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Article
Support for Voluntary and Nonvoluntary Euthanasia: What Roles Do Conditions of Suffering and the Identity of the Terminally Ill Play?
Robert Ho 1
and Natalie Chantagul 1
Abstract
This study investigated the level of support for voluntary and nonvoluntary euthan-
asia under three conditions of suffering (pain; debilitated nature of the body; burden
on the family) experienced by oneself, a significant other, and a person in general. The
sample consisted of 1,897 Thai adults (719 males, 1,178 females) who voluntarily
filled in the study’s questionnaire. Initial multivariate analysis of variance indicated
significant group (oneself, significant other, person in general) differences in level of
support for voluntary and nonvoluntary euthanasia and under the three conditions of
suffering. Multigroup path analysis conducted on the posited euthanasia model
showed that the three conditions of suffering exerted differential direct and indirect
influences on the support of voluntary and nonvoluntary euthanasia as a function of
the identity of the person for whom euthanasia was being considered. The implica-
tions of these findings are discussed.
Keywords
mercy killing, voluntary euthanasia, conditions of suffering
OMEGA—Journal of Death and
Dying
2015, Vol. 70(3) 251–277
! The Author(s) 2015
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DOI: 10.1177/0030222815568958
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1 Graduate School of Psychology, Assumption University of Thailand, Bangkok, Thailand
Corresponding Author:
Robert Ho, Graduate School of Psychology Assumption University of Thailand, Hua Mak Campus 592,
Ram Khamhaeng Road, Soi 24, Hua Mak, Bangkok 10240, Thailand.
Email: [email protected]
Over the past half century, the issue of euthanasia has been a topic of heated debate in many countries and shows no sign of abating in the near future. The term euthanasia is synonymous with the phrase mercy killing and involves either assisting in the commission of suicide or administering painless or merciful death to a patient who is hopelessly ill. While the reason for carrying out euthanasia often appears clear, the debate over its support has been driven by the very different and often emotive interpretations provided by those who are for or against the practice. For those who support its practice, euthanasia literally means a good death and that with specific safeguards and in specific circum- stances, the taking of a human life is merciful and that all human beings are entitled to end their lives when they see fit. For those who oppose its practice though, euthanasia is not an act of mercy but an act of homicide and therefore constitutes a “morally outrageous death” (Fergusson, 1997).
Support for Euthanasia
What is the level of public support for euthanasia? This question is important as the answer bears directly not only on how government legislation on the issue is framed but also on how patients are cared for in the future (Moore, 2005). A review of different national polling results showed a growing acceptance of euthanasia among the general public in many countries around the world. Indeed, Anderson and Caddell (1993) pointed out that public support for some form of euthanasia has increased since the 1950s. For example, a study of 356 residents in Edmonton, Canada showed that 65% of the respondents supported active euthanasia while as many as 90% supported a mentally com- petent patient’s right to request the withdrawal of life support (Genuis, Genuis, & Chang, 1994). In Australia, the Newspoll research, conducted in February 2007, found 80% of adults surveyed supported the terminally ill’s right to choose a medically assisted death (Assisted-suicide Blog, 2007). In New Zealand, the Herald-Digi Poll surveyed 756 people in December 2000 and reported that 61% supported euthanasia with 27% opposed. Similarly, a Massey University survey of 1,000 New Zealanders conducted in August and September 2002 found 73% supported assisted suicide for someone with a painful, incurable disease, pro- vided it was a doctor who assisted.
Debate in Asia over the issue of euthanasia lagged behind that in the West. However, available data point to some consensus being reached. One of the few empirical studies conducted in China investigated 400 workers (including medical workers) in Baoding and found 80% in favor of euthanasia in 1987 (Shi, 1991). In their review of several studies conducted in China, Yu and Shek (1998) found that the majority of the general public supported euthanasia including active euthanasia. While active euthanasia remains illegal in China, it is gaining increasing acceptance among doctors and the general populace.
252 OMEGA—Journal of Death and Dying 70(3)
In Hong Kong, support for euthanasia among the general public is higher among those who put less importance on religious belief, those who are non- Christian, those who have higher family incomes, those who have more experi- ence in taking care of terminally ill family members, and those who are older (Chong & Fok, 2004).
While public opinion polls have consistently shown moderate to high support for euthanasia in both the West and Asia, the discussion and debate over the issue of euthanasia have often been clouded by the nature of the topic itself. That is, although much of the debate had focused on the right of a person to die with dignity, it is often not clear what kinds of euthanasia were being discussed. Specifically, the discussion and debate have tended to treat euthanasia as a singular concept about the right to death, when in fact the decision to end life relates to different decision-making processes centering on the two major sub- categorical distinctions of active versus passive euthanasia and voluntary versus nonvoluntary euthanasia.
The Categorical Distinctions of Euthanasia
Active euthanasia is considered an intentional act that causes death (e.g., a lethal injection of potassium chloride), whereas passive euthanasia is an intentional act to avoid the prolongation of life (e.g., removal of a life support system) (Hunter, 1980). Although both procedures result in the same outcome—death, it is the difference between killing people and merely letting people die that has caused a great deal of controversy.
On the basis of the presence or absence of the wish of the patient to die, euthanasia can be either voluntary or nonvoluntary. Voluntary euthanasia occurs when a person clearly indicates his/her wish to die through directives such as verbal statements or living wills. Nonvoluntary euthanasia occurs when one causes the death of a person, supposedly in the interest of that person, even when that person has not asked for euthanasia (e.g., a person who is comatose with little or no prognosis for recovery).
While the debate over euthanasia across the past three decades has centered primarily on the distinction between active and passive euthanasia, more recent research findings suggest that the active versus passive distinction may not be as important a determinant of attitudes toward euthanasia as the literature has suggested. Rather, as Ho (1998) has shown, the decision regarding the termination of life appears to key primarily on the perceived morality of a decision made on the basis of whether or not consent has been given by the patient, that is, voluntary versus nonvoluntary. On the basis of such a decision, it could be argued that people would feel more morally secure about terminating the life of another person if that person had specifically asked to die.
Ho and Chantagul 253
Conditions of Suffering and Euthanasia: Pain; Burden on the Family; Incapacitated Nature of the Body
Attitudes toward euthanasia are more complicated than simply voicing an opin- ion in favor of or against it. Attitudinal complexity is the result of various factors which have a great influence on most individuals’ view of euthanasia. These include demographic factors (cultural and religious beliefs, age, gender, and sociodemographic factors), physical (acute pain), and psychological factors (feelings of stress associated with the perception of being a burden on others) (Baumeister, 1991).
Pain
When a request for euthanasia or assisted suicide is made, it is usually made on the basis of severe patient distress or significant suffering. Suffering comes in many forms and can be defined as an aversive experience characterized by the perception of personal distress that is generated by adverse factors that under- mine the quality of life (Cherny, Coyle, & Foley, 1994). Chief among these adverse factors is physical pain, and both the experience of uncontrollable pain and the fear of it have played prominent roles in recent debates about euthanasia.
There is no denying that pain influences the end-of-life experience for patients and their caregivers, contributing to their diminished quality of life (Abrahm, 2001). Lynn et al. (1997) studied the experience of dying in older, seriously ill patients from the perspective of close family members. They reported that 40% of patients experienced severe pain most of the time during the last 3 days of life. In their effort to better understand pain at end of life, Weiss, Emanuel, Fairclough, and Emanuel (2001) interviewed 988 terminally ill patients. They found that pain was not limited to those patients with cancer, but that a similar proportion of terminally ill patients with other diseases experienced substantial pain. No wonder then, in the ongoing debate over euthanasia, the most common argument in support of euthanasia and physician-assisted suicide is that some- times they are the only ways of relieving unbearable pain and suffering. This is a powerful argument as nobody wants their life destroyed by pain or other cir- cumstances beyond their control.
Family Burden: Impact on the Family
An important aspect of care-burden at the end of life is how dying persons experience and manage the fear of being a burden on their families. Steinhauser et al. (2000) investigated factors considered important at the end of life by terminal patients and found that 89% of the patients perceived “not be a burden to family” as a very important attribute at the end of life, and 81%
254 OMEGA—Journal of Death and Dying 70(3)
rated “not be a burden to society” as very important as well. Ganzini, Johnston, and Hoffman (1999) interviewed 100 patients with amyotrophic lateral sclerosis and found that 91% felt that their medical condition was a cause of stress for family members, 65% felt they were a burden to their families, and 48% thought that their medical condition resulted in financial hardship to their families. In a series of interviews by Ashby, Op’t Hoog, and Kellehear (2005), long-term dia- lysis patients who decided to stop receiving treatment cited not wanting to be a burden on others was a major factor in their decision. Morita, Sakaguchi, Hirai, Tsuneto, and Shima (2004) interviewed 290 family members of Japanese termin- ally ill cancer patients in an attempt to clarify the reasons for desiring death and requests to hasten death. They found that a major reason in 42% of cases was a sense of being a burden to others, especially to one’s family.
Together, these research findings show a strikingly consistent belief that being a burden or being dependent on others is a universal concern among chronically ill patients. This concern is reflected in the knowledge that the resources of family members and of professional services are both finite. Severe family fatigue and distress are not uncommon in the face of limited resources to effectively deal with the patient’s suffering without severely compromising the current or future welfare of family members (Davies, Reimer, & Martens, 1990; Schachter, 1992). In an age of spiraling health costs and complex care needs, it is all too easy for some patients to feel that they are simply too much of an economic and emo- tional drain on their families and that the best way out is to end their life (Sullivan, Hedberg, & Hopkins, 2001).
The Incapacitated Nature of One’s Body
Advances in medical technology since the 1950s have made it possible to prolong life, even for the seriously ill. However, prolonged lives do not necessarily mean quality lives. If one considers quality of life as a continuum ranging from poor to good, then the extreme poor end of the spectrum includes (a) those patients who exist in a persistent vegetative state and kept alive by artificial means and (b) those patients while conscious, are incapacitated and in pain, confined to bed and kept alive by artificial means for weeks, months, and even years. These patients who have lost control of all their bodily functions can be said to be in a persistent state of suffering. Such suffering, when impossible to relieve, undermines the value of life for the sufferer. When the incapacitated nature of one’s body severely undermines the quality of one’s life, proponents of euthan- asia have argued that it would be more humane for these patients, their families, and professional health care providers to focus more on the quality of death rather than on the prolongation of life through artificial means. This view is in line with Nitschke’s (1998) suggestion that one possibility contained within a patient’s request to die may be an effort to take control over life, even if this control is illusory and paradoxical. As pointed out by Nitschke, when a patient
Ho and Chantagul 255
has lost control over every aspect of life, the only place control may be estab- lished is by asking for death.
Persons for Whom Euthanasia is Recommended: Oneself, Significant Others; People in General
Apart from considering the types of euthanasia (active, passive, voluntary, non- voluntary) and the conditions of suffering (pain, family burden, incapacitated nature of one’s body) when deciding whether to terminate life, another import- ant factor that may impact on the decision-making process is the person for whom euthanasia is recommended. While past research has shown strong sup- port for euthanasia, it is unclear whether the level of support will vary as a function of the terminally ill person being considered for euthanasia—for exam- ple, for a significant other, a nondescript member of the public, and oneself. Wade and Anglin (1987) found that people employed different criteria in the decision to terminate their own lives as opposed to their significant others’ (e.g., parents’) lives. They concluded that people in general are more definite about the conditions under which they would want to die but are less clear when the decision relates to a loved one, such as one’s parents, spouse, or children. These findings are in line with those obtained by Kinsella and Verhoef (1993) who found that physicians were more uncertain about considering euthanasia for a close relative than for themselves. As people are more hesitant to terminate care for a relative than for themselves, then, even if a patient’s preferences are known, proxy decision makers may be hesitant to implement them as they want to avoid the moral and psychological responsibility for terminating life- sustaining treatments for a loved one.
While making life or death decisions for someone is psychologically stressful, the situation is often different when euthanasia is being considered for oneself. According to Heyland, Rocker, O’Callaghan, Dodek, and Cook (2003), the majority of terminally ill patients prefer to be aware of their diagnosis and feel empowered when making their own decisions. For these patients, not know- ing the truth can often cause more anxiety, as well as directly inhibiting their involvement in crucial end-of-life discussions (Costello, 2001; Fallowfield, Jenkins, & Beveridge, 2002). Also, Hilden and Honkasalo (2006) suggested that patients often express their need for control. Thus, the ease with which many terminally ill patients request and accept euthanasia may reflect their way to take control of life (Nitschke, 1998), even if such control ultimately ends in their death.
In sum, a clear understanding of the way respondents perceive and respond to the issue of euthanasia appears to be a perquisite for continued research and understanding in the area of right to die attitudes. The present study has been designed to address this issue, by examining (a) the influences of the factors of pain, being a burden on one’s family, and the incapacitated nature of one’s body on
256 OMEGA—Journal of Death and Dying 70(3)
respondents’ level of support for voluntary and nonvoluntary euthanasia and (b) how their level of support may vary when these two types of euthanasia are considered for a person in general, for oneself, and for a loved one. To achieve these two aims, the present study posits a euthanasia model that represents the hypothesized sequential influences of the factors of being a burden on one’s family, the incapacitated nature of one’s body, and pain on respondents’ level of support for voluntary and nonvoluntary euthanasia. More specifically, the model hypothesizes that the influences of the variables of burden on the family and nature of one’s body on support for euthanasia will vary as a function of different types of people—a significant other, a nondescript member of the public, and oneself. For the posited model, the experience of pain is hypothe- sized to be the crucial motivator in the decision-making process, acting as the trigger for the decision to support euthanasia when the perceived burden on one’s family and the debilitated nature of one’s body become too much to bare. Figure 1 presents the euthanasia model representing the structural rela- tions hypothesized to exist between the exogenous variables of perceived burden on one’s family and incapacitated nature of one’s body, the mediator variable of
Figure 1. Euthanasia model representing the hypothesized sequential influences of burden
on one’s family, incapacitated nature of one’s body, and pain, on the level of support for
voluntary and nonvoluntary euthanasia.
Ho and Chantagul 257
pain, and the dependent variables of level of support for voluntary and nonvolun- tary euthanasia.
Method
Participants and Procedure
Prior to the collection of data, ethical approval for the conduct of the study was received from the Ethics Committee of the Graduate School of Psychology, Assumption University of Thailand. It should also be noted that, as this study is based in part on the second author’s PhD thesis, it was not funded by any organization.
Participants were volunteers who were recruited from the Bangkok metro- politan area (Thailand) between February and May 2012 by the second author. Potential participants were approached and were informed of the general nature of the study, that is, to investigate people’s attitude toward euthanasia. Participants were then invited to fill in the study’s questionnaire. They were informed that (a) they could withdraw from filling in the questionnaire at any time, (b) no names were recorded to guarantee the participant’s anonymity, and (c) the data collected were to be used only for the purpose of this study and only by the researchers.
The total sample consisted of 1,897 respondents (male: n¼719, 37.9%; female: n¼1,178, 62.1%), with an age range of 18 to 66 years and over, and a mean age within the range of 26 to 35 years. In terms of their education, 60.1% of the sample possessed a university degree. In terms of their employment status, 55.8% of the sample was unskilled or semiskilled blue-collar workers, while 44.2% were small business employers, professionals, and executives of large companies.
Material
This study employed a self-administered Likert-type rating questionnaire which consisted of three sections. Section 1 consisted of items written to elicit the participants’ demographic information of gender, age, level of education, mari- tal status, employment rank, and monthly income.
Section 2 consisted of the 12-item Euthanasia Scale (ES) developed by Ho (1998). Of the 12 items, 5 tap the level of support for voluntary euthanasia (one item was removed due to its low corrected item-total correlation) and 6 tap the level of support for nonvoluntary euthanasia. Each item was to be rated on a 5-point scale that ranged from 1¼strongly disagree, 2¼disagree, 3¼undecided, 4¼agree, and 5¼strongly agree, with high scores indicating stronger support for that type of euthanasia.
Section 3 consisted of 18 items written to tap the level of support for euthan- asia under three conditions of suffering—physical pain (6 items), incapacitated
258 OMEGA—Journal of Death and Dying 70(3)
nature of the body (6 items), and impact/burden on the family (6 items). The writing of these items was guided by (a) a thorough literature review of the three conditions of suffering and (b) Ho’s (1999) study of factors that influenced the decision to terminate life. Each item was to be rated on a 5-point scale ranging from 1¼strongly against euthanasia to 5¼strongly for euthanasia.
Questionnaires to Measure Support for Euthanasia for “A Significant Other,” “A Nondescript Member of the Public,” and “Oneself”
It should be noted that a major aim of the present research was to investigate whether the level of support for euthanasia (under the conditions of impact/ burden on family, incapacitated nature of the body, and pain) varied as a function of the terminally ill person being considered for euthanasia—that is, for a sig- nificant other, a nondescript member of the public, or oneself. As such, Section 3 of the questionnaire had three iterations in which the wording of the items was changed to reflect support for euthanasia for the three targeted groups of a significant other, a person in general, and oneself. For example, a pain item that referred to oneself reads The pain that I experience from my terminal illness is extremely severe and unwavering; the same pain item that referred to a signifi- cant other reads The pain that the significant person in your life is experiencing from his/her terminal illness is extremely severe and unwavering; the same pain item that referred to a person in general reads The pain that the person is experi- encing from his/her terminal illness is extremely severe and unwavering.
Questionnaire translation. As the participants in this study were Thai nationals (i.e., English is not their first language), it was necessary to translate the original English version of the study’s three questionnaires into Thai. The questionnaires were translated into Thai and back-translated into English with the help of two bilingual (English–Thai) experts to ensure stability and equality of the transla- tions. The translation of the original English version of the questionnaire was completed by a Thai language expert from the School of Religion at Loma Linda University in the United States. The back-translation was completed by another Thai language expert from the Autism Awareness Thailand Centre. The back-translation was validated by a bilingual lecturer at the Graduate School of Education, Assumption University.
Results
The substantive purpose of the present study is to investigate the influence of the factors of pain, being a burden on one’s family, and the incapacitated nature of one’s body on the support for voluntary and nonvoluntary euthanasia (see Figure 1); as well as to investigate how the participants’ level of support may vary when euthanasia is considered for a person in general, for oneself, and for a loved one.
Ho and Chantagul 259
GLM Multivariate Analysis of Variance to Test for Group Differences (Oneself, Significant Other, Person in General)
Each of the five factors of voluntary euthanasia, nonvoluntary euthanasia, pain, burden on family, and incapacitated nature of one’s body was computed by summing across the items that make up that factor and their means calculated. General Linear Model (GLM) multivariate analysis of variance was conducted initially to investigate group differences (oneself, significant other, person in general) for the five computed variables. Significant group differences would suggest possible differences in the influence of pain, burden, and the incapaci- tated nature of the body on the decision-making processes regarding voluntary and nonvoluntary euthanasia, as a function of the three target groups.
The following Table 1 presents the means and standard deviations for the five computed factors as a function of the three target groups.
In terms of support for euthanasia, the results showed that overall support is higher for voluntary euthanasia (M¼3.50) than for nonvoluntary euthanasia (M¼3.09). For the three conditions of suffering, the experience of pain gener- ated the highest level of support for euthanasia (M¼3.16) than the factors of being a burden on one’s family (M¼2.86) and the incapacitated nature of one’s body (M¼2.80).
The results showed that there was an overall group effect for the five variables combined, F(10, 3844)¼34.22, p< .001. Follow-up tests of between-subjects effects showed that group has a significant effect for all five dependent variables: voluntary euthanasia, F(2, 1925)¼4.28, p< .05; nonvoluntary euthanasia, F(2, 1925)¼3.44, p< .05; pain, F(2, 1925)¼26.05, p< .001; body, F(2, 1925)¼63.98, p< .001; burden, F(2, 1925)¼141.68, p< .001. Examination of the marginal means plus Scheffé post hoc test of group differences revealed the following:
Table 1. Means and Standard Deviations for the Computed Factors of Voluntary
Euthanasia, Nonvoluntary Euthanasia, Pain, Burden on Family, and Incapacitated Nature of
One’s Body as a Function of the Three Target Groups.
Oneself Significant other Person in general Total
F(2, 1925) Sig.M SD M SD M SD M SD
Voluntary euthanasia 3.50 .95 3.42 1.07 3.58 .89 3.50 .97 4.28 <.05
Nonvoluntary euthanasia 3.07 .82 3.03 .91 3.15 .82 3.15 .85 3.44 <.05
Pain 3.30 .91 2.95 1.08 3.24 .90 3.16 .98 26.05 <.001
Body 3.01 .88 2.46 .97 2.90 .89 2.80 .94 63.98 <.001
Burden 3.26 .97 2.37 .97 2.95 .87 2.85 1.00 141.68 <.001
260 OMEGA—Journal of Death and Dying 70(3)
Voluntary euthanasia. Participants endorsed significantly greater support for vol- untary euthanasia when the patient is a person in general (M¼3.58) than when the patient is a significant other (M¼3.42) (mean difference¼ .16), p< .05.
Nonvoluntary euthanasia. Participants endorsed significantly greater support for nonvoluntary euthanasia when the patient is a person in general (M¼3.15) than when the patient is a significant other (M¼3.03) (mean difference¼ .12), p< .05.
Pain. Under the condition of experiencing excruciating pain, participants endorsed significantly lower support for euthanasia when the patient is a signifi- cant other (M¼2.95) than when the patient is oneself (M¼3.30) (mean differ- ence¼ .35), and when the person is a person in general (M¼3.24) (mean difference¼ .30), p< .05. There is no significant difference in support for euthan- asia under the condition of pain when the patient is oneself or a person in general, p> .05.
Body. Under the condition of the body being totally incapacitated, participants endorsed significantly lower support for euthanasia when the patient is a signifi- cant other (M¼2.46) than when the patient is oneself (M¼3.01) (mean differ- ence¼ .55), and when the person is a person in general (M¼2.90) (mean difference¼ .44), p< .05. There is no significant difference in support for euthan- asia under the condition of the body being totally incapacitated when the patient is oneself or a person in general, p> .05.
Burden. Under the condition of being a burden to one’s family, participants endorsed significantly higher support for euthanasia when the patient is oneself (M¼3.26) than when the patient is a significant other (M¼2.37) (mean differ- ence¼ .87), or a person in general (M¼2.95) (mean difference¼ .28), p< .05. Participants also endorsed significantly higher support for euthanasia when the patient is a person in general (M¼2.95) than when the patient is a significant other (M¼2.37) (mean difference¼ .58), p< .05.
Multigroup Confirmatory Factor Analysis: Evaluation of the Consistency of the Measurement Model Across the Three Groups of People for Whom Euthanasia is Considered
Before evaluating the fit of the path model presented in Figure 1, it was neces- sary to (a) verify that the 29 measurement items written to reflect the five latent constructs (voluntary euthanasia, nonvoluntary euthanasia, pain, burden, and body) did so in a statistically reliable manner and (b) test whether the items’ factor loadings (regression weights) are similar (invariant) or different (variant) across the three groups. Figure 2 presents the measurement model (for the three
Ho and Chantagul 261
Figure 2. Measurement model representing the latent variables of voluntary euthanasia,
nonvoluntary euthanasia, pain, burden, and body together with their respective measure-
ment indicators.
262 OMEGA—Journal of Death and Dying 70(3)
groups of respondents: oneself, significant other, person in general), with the five latent variables and their respective measurement indicators. For this model, all factor loadings were freed, items were allowed to load on only one factor, and the five factors were allowed to correlate.
Multigroup confirmatory factor analysis, via structural equation modeling, was employed to determine the consistency of the model across the three groups of respondents (oneself, significant other, person in general). The following sequence of hypotheses was developed to explore differences between the groups’ measurement models: (a) The models have the same form (i.e., the same pattern of fixed and free parameters); (b) the factor loadings are identical (invariant) across groups. In determining the consistency of the model across these three groups, the model was first specified to have the same pattern of fixed and free parameters for the three groups, but allowed these parameters to be estimated separately within each group.
Results indicated that this unconstrained (variant) model fitted the data well. Although the overall chi-square value was significant, �2(df¼1101)¼3586.35, p< .001, the incremental fit indices (normed fit index [NFI], incremental fit index [IFI], Tucker–Lewis index [TLI], comparative fit index [CFI]) are close to or above .90 (range: .87 to .92). These fit indices indicated that the model provided a good fit relative to a null or independence model and support the hypothesized structure of the model posited for the three groups of respondents.
The preceding model specified the same pattern of fixed and free parameters for the three groups of respondents but estimated these parameters separately within each group. The next series of analyses involved constraining the factor loadings to be invariant for the three groups. Results from the analysis indicated that this constrained model also fitted the data well. Although the overall chi- square was significant, �2(df¼1149)¼3670.24, p< .001, the incremental fit indi- ces (NFI, IFI, TLI, CFI) are close to or above .90 (range: .87 to .92). Results of a chi-square difference test indicated that the unconstrained (variant) model fitted the data set significantly better than the constrained model, �2(df¼48)¼83.88, p< .001. This finding indicated that there are significant differences in the items’ factor loadings for the three groups of respondents. This was confirmed by the calculation of critical ratios for pair-wise differences among all factor loadings in the model. The critical ratio for a pair of estimates provides a test of the hypoth- esis that the two parameters are equal (Arbuckle & Wothke, 1999). The results showed significant group differences for the factor loadings associated with the ES items of e4, e6, e7, e8, e10, and e12, and the pain, burden, and body items of s2, s5, s6, and s13. These group differences in factor loadings were incorporated in the analysis of the structural path model.
The standardized regression weights, residual, and explained variances for the five-factor model (for oneself, significant other, person in general) are presented in Table 2.
Ho and Chantagul 263
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.6 3
.6 9
.5 6
.6 1
.3 1
.4 4
.3 9
e 1 2
.4 9
.4 9
.5 9
.7 6
.7 4
.6 6
.2 4
.2 6
.3 4
P a in !
s3 .8
0 .8
5 .8
3 .3
6 .2
8 .3
0 .6
4 .7
2 .7
0
s4 .8
1 .8
7 .8
4 .3
5 .2
5 .2
9 .6
5 .7
5 .7
1
s7 .8
2 .8
6 .8
5 .3
3 .2
6 .2
8 .6
7 .7
4 .7
2
s1 0
.8 5
.8 5
.8 1
.2 8
.2 8
.3 5
.7 2
.7 2
.6 5
s1 2
.8 0
.7 8
.7 4
.3 7
.3 9
.4 5
.6 3
.6 1
.5 5
s1 8
.8 1
.8 6
.8 2
.3 5
.2 6
.3 2
.6 5
.7 4
.6 8
B o d y !
s1 .6
3 .7
3 .7
6 .6
0 .4
6 .4
2 .4
0 .5
4 .5
8
s2 .7
8 .7
8 .7
3 .3
9 .4
0 .4
7 .6
1 .6
0 .5
3
s5 .8
4 .8
2 .8
5 .2
9 .3
3 .2
8 .7
1 .6
7 .7
2
(c o n ti n u e d )
264
T a b
le 2 .
C o n ti n u e d .
P a ra
m e te
r
S ta
n d a rd
iz e d
re g re
ss io
n w
e ig
h ts
R e si
d u a l v a ri
a n c e s
E x p la
in e d
v a ri
a n c e s
O n e se
lf
S ig
n if ic
a n t
o th
e r
P e rs
o n
in
g e n e ra
l O
n e se
lf
S ig
n if ic
a n t
o th
e r
P e rs
o n
in
g e n e ra
l O
n e se
lf
S ig
n if ic
a n t
o th
e r
P e rs
o n
in
g e n e ra
l
s6 .8
5 .8
2 .7
9 .2
8 .3
2 .3
7 .7
2 .6
8 .6
3
s1 5
.7 8
.8 0
.8 1
.3 9
.3 5
.3 4
.6 1
.6 5
.6 6
s1 6
.7 6
.8 4
.8 3
.4 2
.2 9
.3 1
.5 8
.7 1
.6 9
B u rd
e n !
s8 .8
1 .8
1 .8
0 .3
4 .3
5 .3
6 .6
6 .6
5 .6
4
s9 .8
2 .8
3 .8
1 .3
3 .3
2 .3
5 .6
7 .6
8 .6
5
s1 1
.8 7
.8 4
.8 3
.2 5
.3 0
.3 2
.7 5
.7 0
.6 8
s1 3
.8 8
.8 3
.8 0
.2 3
.3 0
.3 6
.7 7
.7 0
.6 4
s1 4
.8 3
.8 0
.7 5
.3 2
.3 7
.4 4
.6 8
.6 3
.5 6
s1 7
.8 7
.8 6
.8 4
.2 5
.2 7
.3 0
.7 5
.7 3
.7 0
N o te
. V o l_
e u th ¼
v o lu
n ta
ry e u th
a n a si
a; N
o n v o l_
e u th ¼
n o n v o lu
n ta
ry e u th
a n a si
a; P a in ¼
e x p e ri
e n c e
p a in
; B
o d y ¼
in c a p a c it a te
d n a tu
re o f b o d y ; B u rd
e n ¼
b u rd
e n
o n
o n e ’s
fa m
il y.
265
The standardized regression coefficients (factor loadings) for the measure- ment variables were all positive and significant by the critical ratio test, p< .05. Standardized loadings ranged from .43 to .88 for oneself respondents, from .51 to .87 for significant other respondents, and from .56 to .85 for person in general respondents. These values indicated that each measurement variable was adequately related to the latent variable it was hypothesized to measure. For the oneself respondents, the percentage of residual (unexplained) variances for the 29 measurement variables ranged from 23% (i.e., 77% of the variance explained) (s13) to 82% (i.e., 18% of the variance explained) (e3). For the sig- nificant other respondents, the percentage of residual (unexplained) variances for the 29 measurement variables ranged from 25% (i.e., 75% of the variance explained) (s4) to 63% (i.e., 37% of the variance explained) (e3). For the person in general respondents, the percentage of residual (unexplained) variances for the 29 measurement variables ranged from 28% (i.e., 72% of the variance explained) (s7) to 69% (i.e., 31% of the variance explained) (e3).
Multigroup Path Analysis: Evaluation of the Consistency of the Body-Burden-Pain Euthanasia Model Across the Three Groups of Respondents (Oneself, Significant Other, Person in General)
Multigroup path analysis was carried out to investigate whether or not the pattern of structural relationships represented in the path model presented in Figure 1 follows the same dynamics for the three groups of respondents. That is, the analysis was conducted to determine the extent to which the posited model is consistent across the three groups. Based on the findings from the confirmatory factor analysis, 10 of the 29 factor loadings (e4, e6, e7, e8, e10, e12, s2, s5, s6, s13) were freed, that is, they were to be estimated separately within each group; the other 19 factor loadings were fixed to be invariant across groups. The fol- lowing sequence of hypotheses was developed for analyzing group differences in this model: (a) path coefficients have the same pattern for the three groups of respondents and (b) path coefficients are identical for the three groups of respondents.
In determining the consistency of the model across groups, the model was first specified to have the same pattern of path coefficients for all three groups, but allowed these coefficients to be estimated separately within each group. For this unconstrained/variant model, �2 (df¼1129)¼3610.30, p< .001. The incremen- tal fit indices (NFI, IFI, TLI, CFI) are close to or above .90 (range: .87 to .92). These fit indices indicated that the posited model provided a reasonably good fit relative to the null or independence model and support the hypothesized struc- ture of the model posited for the three groups of respondents.
The preceding model specified the same pattern of fixed and free parameters for the three groups but estimated these parameters separately within each group. In order to test the consistency of the model across groups, the model
266 OMEGA—Journal of Death and Dying 70(3)
was respecified to have the path coefficients constrained to be invariant across the three groups of respondents. Results from the analysis indicated that this constrained/invariant model fitted the data reasonably well, �2(df¼1145)¼3694.76, p< .001; the incremental fit indices of NFI, IFI, TLI, CFI ranged from .87 to .92. Results of a chi-square difference test comparing this model with one that simply specified the same pattern of path coefficients indicated that the unconstrained/variant model fitted the data significantly better, �2 (df¼16)¼84.46, p< .001. This suggests that some of the structural relationships represented in the path model are significantly different when con- sidering euthanasia for oneself, a significant other, and a person in general.
The goodness-of-fit of competing models can also be compared by means of the Akaike Information Criterion (AIC) measure (Akaike, 1987). In evaluating hypothesized models, this measure takes into account both model parsimony (i.e., achieving a higher degree of fit per degree of freedom used) and model fit. Simple models that fit well receive low scores, whereas poorly fitting models get high scores. Comparing the AIC measures for the constrained (invariant) model and the unconstrained (variant) model, it is evident that the AIC for the uncon- strained model (4136.30) is lower than that for the constrained model (4188.76), indicating that the unconstrained model is both more parsimonious and better fitting than the constrained model. Table 3 presents the goodness-of-fit indices for both these models, together with the model comparison statistics.
The significant standardized path coefficients for the euthanasia path model for the three groups of respondents (level of support for euthanasia for oneself, a significant other, and a person in general) are shown in Figure 3.
Standardized Regression Paths for “Oneself”
As shown in Figure 3, for respondents who considered euthanasia for oneself, the exogenous variables of body and burden were not found to relate directly to
Table 3. Chi-Square Goodness-of-fit Values, Incremental Fit indices (NFI, IFI, TLI, CFI),
Akaike Information Criterion (AIC), and Model Comparison.
Model �2 (N¼1,928) df p NFI IFI TLI CFI AIC
Null model 32983.58 1305 <.001 .00 .00 .00 .00 33157.58
Model A unconstrained (variant) model 3610.30 1129 <.001 .89 .92 .91 .92 4136.30
Model B constrained (invariant) model 3694.76 1145 <.001 .89 .92 .91 .92 4188.76
Model comparison
Model A versus Model B 84.46 16 <.001 .01 .01 .01 .00 52.46
Note. NFI¼normed fit index; IFI¼ incremental fit index; TLI¼Tucker–Lewis index; CFI¼comparative fit
index.
Ho and Chantagul 267
the dependent variables of support for voluntary and nonvoluntary euthanasia (p> .05). Rather, the relationship was found to be indirect, being mediated by the experience of pain, and only for the dependent variable of nonvoluntary euthanasia. Thus, when considering nonvoluntary euthanasia for oneself, the greater the perception of one’s body being incapacitated and the greater the perception that one’s illness represents a burden to one’s family, the greater is the pain experienced (b¼ .69 and b¼ .29 respectively); the greater the pain experienced the higher is the support for nonvoluntary euthanasia for oneself (b¼ .53).
Figure 3. Euthanasia path model for the three groups of respondents (euthanasia for
oneself, a significant other, and a person in general) together with the model’s significant
path coefficients (in bold).
268 OMEGA—Journal of Death and Dying 70(3)
Standardized Regression Paths for a “Significant Other”
When considering euthanasia for a significant other, the results from the path analysis showed that the exogenous variables of body and burden related dir- ectly and significantly to the dependent variable of voluntary euthanasia. Body was also found to be related directly and significantly to the dependent variable of nonvoluntary euthanasia. Thus, the greater the perception of the significant other’s body being incapacitated, the higher is the support for both voluntary (b¼ .29) and nonvoluntary (b¼ .30) euthanasia. Also, the greater the perception that the significant other’s illness represents a burden to his/her family, the lower is the support for voluntary euthanasia for the significant other (b¼�.23).
Results from the path analysis also showed that the exogenous variable of body related indirectly to both dependent variables of voluntary and nonvolun- tary euthanasia, being mediated by the experience of pain. Thus, when consider- ing voluntary and nonvoluntary euthanasia for a significant other, the greater the perception of that person’s body being incapacitated, the greater is the pain perceived to be experienced by that person (b¼ .87); the greater the pain per- ceived to be experienced by that person the higher is the support for voluntary (b¼ .43) and nonvoluntary (b¼ .40) euthanasia for that significant other.
Standardized Regression Paths for a “Person in General”
When considering euthanasia for a person in general, the results from the path analysis showed that the exogenous variable of burden related directly and sig- nificantly to the dependent variable of nonvoluntary euthanasia. Thus, the greater the perception that a general person’s illness represents a burden to his/her family, the higher is the support for nonvoluntary euthanasia for that person (b¼ .32).
Results from the path analysis also showed that the exogenous variable of body related indirectly to both dependent variables of voluntary and nonvolun- tary euthanasia, being mediated by the experience of pain. Thus, when consider- ing voluntary and nonvoluntary euthanasia for a person in general, the greater the perception of that person’s body being incapacitated, the greater is the pain perceived to be experienced by that person (b¼ .84); the greater the pain per- ceived to be experienced by that person the higher is the support for voluntary (b¼ .29) and nonvoluntary (b¼ .28) euthanasia for that person in general.
Residuals (Unexplained Variance)
Figure 3 also shows the standardized residual for each endogenous variable in the model for the three groups of respondents. These coefficients provide an estimate of the proportion of variance in each endogenous variable not predicted by the model. Alternatively, subtracting these values from 1.00 indicates the
Ho and Chantagul 269
proportion of variance predicted by the model. These coefficients indicated that the posited euthanasia model for oneself accounted for 30% of the variance in support for voluntary euthanasia and 28% of the variance in support for non- voluntary euthanasia; for oneself, the perception of the body being incapacitated together with one’s illness being a burden on one’s family accounted for 90% of the variance in the reported pain experienced.
The posited model for a significant other accounted for 28% of the variance in support for voluntary euthanasia and 37% of the variance in support for nonvoluntary euthanasia; for a significant other, the perception of the body being incapacitated together with one’s illness being a burden on one’s family accounted for 58% of the variance in the reported pain experienced.
The posited euthanasia model for a person in general accounted for 14% of the variance in support for voluntary euthanasia and 32% of the variance in support for nonvoluntary euthanasia; for a person in general, the perception of the body being incapacitated together with one’s illness being a burden on one’s family accounted for 77% of the variance in the reported pain experienced.
Discussion
Overall, the study’s results are consistent with the expectations relating to the level of support for euthanasia under the three conditions of suffering (pain, debilitated nature of the body; burden on the family) experienced by oneself, a significant other, and a person in general. First, the finding that the participants endorsed significantly greater support for both voluntary and nonvoluntary euthanasia for a person in general than for a significant other corroborated suggestions by past researchers (e.g., Costello, 2001; Fallowfield et al., 2002; Hilden & Honkasalo, 2006; Nitschke, 1998) that it is easier to make a life-and-death decision for a nondescript person than for a significant other (e.g., father, mother, sibling). This finding is intuitively clear when the decision to end the life of a nondescript person (someone with whom we have no personal ties) is much less complicated ethically, morally, and legally than the decision to end the life of a significant other. As shown by Wade and Anglin (1987), many more variables are taken into account when one contemplates euthanasia for a loved one (e.g., a parent) than for a person in general. People are less definite about what situations would justify euthanasia for a loved one than for a nondescript person in general.
Second, the finding that the experience of physical pain is the most important determinant of the level of support for euthanasia lends further support to past research that has shown persistent pain associated with terminal illness to be the primary reason for requests for physician-assisted suicide (Kelly, 2002; Kelly et al., 2003; Kuuppelomaki, 2000; Wilson, Scott, & Graham, 2000). Many ter- minally ill patients often experienced what may be termed refractory pain as they approach the end of life (Cherny, 1996). According to Cherny and Portenoy (1994), the term refractory is used to describe pain symptom that cannot be
270 OMEGA—Journal of Death and Dying 70(3)
adequately controlled despite aggressive efforts to identify a tolerable therapy. When the treatment of pain is no longer effectual and the suffering becomes too much to bear, family members, practitioners, and ethicists may accept euthan- asia as a beneficent option (Abrahm, 2001; Brody, 1992; Pitorak, 2003).
The results from the path analysis shed light on the way one endorses euthan- asia for oneself, a significant other, and a nondescript person under the three conditions of suffering, that is, the experience of pain, the debilitated nature of the body, and burden/impact on the family. Specifically, the results showed that support for both voluntary and nonvoluntary euthanasia is greater under both the burden/impact and debilitated body conditions when the terminally ill person is defined as a significant other. A number of conclusions can be drawn from these findings. First, for many terminally ill patients, requests for assisted suicide stem from the desire not to be a burden on the family. For the terminally ill, a major source of depression is the empathic perception of family distress, in particular, the recognition that one’s chronic illness is a major contributor to the physical, financial, and psychological sequelae of the burden of care (Davies et al., 1990; Schachter, 1992). The desire to spare the family and loved ones from such burden is clearly judged as an important reason to die.
Second, the finding that the debilitated body condition was perceived to be an important reason for supporting euthanasia for a significant other may indicate the empathic suffering with a loved one’s distress at the loss of dignity and control associated with a debilitated body. Such empathic distress reflects the very human desire of not wanting a loved one suffer a lingering death under conditions that would severely undermine the quality of his/her life. Overall, these findings relating to a significant other are not surprising when the issues of love, loyalty, and devotion to a loved one (e.g., a parent) are taken into account. Indeed, such attitudes are not unexpected given Asian people’s exposure to Confusian values which stress filial piety and respect for the aged (Lee, Kleinbach, Hu, Peng, & Chen, 1996).
The study’s findings showed that when considering euthanasia for oneself, it is the experience of pain that exerted the greatest influence on support for non- voluntary euthanasia. This finding is consistent with past arguments that have pointed to the fear of dying a painful death that has motivated many patients’ request for a quick death. For many people, the fear of dying in pain, especially severe uncontrolled pain, is a powerful and often expressed sentiment in support for euthanasia (Pitorak, 2003). This is clearly an understandable sentiment as nobody wants their life destroyed by pain or other circumstances beyond their control. As pointed out by Ho (1999), the fear of pain can be so acute among those suffering illnesses that they are willing to accept certain types of pain control even if they risk or bring about death.
When considering euthanasia for a nondescript person in general, the findings showed that the perceived burden that the person’s illness has placed on his/her family is an important motivator for the support for nonvoluntary euthanasia.
Ho and Chantagul 271
This burden can have emotional, physical, social, and financial aspects. Many terminal patients are cognizant of the fact that their chronic illness affects not only themselves but also their spouses, children, relatives, friends, and other significant persons. In addition, they are also aware that the resources of family members and of professional services are both finite. As pointed out earlier, severe family fatigue and distress are not uncommon in the face of limited resources to effectively deal with the patient’s suffering without severely compromising the current or future welfare of family members (Davies et al., 1990; Schachter, 1992). With spiraling health costs and complex care needs, it is not unexpected for some patients to feel that they are simply too much of an economic and emotional drain on their families and that the best way out is to end their life (Sullivan et al., 2001). Thus, for a person in general, it is the care- burden at the end of his/her life that underlies their life-and-death decision- making process.
The findings from the present study carry a number of important implications for the understanding of how people regard euthanasia, and more importantly how their attitude may vary as a function of different conditions of suffering (e.g., pain, debilitated nature of the body, burden on the family) experienced by oneself, a significant other, and a nondescript person in general.
First, the finding that voluntary euthanasia was endorsed higher than non- voluntary euthanasia suggests that the issue of autonomy/personal-control plays a very important role when making life-and-death decisions. Indeed, supporters of euthanasia have always championed the argument that a dignified death occurs when the person has the autonomy to decide that they have had enough and wish to die. It is not unusual for a competent terminally ill patient to express his/her right to choose a dignified and humane death rather than to be reduced at the end of his/her existence to a childlike state of helplessness, dia- pered, sedated, and incontinent. Thus, in the emotive fervor that surrounds the euthanasia debate, it is important for the public and the government not to lose sight of the one thing that terminally ill patients still have control of toward the end of their lives—their freedom to choose whether to live or to die.
Second, the finding that the experience of physical pain is an important medi- ator for the level of support for euthanasia is in line with Verbakel and Jaspers’ (2010) argument that the pain factor is an important anchor for the death with dignity hypothesis and is responsible for raising awareness of the euthanasia debate from the individual level to the national level. That is, while the fear of unbearable pain and suffering might be a result of someone’s personal experi- ence, the argument is that if enough people experience or observe much suffer- ing, then the issue of pain and suffering becomes national and the death with dignity argument becomes more significant.
Third, the finding that the study’s respondents supported euthanasia that was presented as nonvoluntary points to the conviction that many people have about the right to die. Indeed this finding may be troublesome for those who emphasize
272 OMEGA—Journal of Death and Dying 70(3)
the slippery slope argument in their opposition to euthanasia. Much of the eth- ical discussion of euthanasia keys on the voluntariness of the patient’s decision to die. Yet, the majority of the study’s respondents, were they in a decision- making position, would support the termination of the patient’s life without his/ her specific wish to die. Although the nonvoluntary euthanasia condition was presented in the present study as a means to relieve the suffering of a patient who was described as being in a “state of constant suffering and unconsciousness,” the finding appears to justify the concerns of those who oppose euthanasia, and raise the possibility that acts licensed under a narrow set of justifications may be taken into a somewhat wider, and perhaps less justified set of circumstances (Darley, Loeb, & Hunter, 1996).
Fourth, the study’s findings suggest that the burden of care associated with a loved one is weighted more positively than the burden of care associated with oneself. This finding is not surprising given that the devotion that one has toward a loved one may override the concerns associated with the burden of care when that person becomes terminally ill. As stated earlier, such attitudes are not uncommon among Asian people exposed to Confusian values stressing filial piety and respect for the aged but have been shown to be less common among Westerners. The present findings, in conjunction with those obtained by Ho (1999) from his Australian sample, suggest that such attitudes, when considered within the context of the life and death debate, may be more universal than what past research has shown.
Fifth, the finding that the posited euthanasia model accounted for only 14% to 37% of the variance in support for voluntary and nonvoluntary euthanasia, suggests that in addition to the predictor variables of pain/body/burden, there may be other variables that should be considered for inclusion as predictors. Chief among these is religion and the role that it plays in motivating support or nonsupport for euthanasia. The exhortation to respect life by many religions gives rise to the suggestion that religion disapproves of euthanasia. Indeed, a number of past studies have found significant differences between believers and nonbelievers in attitudes toward the legalization of euthanasia (Dickenson, 2000; Ryynanen, Myllykangas, Viren, & Heino, 2002; Sorbye, Sorbye, & Sorbye, 1995). However, other studies have found that while nonbelievers are more open to euthanasia than believers, a majority in the religious groups studied favored the legalization of euthanasia or were prepared to assist in euthanasia themselves (Kitchener, 1998; Kuhse & Singer, 1993). These conflicting findings suggest that further research is required to understand the seemingly complex relationship between religion and attitudes toward euthanasia.
Conclusion
Understanding how people regard euthanasia under different conditions of suf- fering (pain, incapacitated nature of the body, burden on the family) and for
Ho and Chantagul 273
different types of patients (oneself, a significant other, a person in general) pro- vides directions for more informed debates and ultimately better informed deci- sions on possible legislation initiatives that focus on the needs of the terminally ill and how these needs can best be catered for toward the end of their lives. It is clear that there is a determined movement in most countries around the world to develop policies that can adequately guide the right to die decision-making pro- cess. As this movement gathers strength, there is an increasing need to have an appropriate knowledge base to guide these policies. The development of such a knowledge base relies heavily on empirical research carried out to determine public attitudes toward euthanasia, such as what was conducted in the present research. Given that the right to die issues are extremely complex in nature, it is important that the assessment approach used in such research must accurately reflect attitudes toward these important issues. A clear understanding of such attitudes should lead to improved accuracy in assessing public attitudes regard- ing right to die issues and should be an important means of informing public policy decision making.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies
Robert Ho received his DPhil from Waikato University, New Zealand, in 1978. He is presently Associate Professor in the Graduate School of Psychology at the Assumption University of Thailand. His research interests include quantitative methods, health psychology, and social psychology.
Natalie Chantagul received her Doctor of Philosophy in Counseling Psychology from the Assumption University of Thailand, in 2012. She is presently a lecturer in the Graduate School of Psychology at the Assumption University of Thailand.
Ho and Chantagul 277
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