Euthanasia: trends and opinions in Spain.

OBJECTIVE: Analyse the evolution of opinions about euthanasia by the general public and clinical physicians from 1995 to 2019 and their influence at the present time. MATERIAL AND
METHOD: Bibliographical review based on relevance and quality of publications in open access and academic access platforms. Main surveys review of public and private institutions. Congress and Senate Official Journal Sessions.
RESULTS: Recent surveys show that clinicians support the regulation of euthanasia. This position matches the general public's belief, which has grown steadily in recent decades. DISCUSSION: Social and clinical support for the regulation of euthanasia has been fundamental. In the last two decades political parties have changed their positions, thus creating a window of opportunity.

Introduction

Spain is moving ever closer to regulated euthanasia. The issue has been debated before in the national Congress, but the window of opportunity opened by this legislature could be the one to finally decriminalise and develop a law with the scenarios in which such a practice could be permitted.

If the events taking place in Spain over the last 25 years are any indication, the conclusion is that processes at the end of life such as euthanasia, assisted suicide and dignified death are issues that have often been present in public policy, public opinion and in the media, which have favoured the current context.

The first issue to be tackled in the area of public policy was a dignified death, relating to palliative care and the rights of patients in Law 41/2002, and later specified in laws on dignified death by many Spanish Autonomous Communities. Later issues included euthanasia and assisted suicide; the first being understood as a request made by a patient who is capable and with no hope of a cure, who voluntarily, repeatedly and actively asks a professional to end his/her life as a result of unbearable suffering. In the case of assisted suicide, the professional provides the patient with the necessary medication to enable him/her to carry out the process him/herself.

This article sets out to highlight the evolution of public opinion and its position regarding euthanasia. The study found that arguments relating to individual autonomy and freedom in making decisions about ending life, along with the desire to put an end to unbearable suffering under certain exceptional circumstances, reinforce a favourable attitude and have acquired increasing weight over the years. This growing support can also be seen in surveys of physicians, who are major stakeholders in this debate.

Material and method

An analysis was carried out of the main publications according to criteria or relevance and quality that were obtained in public repositories and libraries open to researchers of the Spanish University of Distance Learning (Universidad Nacional de Educación a Distancia (UNED)); reviews of public opinion surveys published by public and private institutions; reviews of the parliamentary reports (1995-2018) of the Congress and the Special Committee of Study on Euthanasia (Comisión Especial de Estudio sobre la Eutanasia (CEEE)) of the Senate 1999-2000. The limiting term euthanasia was used for the survey analysis.

Results

In 2002, the Spanish Centre of Sociological Research (Centro de Investigaciones Sociológicas (CIS)) asked physicians for their opinion about the possibility of decriminalising and regulating euthanasia (Question 19). 41.5% agreed, as long as the patients were terminally ill and maintained all their faculties, while 18.4% were in favour, regardless of the irreversibility of the disease. The total of both categories is 59.9% of the overall total. Question 21 asked about the degree of agreement with the decriminalisation of euthanasia, on a scale of 1/10, and the average was 6.22.

Recent data from surveys published by a number of official medical practitioners associations in 2018 and 2019 continued to show favourable trends. The association in Vizcaya province, which was the first one to carry out a survey, showed that 67.2% considered that euthanasia should be regulated by the law. The percentages in some other Spanish provinces were as follows: Tarragona, 76% in favour; Las Palmas, 68.5%; and 69.2% in Madrid. The four surveys included a category of answer that showed a degree of agreement with regulated euthanasia, but with some doubts. This category was excluded from the analysis to prevent false positives.

The trend amongst physicians towards favouring regulated euthanasia is linked to debates about euthanasia not being a clinical issue but rather a question that merits discussion by society as a whole, and to the need to adapt a doctor’s role to needs at the end of life. However, governing bodies of medical practitioners are still reluctant to favour regulation.

Support from the general public has increased over time. In 1992, 64% of the public did not believe that life should be artificially prolonged when there is no cure (Q19), and 66% were in favour of a law that would permit doctors to end the life of a patient who asked him/her to do so when he/she had a disease that caused unbearable suffering (Q22). In 1995, the CIS once again asked if a sick patient with an incurable disease that caused unbearable suffering would have the right to ask doctors to provide a product that would end his/her life. The result was 62% in favour (Q17).

In 2009, the CIS again asked if euthanasia should be regulated in Spain. 58.4% totally agreed, while 15.2% said yes but with some reservations. In 2011, the CIS asked about dignified death, and 76% agreed that a law should be approved in Spain that regulated the right of people to have a dignified death (Q31).

In 2015, the company Ipsos carried out a study in 15 countries and in Spain held a total of 2,112 interviews with people between 16 and 65 years of age. The result showed that 65% of the respondents were in favour of regulating the right to die. In 2019, another private organisation, the Fundación BBVA, carried out a survey on the level of acceptance of euthanasia, understood as referring to accelerated death with medical assistance for patients in the terminal phase of an incurable disease who had expressed a wish to not continue living. The results showed (on a scale of 1 to 10) a level of acceptance between 8 and 10, in 59% of the population; 6-7, in 12%, and the same for persons whose level of acceptance was 5. 83% of the population fell between levels 5 and 10 of acceptance, with an average in Spain of 7.4; in France, 7.9; in the UK, 7.2; in Germany, 7.2; and in Italy, 6.2 (Table 1 and Figure 1).

Table 1

Surveys of the general public and medical professionals in Spain, and level of opinion in favour of euthanasia (1992-2019).

Group	Year	Institution	Question (P)	In favour	No.	Sample error
General public	1992	CIS	(Q19)	64%	2.492	(+/-) 2.00
	1992	CIS	(Q22)	66%	2.492	(+/-) 2.00
	1995	CIS	(Q17)	62%	2.466	(+/-) 2.00
	2009	CIS	(Q37)	59,4 and 15,2%	2.481	(+/-) 2.00
	2011	CIS	(Q31)	76,90%	2.580	(+/-) 1.96
	2015	Ipsos	(Q4)	64%	2.112	-
	2019	Fundación BBVA	(-)	83%	1.500	(+/-) 5.00
Medical profession	2002	CIS	(Q19)	41,5% and 18,4%	1.057	(+/-) 3.10
	2018	Off. Med. Assoc. Vizcaya	(Q4)	67,20%	382	(+/-) 5.00
	2019	Off. Med. Assoc. Tarragona	(Q4)	76%	365	(+/-) 5.00; (+/-) 3.3 and (+/-) 11.3%
	2019	Off. Med. Assoc. Las Palmas	(Q4)	68,50%	300
	2019	Off. Med. Assoc. Madrid	(Q4)	69%	1.044	(+/-) 5.00

Note. CIS: Centro de Investigaciones Sociológicas (Centre of Sociological Research); Off. Med. Assoc.: Official Medical Association. Own preparation based on information published by the following institutions: CIS, Ipsos, the Official Medical Associations of Vizcaya, Tarragona, Las Palmas and Madrid and the Fundación BBVA.

Figure 1

Evolution of opinions in favour of euthanasia amongst Spanish health professionals and members of the public (1992-2019).

Other independent academic studies used comparisons by time series in 1981, 1990, 1999 and 2008, with data taken from the European Values Survey. In 1999, Spain showed a level of acceptance of 52%, with an upward trend since 1981. The same trend was found in subsequent studies, in which acceptance of euthanasia was 6.08, with Denmark showing the highest level of acceptance at 6.79, followed by Belgium with 6.75 (a country where euthanasia is a regulated practice). In the case of Spain, a shift was seen from position 19 in the ranking of acceptance in 1999 to position 7 in 2008, making it a country where trends have changed very rapidly.

This degree of support is closely related to advances in patients’ rights, the ongoing debate about individual freedom and autonomy and informed decisions about ending a life in certain circumstances. All this has taken place in a context where: 1) the ideal model of dying or canon of death in Spain is linked to a fast and painless death; 2) the technological revolution of the 20th century and the fact that a longer life does not necessarily imply a greater quality of life; and 3) personal cases that have been made public in the media and which have become major factors in the debate.

Discussion

Euthanasia has now become part of the political agenda, due to a great extent to the support given to the issue by public opinion, which includes members of the medical profession. The survey results provide further leverage that has obliged political parties to change their postures on the issue and to acknowledge that there is a consensus and that the time is right to propose a draft bill in the Spanish Congress.

At the same time, euthanasia continues to be a complex issue with polarised opinions, in which the coalition of stakeholders opposing regulation argue that biased “market research” disguised as democracy asks leading questions. This article shows that there is a growing degree of acceptance with data from a range of surveys taken in recent decades, and that this change in values has also been influenced by social, legal, bioethical and clinical elements that have enabled such a process to take place.

However, the surveys make no mention of the scenarios or procedures that might be enacted by any future law, which is a limitation of this study and a challenge for the decision makers, and which shall be the central focus of any debates on the matter.