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FACTORS INFLUENCING DECISIONS TO TERMINATE LIFE: CONDITIONS OF SUFFERING AND THE IDENTITY OF THE TERMINALLY ILL
by Robert Ho This study investigated (1) the level of support for euthanasia under three conditions of suffering (physical pain; the debilitated nature of the body; impact on the family) experienced b), oneself a significant other, and people in general, and (2) the level of support for four types of euthanasia (voluntary active, voluntary passive, involuntary active, involuntary passive). Respondents were 357 Australian adults (136 males, 221 females). Initial analysis indicated no sex differences in attitudes toward the study's criterion variables. Descriptive statistics indicated general support for all four types of euthanasia, with the highest support shown when euthanasia was presented as both voluntary and passive; the least support was recorded when euthanasia was presented as involuntary and active. Multivariate analysis of variance indicated that endorsement of euthanasia varied as a function of both the conditions of suffering and the identity of the person for whom euthanasia was being considered. The implications of these findings are discussed. Euthanasia is defined in Webster's Dictionary as "The act or practice of killing or permitting the death of hopelessly sick or injured individual,; in a relatively painless way for reasons of mercy". Implicit in this definition is the acknowledgement that under certain circumstances, the intentional termination of the life of one human being by another is justifiable, and may even be desirable. Arguments for euthanasia emphasise the right of patients to choose their own death, the duty of the physician to end hopeless suffering, and the right of the patient to die with dignity and lucidity. Antieuthanasia arguments, on the other hand, emphasise the sanctity of life, the commitment of physicians to save lives, and the possible dangers of mistakes and abuse if euthanasia is legalised. Over the course of these arguments, the right to die debate has centered primarily around the distinctions between active and passive euthanasia, and between voluntary and involuntary euthanasia. While it is recognised that other subcategories exist, such as assisted suicide, rational suicide, suicide, and homicide (Rogers, 1996), the distinction between active, passive, voluntary, and involuntary euthanasia remains the most important element in examining attitudes toward physician-assisted death (Sugarman, 1986). Active euthanasia, sometimes referred to as mercy killing, 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 have the same consequences, it is the difference between killing people and merely letting people die that has caused a great deal of controversy. The belief that there is an important moral difference between active and passive euthanasia is illustrated by a number of studies that suggest that individuals are significantly more accepting of acts of euthanasia if they are presented as passive in nature as opposed to active (see e.g., Finlay, 1985; Ho & Penney, 1992; Ostheimer, 1980). On the basis of the presence or absence of the wish of the patient, euthanasia can be either voluntary or involuntary (Darley, Loeb, & Hunter, 1996). A voluntary act of euthanasia occurs when an individual clearly indicates an expressed wish to die through directives such as verbal statements or living wills. Involuntary euthanasia is defined as causing the death of a person, supposedly in the interests of that person but disregarding the fact that the person has not requested euthanasia or has actively rejected it. While the debate continues about the moral differences between these four forms of euthanasia, the arguments for and against euthanasia are further complicated by issues relating to (1) the conditions under which euthanasia is considered an appropriate option, and (2) the person for whom euthanasia is being recommended. These issues represent realistic situations that the majority of people may someday confront. More specifically, these two issues combine to yield specific conditions which can either increase or attenuate the level of support for euthanasia. Conditions under which euthanasia is considered an appropriate option Physical pain A request for euthanasia or assistance in suicide usually derives from severe patient distress and indicates significant suffering. Suffering comes in a variety of form, and can be defined as an aversive experience characterised by the perception of personal distress that is generated by adverse factors that undermine quality of life (Cherny, Coyle, & Foley, 1994). Chief among these adverse factors is physical pain. For terminally ill cancer patients;, prevalence studies of cancer pain reveal that one-third of such patients in active therapy, and two-thirds of patients with far-advanced disease, have significant pain, requiring the use of analgesics (Daut & Cleeland, 1982; Foley, 1985). Studies of public attitudes about cancer demonstrate that pain is one of its most feared consequences (Foley, 1991), with uncontrolled pain being reported as an important contributory factor in a variety of studies that have assessed cancer patients who are at risk for suicide (Bolund, 1985a,b; Coyle, Adelhardt, Foley, & Portenoy, 1990; Helig, 1988; Louhivuori & Hakama, 1979). The fact that fear of pain is acute among those suffering illnesses is reflected in the acceptance of certain types of pain control, even if they risk or bring about death. This view is supported in a survey which found that physicians, nurses, hospital chaplains, and college students overwhelmingly agreed that it was appropriate to give pain medication to terminal patients even though the dosages given might hasten death (Carey & Posavac, 1978-1979).
The debilitated nature of one's body Significant suffering is experienced when the debilitated nature of one's body severely undermines the quality of one's life. A person who has lost control of all his/her bodily functions, or is confined to bed for the rest of his/her life 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. Without hope that this situation will be relieved, patients, their families, and professional health care providers may see euthanasia or assisted suicide as an acceptable alternative. Impact on the family Suffering is not limited to the physical experience of the patient brought on by uncontrollable pain or the debilitated nature of the body. Chronic incurable illness in a family member impacts upon the entire family (Beck-Friis & Strang, 1993; Smith, 1990). Among the contributing factors to the ensuing distress are empathic suffering with the distress of the patient; grief and bereavement; role changes; and the physical, financial, and psychological stress arising from the burdens of care (Davies, Reimer, & Martens, 1990; Schachter, 1992). Simply, the resources of family members and of professional services are both finite. Severe family fatigue and distress are not uncommon in the face of inadequate resources to effectively deal with the patient's suffering, without severely compromising current or future welfare of family members (Davies et al., 1990; Schachter, 1992). Persons for whom euthanasia is recommended While the decision to terminate life may be affected by whether euthanasia is presented as active, passive, voluntary, or involuntary, the decision may also vary as a function of the person for whom euthanasia is recommended. Past findings from public opinion surveys that have shown strong support for euthanasia are based primarily on questionnaire items designed to tap attitudes toward a hypothetical, generalised, and nondescript terminally ill patient (e.g., Borst-Eilers, 1991; Roy Morgan Research Centre, 1995; West, 1993). For example, typical euthanasia questionnaire items used by past research surveys include "Do you think it is sometimes right for a doctor to take (active) steps to bring about a patient's death?", and "Do you think it is sometimes right for a doctor to provide means for a patient to suicide?" (Kuhse & Singer, 1992). While findings obtained from such questionnaire items have shown a generally high level of support for euthanasia, it is unclear whether the level of support changes when the terminally ill person being considered for euthanasia is a significant other, a member of the public, or even oneself. A study by Wade and Anglin (1987) examined whether people would endorse euthanasia in different situations for themselves than they would for their mothers or their fathers. They found that subjects used different criteria in the decision to terminate their own lives as opposed to their parents' lives. Based on data obtained from factor analysis, the researchers concluded that a person is more definite about what situations would justify euthanasia for themselves, but that the decision is less clear when it involves one's parents. While these findings suggest that support for euthanasia varies as a function of the person for whom life and death is being debated, the findings are limited to the type and number of variables that are taken into account when one contemplates euthanasia for parents and for oneself. Focusing solely on the number of variables that justify euthanasia does not clarify the extent of support for the issue when a significant other is involved, nor does it shed light on how the level of support differs when euthanasia is applied to oneself, significant others, and people in general. Moreover, the study by Wade and Anglin (1987) failed to investigate the interaction between the conditions under which euthanasia was contemplated and the identity of the person for whom euthanasia was being considered. The failure to investigate such an interaction makes it unclear how support for euthanasia for different people may vary as a function of the conditions under which euthanasia is considered an appropriate option. The present study has been designed to address these issues, by examining the level of support for euthanasia under three conditions of suffering, experienced by oneself, a significant other, and people in general. The three conditions of suffering include physical pain, the debilitated nature of the body, and the negative impact of the terminal illness on the family. More importantly, the design of the study allows for an examination of the effect of the interaction between the conditions of suffering and the type of terminally ill patient, on level of support for euthanasia. Based on past research findings, a number of hypotheses can be postulated. First, based on the findings by Wade and Anglin (1987) that a person is more definite about what situations would justify euthanasia for themselves than for others, it is hypothesised that support for euthanasia is highest when euthanasia is considered for oneself than for a significant other or for people in general. Second, based on the finding that persistent physical pain is a major contributor to patient distress, it is hypothesised that the level of support for euthanasia is highest when the terminally ill patient is described as experiencing excruciating pain. Third, empathic perception of family distress is assumed to be strongest when the terminally ill patient is oneself. The desire not to be a burden on one's family leads to the hypothesis that subjects are more willing to support euthanasia for oneself than for others, when the impact of the patient's incurable chronic illness on family distress is taken into account. Method Subjects and procedure Respondents were volunteers who were recruited from the Rockhampton metropolitan area in February 1997 by the author, with the assistance of graduate psychology students. The total sample consisted of 357 respondents (136 males, 221 females). Respondents filled in the questionnaire individually. Prior to filling in the questionnaire, they were informed that any words, phrases, or statements that are unclear would be clarified by the experimenter. Sample characteristics The distribution of the sample consisted of 38.1% male and 61.9% female (compared with 49.76% male and 50.24% female in Australia, as indicated in the 1994 Australian census). The sample had an age range of 17 to 60 years and a mean age of 31 years. Comparison with that for the entire country revealed that there was a good fit between the sample and the population distributions in the 17-31 age group, but that the sample tended to under-represent people in the 32-or-more age group. In terms of educational level, the "tertiary/technical-trade educated" level was found to be somewhat over-represented, with 36.7% having achieved either level. In terms of employment status, the sample had an unemployment rate of 4.2% which is lower than the national rate of 8.8%. In terms of the respondents' socioeconomic status (SES), comparisons with occupational groupings used by the Australian Bureau of Statistics revealed that the sample somewhat over-represented people with professional and managerial occupations, and under-represented people in the trade and labor category. In other categories, there was a good fit between sample and population. Together, these characteristics indicate that the sample is somewhat skewed toward those who are female, with high education, and high SES, which suggests that care should be taken when generalising the study's findings to the larger population. Material The study employed a questionnaire which consisted of three sections. Section 1 was designed to elicit information about the respondents' gender, age, educational level, employment status, and current occupation. Section 2 consisted of 18 items designed to tap respondents' support for euthanasia under three conditions of suffering (physical pain, debilitated nature of the body, impact on family) experienced by oneself, a significant other, and people in general. For all three conditions of suffering, the items were worded similarly, except for the reference to the identity of the terminally ill patient, i.e., oneself, a significant other, people in general. For example, in the self situation, the "physical pain" condition was measured by one item: "your terminal illness has given you continuous excruciating pain; the "debilitated body" condition was measured by two items: (1) "you have lost control of all your bodily functions", and (2) "you are confined to bed for the rest of your life"; the "impact on family" condition was measured by three items: (1) "your terminal illness will result in prolonged psychological stress on your family", (2) "your terminal illness will cause you to be a burden on your family", and (3) "caring for your terminal illness will be financially draining on your family". These six items were repeated with changes in the wording to reflect a significant other, and people in general. Each of the 18 items was to be rated on a 5-point scale from 1=strongly against euthanasia, to 5=strongly for euthanasia. Section 3 consisted of four statements regarding the issue of euthanasia, each of which was to be rated on a 5-point scale ranging from 1=strongly not support, to 5=strongly support. These four statements reflect the four types of euthanasia yielded by the following 2 (active/passive euthanasia) X 2 (voluntary/involuntary) factorial combination. The four statements were worded as follows: Voluntary passive euthanasia is letting a patient, who has asked for death, die naturally rather than using extraordinary artificial methods (transplant, life-sustaining drugs, etc), or machines (heart-lung machines, respirators, etc) to keep him or her alive in a constant state of suffering or unconsciousness. Voluntary active euthanasia is the administration of a lethal drug to terminate the life of a patient who has asked for death because he/she is in a state of constant suffering or unconsciousness. Involuntary passive euthanasia is letting a patient die naturally (if members of his/her family request it) rather than using extraordinary artificial methods (transplant, life-sustaining drugs, etc), or machines (heart-lung machines, respirators, etc) to keep him or her alive in a constant state of suffering or unconsciousness. Involuntary active euthanasia is the administration of a lethal drug to terminate the life of a patient (if members of his/her family request it) because he/she is in a constant state of suffering or unconsciousness. Results A multivariate analysis of variance (MANOVA) with one between-groups variable (respondents' gender) was carried out to test for sex difference on the study's 22 euthanasia attitudinal variables. Multivariate Pillais F-test showed no significant overall sex difference (p [is greater than] .05); follow-up univariate F-tests yielded no significant sex difference on any of the attitudinal variables (p [is greater than] .05). Thus, male and female respondents were combined for all subsequent analyses. The 18 items (in section 2 of the questionnaire) were summed to yield the nine distinct conditions generated by the 3 (physical pain/debilitated body/impact on family) X 3 (oneself/significant other/people in general) factorial combination. Table 1 presents the respondents' mean ratings for the nine euthanasia conditions, as well as the mean ratings for the four types of euthanasia. Table 1. Mean Ratings of the Level of Support for Nine Euthanasia Conditions, and Four Types of Euthanasia. | |
% of respondents a
for/against euthanasia
Euthanasia Conditions Mean SD 1
1. Self-Debilitated Body 3.15 1.09 10.4
2. Self-Impact on Family 3.48 1.09 5.9
3. Self-Physical Pain 3.99 1.10 4.5
4. Significant Other-Debilitated Body 2.82 1.02 12.9
5. Significant Other-Impact on Family 2.79 0.97 10.6
6. Significant Other-Physical Pain 3.76 1.09 4.8
7. People-Debilitated Body 3.03 1.01 9.2
8. People-Impact on Family 2.98 0.95 7.3
9. People-Physical Pain 3.82 1.07 3.9
% of respondents a
for/against euthanasia
Euthanasia Conditions 2 3 4 5
1. Self-Debilitated Body 23.0 20.7 31.1 14.9
2. Self-Impact on Family 15.9 18.2 32.7 27.2
3. Self-Physical Pain 7.6 12.0 35.9 40.1
4. Significant Other-Debilitated Body 29.4 29.7 20.2 7.8
5. Significant Other-Impact on Family 33.9 29.1 18.7 7.6
6. Significant Other-Physical Pain 7.3 24.1 35.0 28.9
7. People-Debilitated Body 25.0 27.7 28.9 9.2
8. People-Impact on Family 27.4 32.8 24.9 7.6
9. People-Physical Pain 8.4 19.3 38.1 30.3
% of respondents who b
support/do not support
euthanasia
Types of Euthanasia Mean SD 1
1. Voluntary-Passive 4.19 0.79 1.7
2. Voluntary-Active 4.15 0.91 4.2
3. Involuntary-Passive 3.59 0.81 2.0
4. Involuntary-Active 3.16 0.95 9.2
% of respondents who b
support/do not support
euthanasia
Types of Euthanasia 2 3 4 5
1. Voluntary-Passive 4.7 3.4 41.2 49.0
2. Voluntary-Active 4.5 14.0 30.5 55.5
3. Involuntary-Passive 14.2 12.6 46.2 24.9
4. Involuntary-Active 24.1 15.7 36.2 14.8
| | a 1=Strongly against euthanasia, 5=Strongly for euthanasia b 1:Strongly not support. 5=Strongly support The results indicated that support for euthanasia varied as a function of both the conditions of suffering, and the identity of the person experiencing these conditions. Thus, the majority of the respondents supported or strongly supported euthanasia for the self (75.9%), significant other (63.9%), and people in general (68.3%) when physical pain was experienced. However, when the condition of suffering involved the adverse effects on the family, more respondents were willing to support or strongly support euthanasia for oneself (59.9%) than for a significant other (26.3%) or people in general (32.5%). Similarly, more respondents were willing to support or strongly support euthanasia for oneself (45.9%) than for a significant other (28%) or people in general (38.1%) when the debilitated nature of the body was considered. With regard to the level of support for different types of euthanasia, more respondents clearly supported voluntary euthanasia (88.1%) than involuntary euthanasia (61.05%), and more respondents supported passive euthanasia (80.65%) than active euthanasia (68.5%). Moreover, the results clearly demonstrated an overwhelming majority of respondents either supporting or strongly supporting euthanasia when it was presented as voluntary and passive (90.2%). The least support was given when euthanasia was presented as involuntary and active (51%). The level of support for voluntary active and involuntary passive euthanasia was generally high (86% and 71.1% respectively). In order to further clarify the level of support for the different types of euthanasia, a 2 (voluntary/involuntary) X 2 (active/passive) doubly MANOVA was carried out on the respondents' mean ratings. The analysis yielded significant main effects for both the voluntary/involuntary variable (voluntary: M=4.17, SD=0.85; involuntary: M=3.37, SD=0.88) and the active/passive variable (active: M=3.65, SD=0.93; passive: M=3.89, SD=0.80), F(1,355)=151.97, p [is less than] .001; F(1,355)=12.99, p [is less than] .001, respectively. The interaction effect was also significant, F(1,355)=4.66, p [is less than] .05. As can be seen from Table 1, while the overall level of support for involuntary euthanasia was lower than for voluntary euthanasia, the level of support for involuntary active euthanasia was lowest relative to the other three types of euthanasia. In order to investigate how support for euthanasia varied as a function of the three conditions of suffering, and the identity of the terminally ill patient, a 3 (physical pain/debilitated body/impact on family) X 3 (oneself/significant other/people in general) doubly MANOVA was carried out. The analysis yielded a significant main effect for the identity of the terminally ill patient, multivariate Pillais F(2,355)=123.33, p [is less than] .001. Follow-up univariate F-tests indicated that support for euthanasia was significantly higher for oneself (M=3.54, SD=1.09) than for a significant other (M=3.12, SD=1.03), F(1,356)=76.78, p [is less than] .001; or for people in general (M=3.28, SD=1.02), F(1,356)=176.66, p [is less than] .001. The analysis also yielded a significant main effect for the "conditions of suffering", multivariate Pillais F(2,355)=205.13, p [is less than] .001. Follow-up univariate F-tests indicated significantly higher level of support for euthanasia for the physical pain condition (M=3.86, SD=1.09) than for the debilitated body condition (M=2.99, SD=1.07), F(1,356)=354.79, p [is less than] .001; or for the "impact on family" condition (M=3.08, SD=1.00), F(1,356)=97.89, p [is less than] .001. The interaction between the three conditions of suffering and the identity of the terminally ill patient was also significant, multivariate Pillais F(4,353)=26.32, p [is less than] .001. Figure 1 presents this interaction graphically. Figure 1. Support for Euthanasia as a Function of Three Conditions of Suffering, and the Person for Whom Euthanasia is Recommended. Univariate F-tests indicated that the significant interaction resulted from the respondents' differential endorsement of euthanasia under the "debilitated body" and "impact on family" conditions, as a function of the identity of the person for whom euthanasia was being considered. As shown in Figure 1, when the terminally ill patient was defined as oneself, there was greater support for euthanasia under the "impact on family" condition (M=3.48, SD=1.09) than under the "debilitated body" condition (M=3.14, SD=1.09). However, when the terminally ill patient was defined as a significant other, the level of support for euthanasia under the "impact on family" condition (M=2.79, SD=0.97) dropped below that for the "debilitated body" condition (M=2.82, SD=1.02). Discussion Before discussing the study's findings, the limitations of the study must be acknowledged. The sample used, while relatively large, was accidental rather than stratified. The non-probability sampling technique employed resulted in a sample that is biased toward those who are female, with high education, and high SES. The results, therefore, are tentative, and need to be confirmed in larger scale studies with more representative sample of individuals. Furthermore, the study did not take into account potentially influential variables such as religiosity or personal experience with death or euthanasia (see Finlay, 1985; Ho & Penney, 1992; Lester, Hadley, & Lucas, 1990; Rogers, 1996). For example, research has suggested that Catholics tend to be more opposed to suicide and euthanasia than non-Catholics (Anderson & Caddell, 1993; Singh, Williams, & Ryther, 1986) and, more generally, individuals who believe life belongs to God hold more negative views of right to die behaviours (Ross & Kaplan, 1993-1994). These variables may mediate or temper the decision-making process in the life and death debate. In general, the results point to an overall level of support for active, passive, voluntary, and involuntary euthanasia, and corroborate past survey results that have shown an increasing trend in the support of euthanasia over the past decade (Kuhse & Singer, 1988, 1992; Roy Morgan Research Centre, 1995; Singh et al., 1986; West, 1993). For the present Australian sample, the results suggest that, in making life and death decisions, there may be some agreement among the respondents that dying may be an acceptable alternative to a life that is no longer viable. However, the results also suggest that there maybe some disagreement about the method used to terminate that life, and the extent to which that decision is under one's control. The finding that the majority of the respondents were more accepting of passive than of active euthanasia is in line with past findings that have shown that individuals are significantly more accepting of euthanasia if it is presented as passive in nature as opposed to active (see e.g., Finlay, 1985; Ho & Penney, 1992; Ostheimer, 1980). This finding clearly reflects the perceived moral difference between active and passive euthanasia, and suggests that the perceived difference between killing people and merely letting people die still weighs heavily on the decision-making process of many people. The moral argument extends to the presence or absence of the wish of the patient to die. The higher support for voluntary over involuntary euthanasia indicates the desire to place the onus of responsibility for death squarely on the patient. Presumably, one would feel more morally secure about terminating the life of another person if that person had specifically asked to die, or had left specific instructions about when euthanasia was wished. Such steps would move the euthanasia from the category of involuntary to voluntary and, many would feel, render it more morally acceptable (Darley et al., 1996). The greater acceptance of euthanasia when it was presented as both passive and voluntary in nature is clearly reflected in the overwhelming level of support (90.2%) demonstrated in the present study. On the other hand, the lowest level of support was recorded when euthanasia was presented as involuntary and active. The relatively low level of support for this type of euthanasia is not surprising, given its implication of killing people without their consent. While this type of euthanasia is intended to end the suffering of terminally ill patients who are unable to communicate their wishes (e.g., being in a comatose state), intuitively it does not sit well with people to endorse a type of euthanasia that permits the killing of another who has not expressed a specific wish to die. Indeed, euthanasia that is presented as both involuntary and active exemplifies the basic rationale underlying the opposition to the legalisation of euthanasia in many countries: the concept of the slippery slope. According to Rogers and Britton (1994), the slippery slope hypothesis suggests that "the sanctioning of euthanasia might lead to an acceptance of suicide in circumscribed situations (e.g., rational suicide for people with AIDS), which in turn might result in a loosening of restrictions against suicidal behaviour in general" (pg. 174). According to this argument, if society permits voluntary active euthanasia, then society may slip into permitting involuntary active euthanasia, a situation most recently practiced in Nazi Germany in which decisions made by "experts" or "authorities" led to the termination of those who are elderly, chronically ill, handicapped, or retarded (Lester, 1996). The implication here is that if society permits involuntary active euthanasia, then eventually some people (especially the elderly) may be forced by others to commit suicide when they do not wish to die. This is especially likely if the elderly (or the chronically ill, or handicapped) feel they are a burden (both interpersonal and financial) on their children or other relatives (Lester, 1996). Despite the relatively low level of support for involuntary active euthanasia shown by the respondents in the present study (M=3.16), the results still indicated that the majority supported or strongly supported this type of euthanasia (51.1%). This finding suggests that although there is some uneasiness about a type of euthanasia that involves the termination of another person's life without his or her consent, there is still the perception that there are situations in which death, by any means, is more preferable to a life that is perceived as no longer viable. The results are consistent with the hypotheses relating to the level of support for euthanasia under three different conditions of suffering (physical pain; debilitated nature of the body; impact on the family) experienced by oneself, a significant other, and people in general. First, the finding that the respondents were more accepting of euthanasia for themselves than for a significant other or for people in general, corroborated Wade and Anglin's (1987) suggestion that it is easier to make the decision to end one's life than to make the decision to end the life of another person, especially if the other person is a significant other (e.g., father, mother, sibling). This finding makes intuitive sense since the decision to end one's life is much less complicated ethically, morally, and legally than the decision to end another person's life. This is particularly true when the other person is a significant other, such as a parent. As shown by Wade and Anglin (1987), many more variables are taken into account when one contemplates euthanasia for parents than for self in similar situations. People are less definite about what situations would justify euthanasia for their parents than for themselves. Second, the results support the hypothesis that the experience of physical pain is the most important determinant of the level of support for euthanasia. This finding is in line with past research that has shown persistent pain and terminal illness to be the primary reasons for requests for physician-assisted suicide (Foley, 1991; Helig, 1988). For many terminally ill patients, as the end of life approaches, the relief of physical symptoms can become more difficult, and for some patients, the overall level of suffering experienced may be termed "refractory" (Cherny, 1996). According to Cherny and Portenoy (1994b), the term "refractory" is used to describe a symptom that cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy. In cases where it is recognised that the treatment of pain and suffering is no longer effectual, family members, practitioners, and ethicists may accept elective death by euthanasia as a beneficent option (Brody, 1992; Smith, 1990; Wanzer et al., 1989). Third, the significant interaction between conditions of suffering and the identity of the patient for whom euthanasia was being considered, sheds light on the way one endorses euthanasia for oneself and for a significant other under two specific conditions of suffering, i.e., the "debilitated body" and "impact on family" conditions. The results showed that the respondents were more accepting of euthanasia under the "impact on family" condition than under the "debilitated body" condition, when the terminally ill person was defined as oneself. When the terminally ill person was defined as a significant other, the level of support for euthanasia under the "impact on family" condition dropped below that for the "debilitated body" condition. These findings support the hypothesis that, 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 burdens of care (Davies et al., 1990; Schachter, 1992). The desire to spare the family and loved ones from such burdens is clearly judged as a more important reason to die than to relieve oneself of the suffering brought on by a debilitated body. When the terminally ill patient was defined as a significant other, the results indicated a reduction in the support for euthanasia under the "impact on family" condition, with the "debilitated body" condition perceived as a more important reason for supporting euthanasia. A number of conclusions can be drawn from these findings. First, the finding that the debilitated body condition was perceived as a more important reason than the "impact on family" condition 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. Second, and more importantly, the findings suggest that the burdens of care associated with a loved one are weighted more positively than the burdens of care associated with oneself. This finding is not surprising when the issues of love, loyalty, and devotion to a loved one (e.g., a parent) are taken into account. Simply, the devotion that one has towards a loved one may override the concerns associated with the burdens of care when that person becomes terminally ill. 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 (Lee, Kleinbach, Hu, Peng, and Chen, 1996). The present findings, obtained from Australian respondents, 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. Overall, the results are in line with those collected in recent surveys that have shown a majority of the public in favour of voluntary euthanasia. However, the results also clearly reflect the moral differences many people see exists between different types of euthanasia, as indicated by the relatively low level of support given to involuntary active euthanasia. Nevertheless, the finding that the majority of the study's respondents still supported euthanasia that was presented as both involuntary and active, points to the conviction that many people have about the right to die. Indeed, this finding may be troublesome for those who emphasise the "slippery slope" argument in their opposition to euthanasia. Much of the ethical 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 decisionmaking position, would support the termination of the patient's life without his/her specific wish to die. Although the involuntary active euthanasia condition was presented in the 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 findings appear 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 in a somewhat wider, and perhaps less justified set of circumstances (Darley et al., 1996). Acknowledgements I would like to thank Graham Davidson for his helpful comments on an earlier draft of this article. Accepted for publication: December 1997 References Anderson, J. G., & Caddell, D. P. (1993). Attitudes of medical professionals toward euthanasia. Social Science Medicine, 37, 105-114. Beck-Friis, B., & Strang, P. (1993). The family is hospital-based home care with special reference to terminally ill cancer patients. Journal of Palliative Care, 9, 5-13. Bolund, C. (1985a). Suicide and cancer: 1. 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