Recent Medscape Survey Indicates that Doctors are Divided on Life and Death Issues
by Lisa Blumberg
Medscape is an online resource for healthcare professionals. It provides medical news and information and does surveys on current issues. (1) Its 2022 survey of 4100 U.S. doctors on “Right and Wrong in Medicine: Life, Death and Wrenching Choices” (2) indicates how divided doctors are on so-called life or death issues.
I found aspects of the survey lacking in nuance and social context. For example, the survey does not touch upon whether consideration of healthcare inequities might alter a doctor’s view. There is one question on reporting a doctor for sexual harassment, bullying or racist remarks (3) but no question on ableism or implicit bias against patients with disabilities. This suggests that the latter concerns, although documented in studies (4) are not mainstream enough to ask doctors’ opinion on them. Also, Medscape seems to shy away from asking new questions in keeping with research. Some questions are ambiguous and are not qualified in the way they should be. This is probably one reason why “it depends” is such a common answer.
The survey does illustrate broad trends though and it is useful to read the survey in its entirety. Some of the reported comments are provocative but the better we understand doctors’ views, the better we can hone countervailing arguments. Below is a summary of the responses to the questions directly related to assisted suicide, withdrawal of treatment and futility as well as some brief thoughts on what this response may mean.
Should physician-assisted suicide be legal for terminally ill patients?
The responses were 52% yes, 27% no and 20% stated it depends. (5) In 2010 when a similar question was asked, the responses were 46% yes and 40% no.
It is interesting that the survey does use the term assisted suicide rather than one of the euphemisms used in the press and in legislation. It is also interesting that the survey does not ask whether an individual doctor would assist in a patient’s suicide. The question is framed in terms of legality. However, the increase in medical acceptance of assisted suicide is very troubling and indicates that the practice is being normalized. Doctors respond to public opinion and shifts in sentiments but the reverse is also true, i.e. doctors have political and social clout on issues deemed medical in nature. To a large extent, the public takes its cue from them. We need to continue working with our allies in the medical community to educate health care professionals on the corrupting influences of legal assisted suicide.
Should physician-assisted suicide be legal for patients in intractable pain?
The responses were 34% yes, 34% no and 33% stated it depends. (6) This represents some increase from 2018 when the responses were 27% yes and 40% said no.
Proponents of legalizing assisted suicide have repeatedly assured the public that “only” people close to death would be eligible… Yet these results indicate that two thirds of doctors would support permitting assisted suicide for other patients groups at least in some cases. This would follow the path of countries like Canada, Belgium and Holland.
Pain usually can be controlled. It is instructive to juxtapose the responses to this question with the responses to a later question as to whether a doctor would undertreat for a patient’s pain for fear of being sanctioned. (That question seems to be getting at a doctor’s willingness to prescribe opioids). In 2010, 6% of doctors replied yes, meaning they would undertreat pain. In the recent survey, 37% responded yes or it depends. Thus, there is both a substantial group of doctors saying they might knowingly undertreat pain and a substantial group of doctors saying that lethal prescriptions should be an acceptable solution for pain.
In any event, “patients in intractable pain” is, at least in part, code for allowing assisted suicide for people with chronic diseases or disabilities. The survey question seems to be phrased in a way to make it socially acceptable. However, severe pain is not a leading reason why people consider assisted suicide. People far more often request lethal prescriptions due to perceived lessening of autonomy, or feelings of being a burden. (8) Indeed, a recent study has shown that a fear of going into a nursing home is much more likely to fuel a desire to hasten death than pain is. (9) In Canada where euthanasia is permitted for people with disabilities, individuals have been candid that lack of in-home services allowing them to remain in the community has driven them to this awful alternative. (10)
We need to recognize how assisted suicide is likely to evolve if it becomes legal in a critical number of states. The public must not to be led believe the rhetoric of its supporters. We must continue to combat the “better dead than disabled” ethos in both the medical community and society.
Would you end life support at the family’s request if you think the patient might survive?
The responses were 18% yes, 35% no and 47% stated it depends. (11) In 2010, the replies were 55% no and 29% it depends. The question is so general that the respondents may be interpreting the question in different ways. How life support is defined and where is the person in all this? Can she communicate even if minimally? Did he indicate his wishes or values? The question behind the question is why a family would request this if they have been properly advised that the person might survive. Attitudes about disability are lurking here again.
It is extremely disturbing that so many doctors are now willing to consider withholding of possibly lifesaving care if family members so request. Perhaps, some are concerned about families bringing lawsuits if the person survives but with a permanent need for care. Be that as it may, this indicates that many doctors do not think that saving a life is a paramount goal and are willing to act on “quality of life” beliefs.
Some doctors and palliative care specialists are indeed concerned about “pulling the plug” prematurely (12) and these are the people disability rights activists need to work with to develop more oversight and guidance in cases of withdrawal of care. The present system leaves too much to discretion.
Would you provide life sustaining care at the family’s request if you think it is futile?
The responses were 44% yes, 15% no and 41% stated it depends. (13) These responses are essentially unchanged from 2020. Again, the question is so general that the respondents may be interpreting the question in different ways. The commentary itself points out that there are different definitions of futility and that some doctors will see futility even in situations where the care will be effective in saving a person’s life. It is somewhat incongruous that “life sustaining care” and “futile” are paired together. If the survey really wanted to get at doctors’ views, the question would be two questions, one referring to treatment which won’t appreciably delay death and one referring to treatment that will indeed save the person but the person will have disabilities.
When the replies to this question are compared to the replies to the previous question, the implications are that more doctors would be more willing to defer to a family’s request when the decision is for death than when the decision is for life. 65% of doctors would at least consider taking a person off life support even if there is a chance the patient might survive if that is what the family wants. On the other hand, 56% of doctors would at least consider refusing to provide life sustaining care at the family’s request if they deem it futile.
In conclusion, there seems to be no consensus among doctors about these issues and many appear to be conflicted. This is a cause for hope. There is a core of healthcare professionals that we should be able to work with. However, the trends are not going in our direction and this justifies our sense of urgency. The survey itself is frustrating. Some of the questions are too general and there seems to be an avoidance of the elephant in the room, i.e. attitudes towards disability and other devalued populations. The survey seems to be designed to get at what would be doctors’ decisions but not at the biases behind them. That is its fatal flaw.
