A Scale To Assess Attitudes Toward Euthanasia: OMEGA - Journal of Death and Dying February 2005
A Scale To Assess Attitudes Toward Euthanasia: OMEGA - Journal of Death and Dying February 2005
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JASON WASSERMAN, MA
JEFFREY MICHAEL CLAIR, PH.D.
ABSTRACT
The topic of euthanasia has been a matter of public debate for several decades.
Although empirical research should inform policy, scale measurement is
lacking. After analyzing shortcomings of previous work, we offer a systemat-
ically designed scale to measure attitudes toward euthanasia. We attempt to
encompass previously unspecified dimensions of the phenomenon that
are central to the euthanasia debate. The results of our pretest show that
our attitude towards euthanasia (ATE) scale is both reliable and valid. We
delineate active and passive euthanasia, no chance for recovery and severe
pain, and patient’s autonomy and doctor’s authority. We argue that isolating
these factors provides a more robust scale capable of better analyzing sample
variance. Internal consistency is established with Cronbach’s alpha = .871.
Construct external consistency is established by correlating the scale with
other predictors such as race and spirituality.
229
Ó 2005, Baywood Publishing Co., Inc.
230 / WASSERMAN, CLAIR AND RITCHEY
results across various studies due to the use of a variety of terms (e.g., euthanasia,
physician assisted suicide, etc.; Domino et al., 1996). In their scale, they chose
to use “physician assisted suicide.” Physician assisted suicide represents only
one type of euthanasia. The situation implied by the term is one where a doctor
actively assists in the death of the patient, most typically by prescribing or
administering a lethal drug. But while this is certainly a more controversial form
of euthanasia, other variations of euthanasia also are debated. Passive euthanasia
typically refers to the removal of life-sustaining technology. While the American
Medical Association deems this an ethical practice and lawmakers in the United
States have tended to concur, passive euthanasia still is contested, particularly
by religious groups. Recent events surrounding the removal of life-support in
the Schiavo case highlight that even passive versions of euthanasia are far from
settled in the public eye. Thus, a scale which encompasses broad parameters of
euthanasia would be a step forward in assessing attitudes towards the practice
among the public. Moreover, terms such as euthanasia and assisted suicide have
been manipulated in political rhetoric (Domino, 2003). While these terms carry
a variety of connotations among various public stakeholders, it is possible to
develop a scale that avoids using them.
The scale produced by Domino et al. (1996) is methodologically rigorous. It
focuses, however, on physician assisted suicide and does not encompass certain
salient features of the broader euthanasia debate. Physician assisted suicide is
defined by action on the part of the physician, but passive versions of euthanasia
also are relevant. Furthermore, the items in the Domino et al. scale make no
reference to the suffering of a patient, only to situations of no recovery. Circum-
stances of severe pain are particularly salient in the public debates and scholarly
discussions about the morality of terminating the life of a patient.
Finally, while Domino (2003) is sensitive to the active/passive distinction, the
use of physician assisted suicide as a paradigm convolutes this key distinction.
While respondents are instructed on the issue of action and inaction in Domino’s
(2003) study, the questions used to delineate active and passive versions of
physician assisted suicide do not adequately capture the distinction. In Domino
et al. (1996) the questions are: 1) It would be OK to prescribe a lethal dose of a
substance for a patient, if the patient requested it; and 2) It would be OK for
a physician to actually administer a lethal dose of a substance to a patient who
requested it. Contrary to what one would expect, Domino (2003) found a slightly
higher proportion agreeing with the “administer” item (51%) than the “prescribe”
item (43%). The absence of significantly lower levels of support for the relatively
passive construction is likely the product of nesting the item in a scale whose
paradigm (physician assisted suicide) is inherently active.
Typically, situations of passive euthanasia are those where a patient is dis-
connected from life-sustaining machines and allowed to die. Active euthanasia
most often concerns situations where patients are given enough medicine to
end their lives. Using “prescribe” to represent situations of non-action (passivity)
232 / WASSERMAN, CLAIR AND RITCHEY
THEORETICAL CONSIDERATIONS
We find three considerations necessary for the development of an appro-
priate scale of attitude toward euthanasia. First, the euthanasia debate has long
been characterized by a split between active and passive euthanasia (Rachels,
1975). We believe that public attitudes have, to some degree, been shaped by
the policies of the American Medical Association (AMA) and various state
laws. For example, the AMA finds passive euthanasia permissible, whereas
active euthanasia is not (American Medical Association, 2004). Therefore, a
scale that properly delineates between active and passive euthanasia may show
differences between the two despite the lack of variation found in previous
work (Adams et al., 1978).
There are a number of other possible standards on which someone could
approve or disapprove of euthanasia. The two most commonly recognized reasons
for the termination of the life of a patient are situations of severe pain and those
of no possible recovery. No possible recovery is referenced in the first NORC
question, but severe pain is not. Pain is at the center of current debate and should
presumably register among the public as an important consideration.
Finally, the issue of decision-making has been of paramount importance in
public and academic debates. Discourse on this issue is dichotomized on two
factors: patient’s autonomy and doctor’s authority. The first of the two NORC
questions addresses patient request, but doctor authority is not included. Although
question 2 ambiguously refers to a board of directors making a medical diagnosis,
this addresses concerns about the accuracy of the diagnosis rather than proper
jurisdiction over decision-making.
Item Dimensiona
the variety of possible combinations of these dimensions. Questions six and nine
are phrased negatively and require reverse coding. For these questions, the method
(active or passive) is not specified. The purpose of these questions is to provide
a check on response set bias, the situation where a respondent simply checks
responses without reading questions. If a respondent scores high on all other
items, they should score low on the reversed items. Questions 1 and 3 deal with
circumstances of severe pain where the patient has requested to die, but in
question 1 the method is passive whereas in question 3 it is active. Similarly,
questions 8 and 11 deal with circumstances of no recovery where the patient has
requested to die. For these questions, the method is active in 8 and passive in 11.
Questions 5 and 7 deal with circumstances where the doctor thinks the patient’s
pain is too severe, but make no reference to the patient’s desires. Here too,
question 5 is active and question 7 is passive. Similarly, questions 2 and 4 deal
with circumstances where a doctor believes there is no chance of recovery, but
make no reference to the patient’s desires. The method is active in question 2
and passive in question 4.
Our scale was pretested in several introductory sociology classes at a large,
urban university in the southeastern United States. Using the 10-item scale, we
conducted both a pretest (n = 47) and then tested the same scale in a larger sample
(n = 176) drawn from the same population but containing no respondents from the
first sample. For both, we used the Likert scale response categories of: 1) strongly
disagree, 2) disagree, 3) undecided, 4) agree, and 5) strongly agree. Demographic
characteristics for the pretest (n = 47) showed the sample was disproportionately
female and largely comprised of first- and second-year students. Roughly half of
the students were African American, while the other half were white. This sample
had a mean age of 20.7, slightly younger than the mean age for students at the
university. Demographics from the larger sample (n = 176) reflected a similar
composition, but with a mean age of 21.7, which is still slightly younger than the
mean age of students at the university. While particular sample characteristics
might affect the mean level of support for the sample relative to other populations,
we do not expect they will affect assessment of the internal reliability of the scale
or the correlation of attitudes toward euthanasia and other variables such as
spirituality measured within the samples. Admittedly, additional pretesting in
random samples would buttress these conclusions.
In a preliminary pretest (n = 47) the scale exhibited a Cronbach’s alpha of
.914 with item to scale correlations ranging from .578 to .821. Research into
survey methodology suggests that pretest samples range from 25 to 75 partici-
pants and those participants be slightly more educated than the general public
(Converse & Presser, 1986). Our population of university students fits this
standard. In a larger sample from the same population (n = 176) the scale had a
Cronbach’s alpha .871 with item-to-scale correlations ranging from .481 to.670.
No item could have been deleted to improve the internal reliability of the scale
in either trial.
ATTITUDES TOWARD EUTHANASIA SCALE / 235
questions make no reference to doctors at all, leaving room for those who support
euthanasia, but not as an act of medicine. But our scale may not adequately
capture this variation, particularly if those questions are listed in close proximity
with other items that deal with the medical arena. While our scale is certainly
not all-inclusive, we attempt to systematically incorporate the most prominent
features of discussion on euthanasia. In this regard, we feel that it is an incremental
improvement to previous work.
Further validation of the measure can be accomplished by its incorporation into
empirical research. Those studying euthanasia might correlate this measure with
variables such as spirituality/religiosity measures, gender, age, health status, or
any number of attitudinal variables. While some of these variables have been
tested in previous research, this new measure could potentially yield different
results. Finally, additional pretesting is needed for other populations to establish
its broader applications.
Studying attitudes toward euthanasia is increasingly relevant as the issue
becomes of more immediate concern for public policy. Previous research has
largely been limited by insufficiently operationalized variables. As a system-
atically designed measurement instrument that is both statistically reliable and
substantively valid, we hope our 10-item ATE scale rectifies some operational
problems. Future scale development on attitudes toward euthanasia might benefit
from comparing our ATE scale to other measures, particularly the scale by
Domino et al. (1996). Empirical research might benefit from using the ATE scale
to identify correlates of support for euthanasia and thereby focus policy efforts.
ACKNOWLEDGMENTS
The authors would especially like to thank Kenneth J. Doka, Michael Flannery,
and two anonymous reviewers for their helpful comments on earlier versions
of this article.
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