Attitudes towards euthanasia and physician-assisted suicide among Pakistani and Indian doctors: A survey
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.45448
Source of Support: None, Conflict of Interest: None
Aim: This study attempts to assess the attitude of Pakistani and Indian doctors to euthanasia and physician-assisted suicide.
Keywords: Doctors, euthanasia, India, Pakistan, perception, physician-assisted suicide
In 2002, the Netherlands became the first country to legalise euthanasia. Following this, the rest of the world began to debate the attitudes toward euthanasia or physician-assisted suicide. There is a lot of data from the western world discussing healthcare professionals' or lay people's attitudes toward euthanasia. The Nursing Times in the United Kingdom reported the results of a poll of 2700 nurses that established that two out of three nurses think that euthanasia should be legalised.  In addition, 80% of the British public surveyed in a recent report support changes in existing laws that legalise the option of euthanasia for terminally ill patients.  However, a study from the United States of America, which surveyed 2333 oncology nurses, suggested that only 30% support assisted suicide and 23% approve of euthanasia.  A similar study in Japan showed that 25.7% resident doctors surveyed supported the concept of euthanasia whereas 48% of first-year medical students supported the idea. 
Despite working in resource-poor settings, doctors from developing countries have provided good clinical and ethical perspectives to healthcare issues. This study aims to look at the perceptions of doctors from Pakistan and India about euthanasia and physician-assisted suicide.
A questionnaire was developed discussing two case studies. These case studies described the circumstances of two patients, one with motor neurone disease (MND) and the other with widespread malignancy.
The cases were:
It was distributed, by hand, to a convenience sample of doctors from all specialities, who were trained in Pakistan and India, with most of them still working in these countries. The distribution and collection of questionnaires was carried out over a period of 6 months.
From Pakistan, 52/100 (30 males, 22 females) doctors returned the questionnaires. They belonged to Muslim (47) or Hindu (5) religions. The discipline of the doctors is described in [Table 1]. The mean age of the doctors was 42.8 years (26-66), with a mean experience of 15 years (2-40). Eight of the 52 (15.3%) doctors agreed that euthanasia would be an acceptable course of action for the patient with MND whereas 6/52 (11.5%) agreed that euthanasia should be allowed for patients with malignancies. Seven Muslim, one Hindu, six male and two female doctors supported euthanasia as an appropriate intervention. Their mean age was 41.1 years (29-57) and their mean experience was 13.3 years (3-30).
From India, 60/100 (28 males, 32 females) doctors returned the questionnaires. They belonged to Christian (23), Hindu (26) or Muslim (10) religions. The mean age of the doctors was 35.4 (23-58), with a mean experience 10.2 years (0-34). Sixteen of the 60 (26.6%) doctors agreed that euthanasia could be an option for the patient with MND, whereas 15 (25%) agreed with the idea of euthanasia for the patient with cancer. Four Christian, 16 Hindu, eight male and eight female doctors supported the concept of euthanasia. Their mean age was 31.25 years (23-52) and their mean experience was 6.75 years (0-18).
The motivations that supported their decisions are described in detail in [Table 2].
Until recently, medical ethics in palliative care had been focussed mainly on withdrawing treatment rather than euthanasia. There is a large body of evidence from the developed countries looking into perceptions surrounding euthanasia. One study found that the factors associated with the wish to hasten death were concerns around physical symptoms, psychological suffering, perceiving themselves as a burden to others, higher levels of demoralisation, less confidence in symptom support, fewer social supports, less satisfaction with experiences and fewer religious beliefs.  Another study identified that most nurses found it difficult to deal with persistent requests from patients for assistance with dying. 
While the western world, especially the United Kingdom, has pioneered palliative care provision, the developing world still struggles to achieve these standards. A questionnaire survey from Pakistan revealed that only 54% of the doctors had some experience of Palliative care and most doctors had no training on end-of-life issues.  However, with globalisation of medicine and patient awareness, doctors in developing countries come across situations where such issues are raised with increasing frequency. This study was undertaken to look into the perceptions of doctors while making decisions regarding hastening death for patients with incurable diseases.
It is a small study looking into the perceptions of doctors in the subcontinent. India has a population of 1.027 billion and has a literacy rate of 65%. The main religion is Hinduism, but Islam and Christianity are also sizeable minorities. India maintains a secular entity by law . Pakistan has a population of 137.5 million and has a literacy rate of 38%, with more than 90% of its inhabitants following Islam, which is also the national religion . Islam does not allow euthanasia under any circumstances whereas there are differing Hindu perspectives on euthanasia. ,
Many Hindus would not support a doctor's decision to assist a patient's request for euthanasia because of the ideological belief that this causes an unnatural separation of the body and soul, resulting in damage to the "karma" of both the perpetrator (doctor) and the recipient (patient).
Another ideological Hindu approach is that the provision of euthanasia violates the core Hindu tenet of ahimsa (doing no harm). However, others would argue that assistance in ending a painful life is performing a good deed and hence fulfilling their moral obligation .
Our survey shows that the majority of the doctors did not agree with the idea of euthanasia or physician-assisted suicide. However, among the doctors who supported the idea of hastening death, lesser experience and a younger age group were noted to be prominent variables. No clear association could be made with regard to the doctor's religion and approval for assistance with euthanasia. In Pakistan, doctors approving of euthanasia were more likely to be men. Previous studies have shown that the risk factors for patients requesting euthanasia were concerns with physical symptoms, psychological suffering, perceiving themselves to be more of a burden to others, higher levels of demoralisation, less confidence in symptom support, fewer social supports, less satisfaction with experiences and fewer religious beliefs.  It can be postulated that in these two South Asian countries, family and social supports are more prevalent as is the influence of religious beliefs in the practise of medicine. Doctors were less likely to feel strongly about physical suffering as the abundant psychological and emotional support would moderate the total pain experienced. It is interesting that doctors of both opinions have felt strongly that it was their moral obligation to make their particular opinion. It reflects strongly polarised beliefs expressed elsewhere in the world. Interestingly, both proponents and opponents of euthanasia and physician-assisted suicide arrive at their respective convictions based on their respective moral stances. , Doctors from Pakistan also sighted religious reasons as a strong reason for not hastening death, which appears in line with the country's strong Islamic tradition. However, an association between the doctor's faith and support for euthanasia could not be established, probably reflecting the study's small sample size.
This study was undertaken to look at doctors' perceptions regarding euthanasia and physician-assisted suicide. However, the relevance of the results is limited by the small sample size and other larger studies from these countries are required to confirm the trends observed here and explore other areas of relevance such as patients' perceptions and doctors' motivations for deciding in favor of or against euthanasia. With the current developments in the field of palliative medicine in developing countries, it is important to develop a culture where training of palliative care is provided along with an understanding of issues and ethics that influence important end-of-life decisions.
Part of this study "Attitudes toward euthanasia and physician-assisted suicide among Pakistani doctors" was presented as a poster at the 9 th European Congress of Palliative Care, Aachen, Germany 7-10 April 2005.
[Table 1], [Table 2]