westport) 1980; 11: 281¡/91. Puntillo KA, Benner P, Drought T et al. End-of-life issues in intensive care units: a national random survey of nurses’ knowledge and beliefs. Am J Crit Care 2001; 10: 216¡/29. ¨ zkara E, O ¨ zdemir C O ¸ , HancW IR H, DalgWç M, Civaner M, YagQ mur F. Ankara’da çalWs¸an hekimlerin o¨tanaziye yaklas¸WmW (The attitudes of physicians working in Ankara toward euthanasia). J Ankara Univ Law Faculty 2002; 51: 207¡/14 (in Turkish).

Editor’s note This short article describes the topics taught on one subject to a group of health professionals (paramedics) who have not had any publicity in this journal before. If interprofessional education is to gain prominence, it is important that all health professional groups are aware of each other’s practice and the research underpinning that practice.
