Euthanasia polls: What do they really tell us?
John Kleinsman
Introduction
In recent years, various polls seeking the views of the New Zealand public on euthanasia and assisted suicide have consistently reported that 60-70% of people support their legalisation,1 leading Horizon researchers, for example, to conclude that “Supporters of end of life choice … form a strong majority”2 in New Zealand and the Voluntary Euthanasia Society (VES) to state with confidence that “most New Zealanders support aid-in-dying legislation.” 3
The terminology and questions used in such polls are, however, rarely analysed and the results of these polls are rarely dissected or challenged. All of which means that the conclusions we draw from them need to be treated with caution. As Marcoux et al noted in 2007: “… the use of the argument that public opinion is in favour of euthanasia to support changing laws must be critically examined. There are methodological problems in the wording of survey questions that can bias responses, and the validity of responses may be compromised by pervasive misunderstandings of what euthanasia means.” 4
This article will seek to shed some light on the strengths and limitations of a number of polls carried out in New Zealand and around the world with a view to offering a more nuanced analysis.
Terminology
A number of overseas polls have shown that people’s willingness to support the legalisation of assisted suicide and/or euthanasia depends on the language employed in the questions – specifically whether ‘softer’ or euphemistic descriptions such as ‘medically-assisted dying’ are used rather than those containing alternative technically correct terms such as ‘suicide’.
For example, a 2005 poll carried out by the Pew Research Center for the People and the Press reported: “The survey found that 44 percent of respondents favored making it legal for doctors to ‘assist terminally ill patients in committing suicide’ when the question was worded this way. But support for the practice rose slightly, to 51 percent, when people were asked if they favor making it legal for doctors to ‘give terminally ill patients the means to end their lives.’”5 A 2005 Australian study which investigated cancer patients’ views on euthanasia and physician-assisted suicide likewise concluded that “professed support can depend upon the individual’s own definition, the language used in questions and the specificity of questions.” 6
Similarly, a 2013 Gallup poll found “70% of Americans in favor of allowing doctors to hasten a terminally ill patient's death when the matter is described as allowing doctors to ‘end the patient's life by some painless means.’ At the same time, far fewer – 51% – support it when the process is described as doctors helping a patient ‘commit suicide’.”7
A lack of consistency in the terminology used, as well as a propensity by of many pollsters to use softer language, characterises many New Zealand polls.
Ethical Distinctions
The 2005 Australian study referred to above also demonstrates that many poll respondents who profess support for assisted suicide and/or euthanasia do not understand the distinctions between these and withholding or withdrawing treatment. “Researchers need to be circumspect about framing and interpreting questions about support of ‘euthanasia’, as the term can mean different things to different people, and response may depend upon the specifics of the question asked.”8 In this study, interestingly, “79% of patients said they supported the idea of euthanasia, and 70% agreed ‘a doctor should be able to assist a patient to die’, [yet] 80% did not agree that ‘doctors should be able to kill their patients’.” 9
When terms such as ‘medical aid in dying are used’ the confusion is even greater. A 2013 Canadian survey by Ipsos Marketing, for example, specifically set out to assess what was understood by the people who supported ‘medical aid in dying’. This survey showed one third of Quebecers interpreted the phrase as being a patient’s request for lethal injection by a medical professional, while nearly 30% understood that it meant relieving symptoms through palliative care. Finally, nearly 40% of those surveyed associated it with a discontinuation of intensive medical treatment, or with assisted suicide. The researchers then concluded: “It is therefore essential to clarify applicable terms and tangibly convey the true definition of euthanasia, and avoid using even vaguer expressions such as ‘medical aid in dying’.” 10
Real World Scenarios
A further challenge when interpreting public opinion polls arises from the fact that the nature of the question or questions asked means that the views of respondents are often based solely on hypothetical scenarios.
Emanuel et al11 illustrate this clearly in their 2000 investigation into the attitudes of terminally ill cancer patients. While 60.2% of the participants supported euthanasia in a “hypothetical” situation, only 10.6% indicated that they would seriously consider euthanasia or physician assisted suicide for themselves. This result accords with an earlier study in which it was noted that people’s responses change according to the amount of detail they are given about personal circumstances – the proportion of the general public who agreed with euthanasia for unremitting pain was 66% but this dropped to 49.2%, 36.2% and 29.3% respectively for the categories “functional debility”, “burden on family” and “view life as meaningless”.12
Similarly, in a 2014 Comres/CARE poll carried out in the UK, 73% of those polled indicated support in principle for a Bill designed to enable mentally ill competent adults in the UK who are terminally ill and with a clear and settled intention the right to be provided with assistance to commit suicide by self-administering drugs.13 However, when those who supported assisted suicide in principle were offered a series of practical considerations (such as people feeling pressured so as not to be a burden and the steady rise of numbers in jurisdictions where it is legal), a large proportion, 42% of them changed their minds on the basis of at least one of the arguments. When these figures were added back into the original sample, aggregating all who opposed as a result of the arguments presented while incorporating all who still supported assisted suicide in spite of the arguments, the final result was 43% in favour, 43% opposed and 14% don’t know.
Meanwhile in New Zealand, close scrutiny of the 2012 Horizon Poll already referred to (which shows that 62.9% would support “mentally competent adults in New Zealand to receive medical assistance in ending their life if they are suffering from a terminal illness or an irreversible physical or mental condition that in their view renders their life unbearable”) reveals that people’s support is heavily premised on the need for, and belief in the effectiveness of, strict controls. As the researchers note: “The need for strict controls, like those measured in the survey, is demonstrated by support for them exceeding support for end of life choice overall.”14 As far as this poll goes, therefore, the more adequate and honest conclusion to draw is that 62.9% of New Zealanders believe in receiving medical assistance to end their life on the assumption that harms to others can be prevented by strong and effective safeguards. In the face of international evidence that safeguards are problematic and ineffective15, it is less than honest to use this poll to claim, as the Voluntary Euthanasia Society of New Zealand do, that most New Zealanders would in reality support euthanasia or assisted suicide legislation.
Conclusion
The 2012 Horizon Poll demonstrates that the willingness of New Zealanders to support euthanasia or assisted suicide in New Zealand is premised on an assumption that strict and effective controls can be put in place. Overseas research challenges this assumption; moreover, when polls include additional information about the complexities and risks, the numbers of people prepared to support a law change drops significantly. Overseas research also shows that people often fail to understand the terminology being used as well as the ethical distinctions between euthanasia and/or assisted suicide and withdrawing or withholding treatment.
Because most of the New Zealand polls relied on and quoted by proponents of change have failed to provide the level of nuanced questioning and information that would be required to confidently say their results are reliable, it is incorrect to say that “most New Zealanders support aid-in-dying legislation”16 or to assume that this reflects people’s informed views on euthanasia.
As our Prime Minister Hon John Key, who has previously declared his personal sympathy for a law change, noted recently: “Striking the right legislative balance with both clear definitions and adequately strong protections is an extremely difficult task, and that no bill has yet passed on this issue is testament to that.” 17 A true indication of New Zealanders’ support for euthanasia or assisted suicide will only be possible if and when polls take proper account of people’s understandings of the definitions and complexities associated with the practice of euthanasia and/or assisted suicide.
Dr John Kleinsman is the director of The Nathaniel Centre
[1] See “Legalisation of Euthanasia in New Zealand: Surveys in New Zealand” at http://policyprojects.ac.nz/jasonrenwick/surveys-in-new-zealand/
[2] See, for example, Horizon Research, "New Zealanders' views on End of Life Choices," (Auckland, New Zealand2012). at http://www.horizonpoll.co.nz/attachments/docs/horizon-research-end-of-life-choices-survey--1.pdf, accessed 1 May 2015.
[3] See http://www.ves.org.nz/, accessed 1 May 2015.
[4] Marcoux, Isabelle, Brian L Mishara and Claire Durand (2007) “Confusion between euthanasia and other-end-of-life decisions: Influences on public opinion poll results” Canadian Journal of Public Health 98: 238.
[5] See: “The Right-to-Die Debate and the Tenth Anniversary of Oregon’s Death with Dignity Act” at http://www.pewforum.org/2007/10/09/the-right-to-die-debate-and-the-tenth-anniversary-of-oregons-death-with-dignity-act/, accessed 17 August 2015.
[6] Parkinson L et al. Cancer patients’ attitudes towards euthanasia and physician-assisted suicide: the influence of question wording and patients’ own definitions on responses. J. Bioethical Inquiry 2005, 2: p. 88.
[7] Gallup, "U.S. Support for Euthanasia Hinges on How It's Described," (Washington2013). at http://www.gallup.com/poll/162815/support-euthanasia-hinges-described.aspx
[8] Ibid., p. 82.
[9] Ibid., p. 88.
[10] Ipsos Marketing, "Survey among the Canadian population about end of life issues," (Canada: Ipsos Marketing, 2013), p. 5.
[11] Emanuel EL, Fairclough DL & Emanuel L. “Attitudes and desires related to euthanasia and physician assisted suicide among terminally ill patients and their caregivers.” JAMA 2000 284:2460–2468.
[12] Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. "Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public." The Lancet 347(1996).
[13] ComRes, "Care - Assisted Suicide Poll," (United Kingdom2014). at http://www.comres.co.uk/wp-content/themes/comres/poll/Care_Assisted_Suicide_Poll_July_2014_(with_summary_table).pdf
[14] Ibid., p. 4, emphasis added.
[15] See, for example, Golden M, and Zoanni T. "Killing us softly: the dangers of legalizing assisted suicide," Disability and Health Journal 3, no. 1 (2010); Dr David Jeffrey quoted in Health and Sport Committee, "Stage 1 Report on Assisted Suicide (Scotland) Bill," The Scottish Parliament, http://www.scottish.parliament.uk/S4_HealthandSportCommittee/Reports/her15-06w.pdf at para. 175;Barron H. Lerner and Arthur L. Caplan, “Euthanasia in Belgium and the Netherlands. On a Slippery Slope?” JAMA Intern Med. Published online August 10, 2015.
[16] See http://www.ves.org.nz/, accessed 1 May 2015.
[17] Email sent to writer on behalf of the Prime Minister,