DISCUSSION

There is an ongoing global debate about euthanasia and it resonates strongly in the cancer setting. Generally speaking, the key questions are: In which cases can euthanasia apply? How should euthanasia be carried out? Should informed consent be obtained from patients? The prevailing thought in present-day Turkey (Ozkara, 2001) would restrict euthanasia to the cessation of suffering and only in patients with fatal illnesses. Consistent with this approach, there have been other Turkish studies that reveal the following definition of euthanasia: “the practice of killing someone with a progressive, unbearable and fatal disease and with no hope for recovery despite today's medicine and done painlessly after a long and painful period at a patient's request with the assistance of a physician.” This definition was reported to be accepted by 85.3% of law students, 87% of health sciences students, and 88–96% of doctors (Ozkara et al., 2001, 2002, 2003, 2004a; 11–13). In our current study, we found that 43.8% of the oncologists supported this broader definition and added the following conditions: the patient must request euthanasia, the patient must be conscious in making this request, and the doctor must be present when it is performed.

Dickinson et al. (2002) in their study in England reported that 80% of geriatricians found active voluntary euthanasia (AVE) and PAS unethical. In a study in Washington and South Carolina, USA, it was demonstrated that 80%–84% of doctors were against euthanasia because it could be abused and 56%–67% believed it was in conflict with their religious beliefs (Dickinson et al., 1997–1998). In two recent studies, on terminally ill cancer patients, it was shown that 69% of the patients supported euthanasia and PAS (Suarez-Almazor et al., 2002; Maltsberger, 2003). Kaplan et al. (1999–2000) and Bachman et al. (1996) found in their research that the two main reasons for rejecting euthanasia were (1) its illegal status, and (2) its contrariness to religious beliefs. Studies in Turkey (Ozkara et al., 2002, 2003, 2004b) (11–13) have shown the following to be the most frequently given reasons for objecting to euthanasia: the possibility of its abuse (41.6%–72.8%) and conflict with ethical values (24.9% and %32.9) or with religious beliefs (18.7% and %21.7) (11–13). In our study, the most frequently cited reasons for objecting to euthanasia were its unethical nature and the possibility of abuse. Although the overwhelming majority of the population in Turkey is Muslim, religious rules are not seen as the leading cause of objection to euthanasia. In fact, secularism and education may have influenced people's attitudes toward euthanasia. This is clearly reflected in the questionnaire completed by doctors, who have a high level of education.

Passive euthanasia is understood to mean that treatment is withdrawn or not initiated (Ozkara, 2001) (4). In our study, almost half the doctors noted that they had advised their patients to withdraw from or not to start therapy at all, although the doctors suggested that they did not do so directly. Although the proportion of pediatric oncologists who directed patients not to start treatment was found to be lower than that of adult oncologists, the proportion of pediatric oncologists who had withdrawn treatment was found to be higher than that of other oncologists in our study. This somewhat contradictory finding may be explained by the fact that pediatric cancer patients are more likely to start treatment but suffer more pain than adult patients and they are more likely to be separated from social life during cancer therapy and experience more severe psychosocial problems.

Currently, euthanasia is not on the agenda of public debate in Turkey. Nevertheless, in a multicenter study (Ozkara et al., 2004b) (13), 33.7% of the oncologists and 19% of physicians had been requested to perform euthanasia and 41.5% of oncologists and 55.9% of 949 physicians believed that it had been practiced secretly. Moreover, 42 of 48 oncologists in this study, who believed euthanasia was not practiced in Turkey, admitted to directing patients toward passive euthanasia by suggesting that they not start treatment or request the withdrawal of their treatment. Thus, this subject must be brought into discussion in scientific circles in Turkey. The findings of our study as well as those of the other Turkish researchers referenced in this Brief Report clearly indicate the need for health staff to be provided with in-service training regarding euthanasia and patients rights.