Euthanasia: The role of good care

The results from two surveys in England of relatives and others who knew people in samples drawn from death certificates are reported. The main focus is on a sample of 3696 people dying in 1990 in 20 health authorities, with supporting analysis from an earlier national sample of 639 people dying in 1987. The argument that good care and, in particular, hospice care is effective in reducing the desire for euthanasia has been proposed as an argument against the legalization of voluntary euthanasia. The findings suggest that the picture is in fact more complex. People who received hospice care were, if anything, more likely to have respondents who felt that it would have been better if they had died earlier. The latter held when controlling for other variables found to influence respondents' views, such as the level of distress and dependency experienced by the dying person. It appears possible that the same may apply to the dying peoples' own wishes, although here the time order of events could not be controlled for in the data. It is suggested that this may be due to hospice care being geared to helping patients express their fears and exercise choice. The wish for euthanasia may then be an assertion of personal control, rather than an act of surrender. Alternatively, people (and their relatives) who accept hospice care may be predisposed to consider the benefits of an earlier death. Measures of the quality of care and, where appropriate, symptom relief, from general practitioners, nursing and other domiciliary services, and care in other institutions such as old peoples' homes and hospitals showed only a few and weak associations with the wish to die earlier or requests for euthanasia. Several measures of unmet need for domiciliary services and for treatment for symptoms were associated with the dependent variables. It is suggested that care that is judged to be good may only do a little to counteract peoples' fear of dependency, and indeed might serve to increase feelings of lost autonomy.