End-of-life practices: The opinions of undergraduate medical students at a South African university

Abstract

Modern people live increasingly longer lives owing to advances in medicine and the application of medical technology, but this has raised many ethical questions regarding the prolongation of life, the right to die and euthanasia. [1,2] In South Africa (SA), it is illegal to terminate a person's life or assist therein in order to end pain and suffering, even for a terminally ill patient. The common law criminalises euthanasia, but allows a patient to instruct a doctor to withhold/withdraw potentially life-sustaining treatment. [1] According to the SA Law Commission, terminal illness refers to an illness, injury or other physical or mental condition that, in medical judgment, will inevitably cause the patient's death and is producing extreme suffering, or will cause an irreversible vegetative condition. [1] In 2011, the Ethics Institute of SA (EthicsSA) [3] conducted a scoping survey among doctors and specialists at two medical schools in SA, in which more than 80% of participating doctors indicated that assisted dying should only be contemplated when a patient is terminally ill, while 12% believed that assisted dying does not require a terminal illness. End-of-life decisions are categorised into the following four practices by the legal fraternity: (i) terminal pain management; (ii) withholding or withdrawing of potentially life-sustaining treatment; (iii) advance directives; and (iv) assisted dying. Patients in SA have the right to affordable palliative care in the case of a terminal illness. [4] Under the National Patients' Rights Charter, published by the Health Professions Council of SA (HPCSA), [4-6] patients have the right to refuse treatment. The National Health Act No. 61 of 2003 [6] allows patients, in writing, to designate a person to act on their behalf when they are no longer capable of doing so themselves. 'Assisted dying' is an umbrella term that entails all end-of-life interventions in the dying process. [3] 'Assisted suicide' means that a person intentionally provides the means for a competent person to take their own life. 'Voluntary active euthanasia' means that a competent person at the end of life asks another person to perform an act which is the proximate cause of death. In this article, the term 'assisted dying' will be used in a narrower sense to refer to both assisted suicide and voluntary active euthanasia. While studies have concentrated on what qualified doctors think about end-of-life decisions, it is of interest to ascertain the opinions of medical students ('doctors in training'). A study was conducted among medical students at a university in Croatia about their opinion on euthanasia, before and after bioethics education on the topic. [7] Before the course, their attitudes toward euthanasia largely varied with respect to religion and according to whether they were rural or urban. After the training, students were significantly more positive towards euthanasia, and no differences between subgroups were This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Euthanasia and physician-assisted suicide: a systematic review of medical students’ attitudes in the last 10 years

“…From the 13 selected articles, seven ( 6 - 12 ) were published between 2014 and 2018 and six ( 13 - 18 ) were published between 2009 and 2013. Two studies were from Africa ( 7 , 9 ), four were from America ( 6 , 8 , 12 , 14 ), one was from Asia ( 15 ), and six were from Europe ( 10 , 11 , 13 , 16 - 18 ). The countries involved included Austria (n = 1) ( 18 ), Belgium (n = 1) ( 11 ), Brazil (n = 1) ( 12 ), Canada (n = 1) ( 14 ), Germany (n = 1) ( 10 ), Greece (n = 1) ( 18 ), Mexico (n = 2) ( 6 , 14 ), Pakistan (n = 1) ( 15 ), Poland (n = 2) ( 13 , 16 ), and South Africa (n = 2) ( 7 , 9 ).…”

“…Eight articles addressed the approval rate of medical students regarding legalization of AE, PE or PAS ( 7 - 9 , 11 , 13 , 15 - 17 ); ten stated a positive attitude toward AE exclusively ( 6 - 12 , 15 , 17 , 18 ); six addressed acceptance of PE ( 6 , 9 , 10 , 12 , 14 , 18 ); and, six addressed acceptance of PAS ( 7 , 8 , 10 , 14 , 15 , 18 ). Two articles addressed the students’ personal views on AE, PE or PAS, whether exclusively or conjunctively ( 13 , 16 ).…”

“…Regarding the third focused question, 11 articles ( 6 - 9 , 11 , 12 , 14 - 18 ) highlighted variables that could cause the medical students to approve or disapprove AE, PE or PAS practices. Religion was the most significant variable that had a negative impact (n = 7) ( 6 - 8 , 11 , 12 , 14 , 16 ), followed by religiosity (n = 5) ( 6 , 12 , 14 , 15 , 18 ) as the second most significant variable.…”

“…Variable of gender in influencing the students’ opinions showed mixed results: significant ( 6 , 16 ) and non-significant ( 11 , 12 , 14 , 17 , 18 ). Similarly, for variable of medical students’ current academic year, three studies considered it to be significant ( 9 , 15 , 17 ) and one study reported it as irrelevant ( 6 ). The summarized results are shown in Table 3 .…”

“…In contrast, physicians tend to show a negative attitude toward the topic ( 19 , 20 ). The relevance of clinical experience, as a variable that could influence the acceptance of euthanasia or PAS, was discussed by Marais et al ( 9 ) and Hassan et al ( 15 ), who reported different results depending on whether the students were at preclinical level (without active experience with patients) or on clinical rotations. Marais et al stated that higher clinical-level correlated to medical students’ greater empathy towards patients and respect for their autonomy.…”