Background
The present epoch has witnessed enormous betterment in alleviant attention which has intensified the argument of mercy killing among doctors, medical organisations, scientists, ethicians, legal experts and politicians. Public support for a system for mercy killing is high in western states. Though being Islamic democracy, pattern of mercy killing is non legalized here but it is the necessity of clip that the physicians of Pakistan must hold significant cognition sing this controversial issue and their position should be evaluated.
Aim:
The intent of this survey is to cognize the perceptual experience and the ethical concerns of physicians towards euthanasia in Pakistan and to propose/ develop recommendations for the National ethical guidelines of Euthanasia in Pakistan.
Methods:
It was an institutional based cross-sectional survey conducted from August 2008 to February 2009 in three major authorities infirmaries viz. Civil Hospital Karachi, Jinnah Postgraduate Medical Centre & A ; Lyari General Hospital of Karachi, Pakistan. Sampling frame included physicians working at the station of Professors, Associate Professors, Assistant Professors and Post-Graduate Students. House Officers were excluded from the survey on the footing of less experience in clinical pattern. Ethical reappraisal board blessing was taken prior to the beginning of the survey and merely those physicians who consented to take part were interviewed through a pre tested interviewer administered questionnaire.
To transport out informations entry and statistical analysis SPSS-12.0 was used.
Consequence:
Out of 248 physicians approached 153 ( 61.69 % ) consented to take part in the survey. Among the respondents who consented to take part the male to female ratio was 90:63, the average age was 30.90 with A± 6.580. It was rather interesting that merely 89 ( 58.16 % ) doctors knew about mercy killing therefore the staying consequences were out of those 89 respondents:
Sing different types of mercy killing used 69.66 % of the respondents were cognizant of voluntary mercy killing. Law of Pakistan about the mercy killing was known to 53.93 % . About the ethical considerations the consequences were rather amazing that about one 4th ( 25.84 % ) of the physicians believed that it is ethical to pattern mercy killing on a patient. Active mercy killing was thought to be unethical by most of the physicians ( 52.80 % ) . Twenty two per centum of the physicians in their pattern were encountered in a state of affairs where their sentiment was taken about the pattern of mercy killing on a patient and it was rather astonishing to observe that 60 % of them have advised it. Sing legalisation of mercy killing in Pakistan 53.93 % of the practicing physicians were against it. On inquiry sing the demand of farther research on mercy killing in Pakistan 75.28 % were in favour of it.
Decision:
It is rather amazing that more than a 3rd of the physicians in Pakistan did non even know about this of import and controversial issue worldwide. Merely one 4th of those who knew about mercy killing believed that it is ethical and more than a half were against its legalisation in Pakistan. However, since mercy killing or doctor assisted self-destruction is an of import issue in the attention of terminally sick patients, our wellness professionals are in favour of farther research of this controversial, yet problematic issue for the benefit of our society.
Background
In a huge bulk of patients, decease is frequently preceded by agonies, hurt and wretchedness [ 1, 2 ] . However, the present epoch has witnessed enormous betterment in alleviative attention along with medical installations. This has intensified the argument of mercy killing among doctors, medical organisations, scientists, ethicians, legal experts and politicians which is defined as the deliberate violent death of a dependent human being in his/her supposed benefit, it can be through some action e.g. : by giving deadly injection or by skip i.e. keep backing indispensable medical steps from a individual enduring from an incurable disease. A important facet of the treatment pertains to the indicants [ 3, 4, 5 ] and the methods by which it can be conducted [ 6, 7 ] .
Those recommending the pattern claim that it is now a portion and package of alleviative attention [ 8 ] this is in line of the fact that desperation attach toing most patients with terminal unwellness is due to absence of hope to return towards a meaningful life, and therapy is aimed to cut down the hurting instead than Restoration of map [ 9 ] clemency is attributed in about all faiths and moral values.
The oppositions believe that legalisation of pattern would dishonor the physician ‘s profession, whose primary purpose is to mend the disease [ 10 ] others insist that the patient will be gratified to see that they are non a load [ 11 ] . Another potentially unsafe deduction would be abuse liability of the pattern which can be diminished by rigorous regulative Torahs [ 12 ] . The profound result can besides be due to moral impairment of society is euthanasia is considered as a cheaper option of attention [ 13 ] .
Public support for a system for mercy killing is high in western states, in studies, every bit many as 63 % of Norwegians, 79 % of Swedes, and 68 % of Germans thought that if a patient has an incurable disease and does n’t desire to travel on life, he or she should be allowed to have a deadly injection [ 14 ] .
Though being Islamic democracy, pattern of mercy killing is non legalized here but it is the necessity of clip that the physicians of Pakistan must hold significant cognition sing this controversial issue which is deriving importance twenty-four hours by twenty-four hours. It is besides necessary to cognize the attitude and ethical considerations of Pakistani physicians towards the pattern of mercy killing.
Method:
Setting:
Study design & A ; Sampling Frame:
It was a cross-sectional survey conducted from August 2008 to February 2009 in three major authorities infirmaries viz. Civil Hospital Karachi ( CHK ) , Jinnah Postgraduate Medical Centre ( JPMC ) & A ; Lyari General Hospital ( LGH ) of Karachi, Pakistan. The sampling frame included physicians working at the station of Professors, Associate Professors, Assistant Professors and Post-Graduate Students. House Officers were excluded from the survey on the footing of less experience in clinical pattern.
Materials & A ; Methods:
Interviewer administered questionnaire was prepared to measure the cognition, attitudes & A ; ethical considerations of physicians towards euthanasia. It consists of two parts one to roll up the demographic inside informations and the other part contains 22 closed handed inquiries out of which 10 were on cognition, 5 were on attitudes and staying 6 were to measure ethical considerations. Question figure 1 & A ; 2 were on the consciousness of the term mercy killing & A ; mercy killing severally, the questionnaire was designed in such a manner that if the respondent was non cognizant of both of these footings the interviewer was advised to complete the interview.
Initially a pilot survey by questioning 8 physicians was done to rectify the lacks in the questionnaire and methodological analysis of research after which trained interviewers used an interviewer administered questionnaire for single interview. Before questioning consent was taken from physicians and merely those were included who consented to take part. Non-probability purposive sampling technique was applied in the survey.
To transport out informations entry and statistical analysis SPSS-12.0 was used.
Consequence:
Out of 248 physicians approached 153 ( 61.69 % ) consented to take part in the survey, deficit of clip was the chief ground given by physicians for non-participation in the survey.
Among the respondents who consented to take part the male to female ratio was 90:63, the average age was 30.90 with A± 6.580. Majority of the participants were Muslims ( 83.66 % ) and staying ( 16.33 % ) were hindus.
Cognition:
On inquiry sing the consciousness of term euthanasia the response was rather interesting as merely 45.8 % of physicians were cognizant of it while 53.6 % were cognizant of the term clemency killing. Out of 153 respondents 89 ( 58.16 % ) were cognizant of at least one term and were proceeded to the staying inquiries therefore the undermentioned consequences were out of those 89 respondents:
Sing the different types of mercy killing used 69.66 % of the respondents were cognizant of voluntary mercy killing and doctor assisted suicide while non-voluntary mercy killing, nonvoluntary mercy killing, active mercy killing and inactive mercy killing were known by 51.68 % , 53.93 % , 37.07 % and 41.57 % physicians severally. Law of Pakistan about the mercy killing was known to 53.93 % . About the spiritual positions of practising euthanasia 62.92 % of the respondents answered that their faith does non give permission of it while 7.86 % thought that their faith gives permission of it where as staying 29.21 % did non cognize about their faith positions.
Ethical Considerations:
About the ethical considerations the consequences were rather amazing that about one 4th ( 25.84 % ) of the physicians believed that it is ethical to pattern mercy killing on a patient. Among different types of mercy killing, inactive mercy killing was thought to be justified ethically by 32.58 % of the physicians while 35.95 % of the physicians do n’t cognize about its ethical consideration and merely 31.46 % denied it ethically. Active mercy killing was thought to be unethical by most of the physicians ( 52.80 % ) while merely 8.98 % of the physicians believed that it is ethical and staying 32.20 % do n’t cognize about its ethical consideration. Similarly voluntary and nonvoluntary mercy killing was besides refused ethically by 48.31 % and 47.19 % of the respondents while merely 19 % and 7.86 % supported it severally.
Attitude:
To measure the attitude of the respondents sing mercy killing they were asked that have they of all time encountered in a state of affairs during their professional calling where their sentiment was sought for mercy killing and the response was 22.47 % out of which 95 % were asked 1-5 times in their calling. It was rather astonishing to observe that the physicians who were asked for sentiment about mercy killing out of them 60 % have advised it while staying 40 % refused.
About the rights of the patient being informed about the mercy killing before practicing, bulk of the respondents ( 68.53 % ) have agreed to inform. Similarly 58.42 % of the physicians agreed to inform and explicate the patient ‘s immediate family/friends before practising mercy killing. Sing legalisation of mercy killing in Pakistan 53.93 % of the practicing physicians were against it. On inquiry sing the demand of farther research on mercy killing in Pakistan 75.28 % of the physicians agreed on it.
Comparison of Knowledge, Attitude and Ethical considerations sing mercy killing between Muslims and Non-Muslims, four major fortes i.e. Medicine, Surgery, Paediatrics and Gynaecology / Obstetrics and on the degree of instruction i.e. alumnuss and station alumnuss are given in Table 1, 2 and 3 severally.
Discussion:
Euthanasia being one of the most controversial and perplexing issues of modern medical specialty was taken up by and big to happen the acquaintance, attack and ethical considerations of the physicians towards mercy killing in learning infirmaries of Karachi, but besides to happen out their stance where they stand on this controversial issue. Our research revealed still in this epoch of modern medical specialty merely a small greater than half were cognizant of the term mercy killing and/or clemency killing. Further from these still some of them were non cognizant of nomenclatures related to it and the distressing portion was a good smattering were incognizant of its ethical issues, moral and spiritual deductions, stance of Pakistani jurisprudence on it and more amazingly about half were in favour of legalising it. But the thing we should give them a recognition for is that most of them realized more research is needed on this issue, so that our doctors will go more cognizant of it and if stumble upon such instances they are able to do a more rationale determination.
As a consequence of current statute laws in Netherlands and Belgium sing mercy killing and its application, in several European states the subject sing end-of-life medical specialty has turned highly of import. In order to measure the attitude of its physician members sing different end-of-life medical patterns, such as mercy killing, physician-assisted self-destruction ( PAS ) , and terminal sedation the Ethics Working Group of the German Association for Palliative Medicine ( DGP ) carried out a survey. It was found out that 90 % were against legalisation of mercy killing and likewise 75 % against physician aided self-destruction, whereas merely 9.6 % were in favour of its legalisation. Moral values, know-how of different attacks, acquaintance with ethical guidelines and of countrywide legal lineation, specialised pattern in alleviative attention, were the cardinal judgmental factors derived on from the replies [ 15 ] . Comparing it with our survey merely 53.93 % were non in favour of legalising mercy killing and a similar per centum were familiar with jurisprudence of Pakistan sing mercy killing, and more than half were of the position that their faith does n’t gives permission of such an act.
In Brazil a survey revealed 63.3 % of the doctors answered the definition of mercy killing right, whereas 93.3 % knew active and inactive mercy killing were a different entity and harmonizing to the sentiment of 66.6 % of the doctors that at least one sort of mercy killing may be applied practically [ 16 ] . Whereas in comparing our survey revealed that merely 45.8 % of our physicians were cognizant of the term mercy killing, 37.07 % and 41.57 % of the physicians were cognizant of the footings active mercy killing and inactive mercy killing severally, but merely about half ( 53.93 % ) were against its legalisation.
If we evaluate a survey on doctors on end-of-life determination ( ELD ) in a state like Belgium where mercy killing is legalized. Of the ELD instances 71.3 % were non conferred with the patient and merely 8.1 % were patient ‘s direct petition. The survey besides revealed that during the shutting phases of a patient ‘s life the spiritual vows controlled the actions of doctor. During determination doing patient ‘s and her household ‘s rights to lend in the class of action were barely respected [ 17 ] . Our survey revealed that merely a smattering of physicians were asked for sentiment on mercy killing but out of them bulk recommended it. However most of them were of the position that they would inform non merely the patient but besides their immediate family/friends before practising mercy killing.
Surveies sing mercy killing and PAS have been widely carried out on US doctors in the old decennary. PAS or mercy killing is non regarded ethical by bulk of the US doctors harmonizing to many reliable surveies. There is an incoherent form amongst the US physicians refering its legalisation. For illustration, a survey found out that most of the Michigan physicians 56.6 % were in favour of PAS when they were compelled to choose between a complete prohibition or its legalisation, nevertheless merely 38.9 % favored leting PAS if they were non obligated to choose. If either PAS or mercy killing were legalized merely a smattering would be eager to move upon it. Other dealingss such as spiritual or Catholic US doctors were less in favour of mercy killing or PAS. Overall non-oncologist obtained fewer petitions for mercy killing and PAS than oncologists. PAS petitions obtained by non oncologists were less than 20 % nevertheless amongst the oncologists these Numberss would mount to every bit high as 50 % [ 18 ] . A different survey on US oncologists showed if they were presented with a instance of incurably ailment with grim hurting 22.5 % were in favour of PAS whereas mercy killing was favored by merely 6.5 % . Requests for PAS or euthanasia while their calling was obtained by 62.9 % , greater portion were non performed. Besides deficiency of spiritualty was straight related whereas better pattern in end-of-life medical specialty was indirectly related with the increased public presentation of mercy killing or Pas by the oncologists. But most significantly extended diminution in favorism of mercy killing and PAS was seen amongst the US oncologists, turning cognition on how to ease a “ good decease, ” may be a mark of this lessening doing mercy killings and PAS no longer attractive [ 19 ] . Keeping side by side a survey in the province of Oregon where “ Death with Dignity ” act has been implemented hence legalising PAS, had some interesting consequences to portion. A deadly prescription under Death with Dignity act for the patient was unethical in position of 30 % of the doctors whereas 59 % considered it to be ethical. Majority ( 51 % ) were in favour of the act [ 20 ] . Now in relation with our survey 25.84 % considered euthanasia ethical whereas inactive and active mercy killing was ethically acceptable by 32.58 % and 8.98 % severally. 22.47 % of the physicians were asked about their advice on euthanasia bulk about 1-5 times in their calling and largely advised it every bit good. Now there is difference of sentiment among physicians but spiritual point of position remains the same i.e. against mercy killing. This includes chiefly the Judaic Perspectives ( 1 ) and Sunni e-fatwas ( 2 ) on assisted decease. A survey on the function of faith in this context was carried in USA and it said that faith holds a important function because mode of decease rises many inquiries sing life and decease issues ( 3 ) . Christiaan Barnard, bosom graft sawbones, in his book, Good Life Good Death, supported mercy killing, by indirect agencies, but non by direct agencies. He argued that the chief aim of a physician is to decrease enduring non merely lengthen life-time ( 4 ) .
A survey was carried out in six states Belgium, Denmark, Netherlands, Sweden, Switzerland and Australia, a good figure of physicians were questioned, this survey showed that faith has a really of import function and spiritual physicians recommend/ carry out patient assisted deceasing less frequently ( 5 ) . A survey affecting Flemish alleviant attention physicians indicates that spiritual people are against this phenomenon where as non-religious people have a broadminded attitude ( 6 ) .similar survey was carried in Mexico and it besides demonstrate that faith was important in doing determinations sing PAD ( 7 ) .German and Israeli physicians positions were inquired in a survey and cultural laterality was notable, as in German society patient in crowned head but in Israeli civilisation a physician has to promote patient to populate ( 8 ) .in another survey 443 Judaic physicians were questioned and the result was, faith has a direct relation with recommendation of doctor assisted deceasing. ( 9 ) .Although buddist have yet no clear base on mercy killing but in position of the fact that they have strong values refering decease and life after decease it is non normally cherished ( 10 ) .
Now in relation to our survey it was surprising merely a small above half the physicians opposed legalisation of euthanasia.this is notwithstanding that Pakistan being a Muslim sate has high spiritual and moral values.
In decision I would wish to state since times immemorial adult male has struggled for endurance, since a kid is born, from turning up till his decease he faces assorted challenges, but its human nature he ne’er gives up supports on fighting till the last breath in his organic structure, deceasing is non the option for him. And a clip comes he overcomes those obstructions, so why is the argument for euthanasia different why are n’t patients encouraged to populate, at one topographic point modern medical specialty is seeking ways to protracting life and other manus we see the same entity destructing one. After making such progresss in medicine one should seek ways to conflict this evil out of society. And there are illustrations of it as antecedently described in the survey in the US [ 19 ] . Therefore the argument is similar for our state every bit good, our research might give us a hint that why about half the Pakistani physicians are in favour of legalising mercy killing, because Pakistan being a 3rd universe state the resources are limited and due to extended load of patients the physicians might be of the position that legalising mercy killing might ease of the load of the terminally sick patients, but I am of the position that holding a burden of patients is a blessing instead than a load for the society, because for a minute if we suppose that we legalize mercy killings in a developing state like ours the disadvantages for physicians are that specially for private infirmaries the gross might diminish as these patients are a beginning of uninterrupted income. But the major disadvantages will be for the patients as they are terminally sick most of them hopeless and depressed superimposed with poorness in our apparatus and in some instances might be peer force per unit area would wish to see the easy manner out. However this may besides be due to the fact that most of our doctors are non specially trained in alleviative medical specialty and besides due to miss of hospice installations. Even though more than half of them are cognizant of the fact that non merely their spiritual and moral values oppose it but besides the jurisprudence in Pakistan still they prefer to legalise it. But the distressing portion in our community starts with the fact which our research sheds light upon that a good sum of our physicians are still incognizant of the term mercy killing and nomenclatures associating to it every bit good as its ethical considerations and the stance of Islam and Pakistani jurisprudence on this affair. Therefore one needs to take steps to include such subjects in our system of medical instruction, increase the consciousness of non lone physicians but besides medical pupils and the common people on this topic, allotment of budgets for development of hospice installations and specialised centres and sections for learning and preparation of physicians in the field of alleviative medicine.. In add-on to this I suggest that mercy killing demands to be debated on higher degrees so that our society may be able to harvest maximal benefits. Parameters should be set in order to conserve resources, prevent inveterate sick and terminally staged patients from farther agonies but on the same clip steps should be taken so as to hedge disgusting drama and mala fide Acts of the Apostless. Embroider if exercised should be by competent physicians. Doctors approving/regulating PAD should hold the sense of duty that a life one time lost can ne’er be compensated, and that their ain point of view should ne’er predominate over patient ‘s liberty.
Table-1: Comparison of Knowledge, Attitude and Ethical Considerations sing mercy killing between Muslims & A ; Non- Muslims Doctors.
QUESTIONS MUSLIMS NON MUSLIMS P-VALUE
( % ) ( % )
Awareness of the term Euthanasia 46.1 44 0.513
Awareness of the term clemency killing 53.9 52 0.516
Voluntary euthanasia 68 78.5 0.327
Non-Voluntary mercy killing 50.6 57.1 0.440
Involuntary euthanasia 53.3 57.1 0.514
Physician assisted suicide 69.3 71.4 0.575
Active Euthanasia 34.6 50 0.213
Passive Euthanasia 38.6 57.1 0.161
Ethical to pattern mercy killing on a patient 25.3 28.6 0.339
Ever encountered any state of affairs in your 22.6 21.4 0.613
professional life in which your sentiment is
sought for mercy killing of any patient or any
relative/friend
Advised in favor of Euthanasia 58.8 66.6 0.656
Right of patient to be informed before 68 69.2 0.340
practising mercy killing
Right of patient ‘s immediate family/ friends 61.3 42.8 0.404
of being informed before practising mercy killing
Law of Pakistan gives permission of practising 1.3 21.4 0.002
mercy killing
Should euthanasia be legalized in Pakistan 34.6 50 0.541
Passive mercy killing justified ethically 33.3 28.5 0.238
Active mercy killing justified ethically 8.0 14.2 0.360
Voluntary mercy killing justified ethically 14.6 42.8 0.024
Involuntary mercy killing justified ethically 8.0 7.1 0.973
Your faith gives permission of practising 5.3 21.4 0.075
mercy killing
Alternative of mercy killing 22.6 7.1 0.157
Further research is needed on mercy killing 73.3 85.7 0.383
in Pakistan
Table: 2 Comparison of Knowledge, Attitude and Ethical Considerations sing mercy killing between physicians from different fortes.
QUESTIONS MEDICINE SURGERY PAEDIATRICS GYNAECOLOGY OTHERS P-VALUE
( % ) ( % ) ( % ) ( % ) ( % )
Awareness of the term 47.8 48 37.5 39.1 60 0.724 Euthanasia
Awareness of the term 59.1 60 41.6 43.4 50 0.453
clemency killing
Voluntary euthanasia 71.4 68.7 81.8 50 83.3 0.416
Non-Voluntary mercy killing 57.1 43.7 54.5 35.7 66.6 0.573
Involuntary euthanasia 59.5 62.5 72.7 21.4 33.3 0.049
Physician assisted suicide 73.8 68.7 72.7 50 83.3 0.480
Active Euthanasia 30.9 31.2 63.6 42.8 33.3 0.346
Passive Euthanasia 38.1 50 54.5 28.5 50 0.629
Ethical to pattern euthanasia 23.8 31.2 36.3 21.4 16.6 0.877
on a patient
Ever encountered any state of affairs 19.0 12.5 45.4 14.2 50 0.104
in your professional life in
which your sentiment is sought for
mercy killing of any patient or any
relative/friend
Advised in favor of Euthanasia 50 100 60 50 66.6 0.771
Right of patient to be informed 66.6 75 90.9 46.1 66.6 0.131
Before practising mercy killing
Right of patient ‘s immediate 52.3 75 54.5 50 83.3 0.284
family/ friends of being
informed before practising
mercy killing
Law of Pakistan gives 2.3 0.0 0.0 7.1 33.3 0.032
permission of practising
mercy killing
Should euthanasia be legalized 38.0 37.5 36.3 21.4 66.6 0.660
in Pakistan
Passive mercy killing justified 28.5 37.5 36.3 21.4 66.6 0.424
Ethically
Active mercy killing justified 9.5 6.2 0.0 14.2 16.6 0.853
Ethically
Voluntary mercy killing justified 26.1 12.5 0.0 14.2 33.3 0.201
ethically
Involuntary mercy killing justified 9.5 6.2 18.1 0.0 0.0 0.093
Ethically
Your faith gives permission 7.1 6.2 0.0 20 33.3 0.109
of practising mercy killing
Alternative of mercy killing
Further research is needed on 73.8 68.7 81.8 78.5 83.3 0.904
Euthanasia in Pakistan
Table: 3 Comparison of Knowledge, Attitude and Ethical Considerations sing mercy killing between Graduates and graduate student physicians.
QUESTIONS GRADUATE POSTGRADUATE P-VALUE
( % ) ( % )
Awareness of the term Euthanasia 47.9 42.1 0.299
Awareness of the term clemency killing 52 56.1 0.375
Voluntary euthanasia 64.2 78.7 0.114
Non-Voluntary mercy killing 39.2 72.7 0.002
Involuntary euthanasia 46.4 66.6 0.051
Physician assisted suicide 62.5 81.8 0.045
Active Euthanasia 33.9 42.4 0.282
Passive Euthanasia 42.8 39.3 0.462
Ethical to pattern mercy killing on a patient 37.5 6 0.004
Ever encountered any state of affairs in your 26.7 15.1 0.157
professional life in which your sentiment is
sought for mercy killing of any patient or any
relative/friend
Advised in favor of Euthanasia 73.3 20 0.058
Right of patient to be informed before 67.2 69.6 0.581
practising mercy killing
Right of patient ‘s immediate family/ friends 60.7 54.4 0.697
of being informed before practising mercy killing
Law of Pakistan gives permission of practising 3.5 6 0.840
mercy killing
Should euthanasia be legalized in Pakistan 44.6 24.2 0.130
Passive mercy killing justified ethically 32.1 33.3 0.983
Active mercy killing justified ethically 8.9 9 0.759
Voluntary mercy killing justified ethically 19.6 18.1 0.897
Involuntary mercy killing justified ethically 8.9 6 0.887
Your faith gives permission of practising 7.1 9.1 0.918
mercy killing
Alternative of mercy killing 14.2 30.3 0.103
Further research is needed on mercy killing 78.5 69.6 0.462
in Pakistan