January 5, 2006

Strong Public Support for Right to Die

More Americans Discussing - and Planning - End-of-Life Treatment

Summary of Findings

An overwhelming majority of the public supports laws that give patients the right to decide whether they want to be kept alive through medical treatment. And fully 70% say there are circumstances when patients should be allowed to die, while just 22% believe that doctors and nurses should always do everything possible to save a patient.

Public attitudes on these and many other end-of-life issues are unchanged from 1990, despite advances in lifesaving technology, the aging of the population, and the controversy associated with the Terri Schiavo case. Most Americans believe it should be up to individuals ­ not the government or medical professionals ­ to ultimately determine their end-of-life medical decisions.

The Pew Research Center’s survey, conducted Nov. 9-27, 2005 among 1,500 adults, finds that while overall attitudes are largely stable, people are increasingly thinking about ­ and planning for ­ their own medical treatment in the event of a terminal illness or incapacitating medical condition. Public awareness of living wills, already widespread in 1990, is now virtually universal, and the number saying they have a living will has more than doubled ­ from just 12% in 1990 to 29% today.

People also are much more willing to discuss sensitive end-of-life issues with their loved ones than they were a generation ago. Nearly seven-in-ten (69%) of those who are married say they have had a conversation with their husband or wife about their spouse’s wishes for end-of-life medical care; only about half reported doing so in 1990 (51%). Among those with living parents, 57% say they have spoken with their mother ­ and 48% with their father ­ about the parent’s requests for end-of-life treatment.

There is strong sentiment in favor of letting close family members decide whether to continue medical treatment for a terminally ill loved one who is unable to communicate their own wishes. Roughly three-quarters (74%) say a family member should be permitted to make this decision, which is little changed from 1990 (71%).

But Americans make a distinction between allowing a terminally ill person to die and taking action to end someone’s life. The public is deeply divided over legalizing physician-assisted suicide; 46% approve of laws permitting doctors to help patients to end their lives, while about as many are opposed (45%).

Though most Americans say it is sometimes morally acceptable for people with dire medical conditions to take their own lives, acceptance of this practice is highly dependent on circumstances. Six-in-ten feel that people have a moral right to end their lives if they suffer from great pain and have no chance for improvement. But this view changes under less extreme circumstances. For example, just 29% say a person has a moral right to end their life if he or she has become burdensome to family, with 62% saying someone in that situation does not have a moral right to take their life.

The survey finds that in many ways, public attitudes toward death and dying defy easy categorization. A majority believes that it is at least sometimes justifiable for a person to kill their spouse, again in extreme circumstances. Roughly six-in-ten (61%) feel that the ‘mercy killing’ of a spouse is always (6%) or sometimes (55%) justified, if the spouse “was suffering terrible pain from a terminal disease.” About half as many (29%) say such an act is never justified, although that represents a significant increase since 1990 (20%).

People’s views of end-of-life policies and practices do not perfectly mirror their own treatment preferences. While there has been an increase since 1990 in the percentage saying that people generally have a moral right to end their own life if they are facing an incurable illness and great pain (from 55% in 1990 to 60% now), there has also been an increase in the percentage who say they would personally want everything possible done to save their lives in many situations. About a third (34%) now say they would tell their doctor to do “everything possible” to save their life even if faced with a terminal illness and great pain; in 1990, fewer (28%) indicated they wanted everything done to save them in that case.

Other Findings

Right to Die Laws Favored

By more than eight-to-one (84%-10%), the public approves of laws that let terminally ill patients make decisions about whether to be kept alive through medical treatment. This represents a small but significant increase in support for right to die laws since 1990 (79%).

The increase in support has been more pronounced among those over the age of 50 (from 72% to 83% approval), white Catholics (from 80% to 91% approval), and among those who have given a great deal of thought to end-of-life issues (from 79% to 87% approval).

In instances where a terminally ill patient is unable to communicate, the public supports allowing the closest family member to decide whether to continue medical treatment; 74% agree with this approach, while only 15% say that relatives should not be allowed to make such decisions. Here, too, the public is united across political and demographic lines, with approximately three-quarters of Republicans (72%), Democrats (78%), and independents (74%) saying that family members should be able to make treatment decisions for sick relatives.

This strong support for allowing the removal of medical treatment and for allowing family members to make these decisions is reflected in public opinion on the Terri Schiavo controversy. Nearly three-quarters (72%) of the public say that Congress should have stayed out of the Schiavo case, while fewer than one-in-five (17%) say Congress, in its effort to ensure that Schiavo continued to receive medical treatment, did the right thing by requiring federal courts to hear the case. This is essentially unchanged from a July 2005 survey, which found only 20% saying Congress did the right thing.

Large majorities of all social and demographic groups, including Republicans and evangelical Protestants, say that Congress should have stayed out of the Schiavo case. Similarly, even among people who believe that doctors and nurses should make every effort to save a patient’s life, as well as those who think family members should not be able to decide whether to continue medical treatment if a patient’s wishes are not known, solid majorities say that Congress overstepped its bounds in the Schiavo case.

Assisted Suicide: Stark Religious Differences

Though Americans are broadly supportive of allowing patients and their families to decide whether medical treatment should be removed, the public is divided over laws that let doctors prescribe lethal doses of drugs to assist terminally ill patients end their lives. Nearly half (46%) approve of such laws, while about as many (45%) disapprove.

On this issue, Americans are divided along religious and political lines. By two-to-one (61%-30%) white evangelical Protestants oppose physician-assisted suicide laws; by nearly identical margins, white mainline Protestants and seculars approve of such laws. Catholics, on balance, oppose such laws (by 50%-40%).

Small majorities of Democrats (52%) and independents (52%) approve of allowing physician-assisted suicide. Most Republicans oppose these laws (by 55%-34%), and conservative Republicans oppose them by a margin of two-to-one (62%-29%).

Views on assisted suicide are also affected by the amount of thought given to end-of-life issues; 57% of those who have given a great deal of thought to these issues approve of legal assisted suicide, a view shared by only 35% of those who have given little or no thought to these matters.

Politics of End-of-Life Issues

The Democratic Party holds a modest advantage over the GOP as the party seen as better able to handle end-of-life issues. Roughly a third (34%) say the Democrats could do a better job in these matters, compared with 22% who favor the Republicans. Many see neither party as particularly good on the issue (16%) and about a quarter (26%) say they don’t know which party could do a better job.

Predictably, there is a strong partisan component to opinion on this issue, with Republicans favoring the GOP and Democrats favoring the Democratic Party. Independents who choose a side favor Democrats over Republicans (by 27% to 14%), and self-described moderates give the Democrats an even bigger advantage (40% for the Democrats, 16% for the Republicans).

Support for Allowing Patients to Die

The vast majority of Americans ­70% ­ say that there are sometimes circumstances in which a patient should be allowed to die; only 22% believe that doctors and nurses should always do everything possible to save the life of a patient. The number of people who think there are times when medical treatment should be ended has changed little since 1990, though the percentage believing that all possible efforts should be made has grown modestly during the period (from 15% in 1990).

Only among African Americans does a majority (51%) think doctors and nurses should always do everything possible to save a patient (40% disagree). In addition, 35% of those ages 18-29 say everything should be done to keep a patient alive; no more than one-in-five in any other age category agrees.

But Fewer Would Halt Treatment for Themselves

While most people support the general idea of stopping medical treatment in some circumstances, fewer would personally ask their doctor to cut off treatment if they faced a terminal or debilitating illness. If facing an incurable illness and suffering a great deal of physical pain, 53% would opt to stop medical treatment, while 34% would tell their doctor to do everything possible to save their life.

Fewer Americans (44%) say they would ask to end care if they had an illness that made them totally dependent on another person for all of their care, while 38% say they would want everything done to save them. There is an almost even division of opinion over ending treatment if a person had no hope of improvement and had difficulty functioning; 42% say they would ask that treatment be halted in that case, while 43% say they would tell their doctor to do everything possible. Since 1990, there has been a modest increase in the numbers who say they want everything done medically under these scenarios.

As with the general question of whether there are circumstances under which care should be stopped, African Americans and younger people are more likely than others to say they would personally want every effort made to save their life. By contrast, older respondents ­ those ages 50 and older ­ are significantly less likely than others to say they would want this type of care. White evangelicals and people who attend religious services at least once per week are also more apt than others to want every effort made on their behalf.

Views of a Parent’s Treatment Wishes

After being asked about their own wishes in response to these situations, respondents who had at least one living parent were asked what their parent would want done in the same circumstances. For the most part, the answers were similar to their own wishes: A small majority says their parent would opt to stop treatment if faced with a terminal illness and great pain, while reactions to the other two scenarios were more divided.

There are no significant differences in opinion about what a person’s mother or father would want done in these circumstances, with one notable exception. In a situation where an illness left the person totally dependent on a family member or another person for care, mothers were thought more apt to choose to have all possible efforts made to save her life (by 47% to 37%), while more respondents thought their fathers would tilt the other way if faced with such a choice (45% stop treatment, 41% do everything possible). For both mothers and fathers in this scenario, there was a significant increase since 1990 in the desire to have all possible efforts at treatment (up nine percentage points for fathers, up 14 points for mothers).

The wishes of respondents were usually, but not always, the same as the wishes of the parent they described. Among respondents who said they would opt to stop treatment if personally faced with a terminal illness and great pain, 71% also said their parent would likely make the same choice; 16% said their parent would probably opt for all available treatment.

More See Doctors as Responsive

A growing number of people believe that doctors and nurses are paying a lot of attention to instructions from patients about whether or not to keep them alive. Three-in-ten think that doctors are paying a lot of attention to patients’ end-of-life wishes, up from 20% in 1990. Overall, nearly seven-in-ten (68%) believe that doctors are paying a lot or some attention to the life-sustaining treatment requests of patients.

People who have played a role in determining the end-of-life treatment of a family member or loved one are more likely than others to believe that doctors and nurses pay close attention to patients’ wishes: 41% say they pay a lot of attention, and 34% say they pay at least some attention. Better educated people are also more likely to think doctors and nursers are paying close attention. Four-in-ten college graduates think doctors are paying a lot of attention to patients about whether or not they want treatment to keep them alive. This is up 16% since 1990 when 24% of college graduates felt this way, the largest increase among any demographic group.

A Moral Right to End One’s Own Life?

A solid majority of Americans (60%) believe a person has a moral right to end their life if they are suffering great pain and have no hope of improvement. Nearly as many (53%) believe a person has a moral right to end their life if suffering from an incurable disease. But far fewer see a right to suicide in other circumstances. Just a third say a person is morally justified in ending their life because living has become a burden. Slightly fewer (29%) favor a right to suicide when a person has become an extremely heavy burden on his or her family.

There are significant gender and racial differences over the moral right to suicide. Men are more likely than women to support a right to end one’s own life in a situation where there is no hope of improvement and great pain (66% for men, 54% for women). A solid majority of whites (62%) say a person has a moral right to end their life under such circumstances, compared with just 43% of African Americans.

Attitudes on this question are also strongly related to the respondent’s religious beliefs, as well as to party and ideology. Fewer than half of white evangelical Protestants (42%) believe that an individual suffering a great deal of pain with no hope of improvement has a moral right to end their life, compared with 73% of white mainline Protestants. Most Catholics (60%) support the moral right to suicide under these circumstances, as do an overwhelming majority of seculars (78%). Similarly wide disparities are seen in terms of church attendance, with frequent attenders less supportive of such a right.

There are wide differences between Republicans and Democrats on this question as well. Fully 83% of liberal Democrats think people have a moral right to end their own lives under these circumstances, while just 41% of conservative Republicans agree. Moderate and liberal Republicans (63%) and conservative and moderate Democrats (62%) fall in between.

Many See ‘Mercy Killing’ as Sometimes Justified

Beyond supporting an individual’s moral right to take their own life under certain circumstances, a majority of the public believes that helping a terminally ill spouse commit suicide ­ or even killing a spouse in this situation ­ can at least be sometimes justified. Despite the stark difference in the framing of these options, the public makes little distinction between justifying the killing of a spouse or helping a spouse to commit suicide.

Most Americans (55%) say that killing a spouse who is terminally ill and suffering from terrible pain is sometimes justified, but far fewer (6%) believe it is always justified. Only 29% say it is never justified, though that is up from 20% when the question was first asked in 1990. White evangelical Protestants are more likely than other religious groups to believe that killing a spouse is never justified, but even among this group only about half (47%) hold this view.

Despite the widespread sentiment that killing a spouse, or helping a spouse commit suicide, is sometimes justified, most people say they cannot imagine actually taking such actions themselves. Only about a third (36%) say they could imagine helping a loved one commit suicide, and even fewer (29%) say they could imagine killing a loved one.

Severely Handicapped Infants

Compared with 15 years ago, more people say that infants born with severe handicaps ­ no matter how severe ­ should receive as much medical treatment as possible. Overall, 60% feel this way, up from 52% in 1990. Just 28% believe that parents have the right to refuse treatment that might save the infant’s life, down from 32% in 1990. African Americans (84%) and younger respondents (70%) are more likely than others to favor providing as much treatment as possible.

Only about half of college graduates (48%) support making every effort medically to save a severely handicapped infant ­ though that is still larger than the percentage saying parents should have the right to refuse treatment (36%).

Support for providing the most treatment possible increases to 65% among people with only a high school diploma and to 73% among those who did not finish high school.

Catholic Priests Raise End-of-Life Issues

Overall, a third of regular churchgoers say that the clergy at their place of worship speak out on end-of-life issues. Roughly half of regular churchgoers say their clergy speak out on abortion (52%) and Iraq (50%). However, only about quarter (27%) say their clergy address the death penalty.

Catholic clergy stand out in their attention to end-of-life issues; half of Catholics who attend church at least monthly say that their clergy speak out on these matters, compared with 28% of evangelical Protestants and 16% of mainline Protestants.

More Catholics than Protestants also report hearing about abortion (71%) and the death penalty (35%) from their clergy.

How Generations Have Changed

This survey made it possible to track opinions and experiences within discrete generations over time ­ most of the key questions were also asked in 1990 and several in 1975 as well. Even though the individuals interviewed in the earlier years were themselves not re-interviewed, the newer polls include age groups that are 15 (or 30) years older and thus represent the same generations interviewed earlier.

One of the most striking changes between 1990 and 2005 is the growth in the
number of people who say they have a living will ­ up 17 points, from 12% in 1990 to 29% now. This growth occurred across generations; while the number saying they have living wills increased the most in the oldest cohort (up 38 points), it also grew by at least 20 points in each of the other three cohorts tracked over this time period.

Another notable change since 1975 is the growth in the number of people who see a moral right to suicide for those suffering great pain with no hope of improvement ­ up nearly 20 percentage points compared with three decades ago. However, most of this increase occurred between 1975 and 1990 (from 41% to 55%); since 1990, there has been a more modest rise in the number expressing this view (five points).

Over the past three decades, increased acceptance of a moral right to suicide has been greatest (from 29% to 46%) among the oldest cohort ­ those Americans who were between the ages of 48 and 62 in 1975, and are now ages 78 to 92. But younger generations also are more supportive of a moral right to end one’s life now compared with 1975.

While more people have come to accept a right to suicide over the past 30 years, the trend on so-called “mercy killing” has moved in the opposite direction. The number of people who believe that killing a terminally ill spouse is never justified, while still a minority, has risen nine percentage points since 1990. However, views on this issue have not changed among the middle cohort ­ those people who roughly correspond to the older end of the baby boomer generation (ages 48 to 62).

Abortion, Death Penalty and End-of-Life Issues

Relatively few Americans subscribe to what may be termed as a consistent “ethic of life” ­ opposing both abortion and the death penalty, and favoring the use of all medical means to keep terminally ill patients alive. Abortion opponents and death penalty opponents alike overwhelmingly believe that there are circumstances in which doctors and nurses should let a patient die.

However, abortion opponents stand out for their overwhelming rejection of both physician-assisted suicide and a moral right to end life under extreme circumstances. Two-thirds (66%) of those who oppose abortion in all cases, or make exceptions only for rape, incest, or to save the woman’s life disapprove of legalizing physician-assisted suicide. That compares with 23% of those who believe abortion should be generally available or available under stricter limits. The gap is between these groups is nearly as large in opinions about whether people who are suffering great pain with no hope of improvement have a moral right to end their life.

Attitudes toward the death penalty bear less relationship to views about end-of-life issues. For example, just over half (53%) of death penalty supporters approve of legalizing physician-assisted suicide, compared with 40% of death penalty opponents. Differences on other questions are of similar magnitude.

Death penalty opponents and abortion opponents share common ground ­ and differ with those on the opposite side of both issues ­ in their personal views of when to halt end-of-life medical treatment. Both groups are fairly evenly divided over whether all medical steps should be taken to save their lives, or whether treatment should be halted. By contrast, solid majorities of those who support the death penalty, and those who believe abortion should be generally available, say they would want medical treatment halted if they had a disease with great pain and no hope of improvement.

Recent Experience with a Loved One’s Illness

Over the past five years, more than four-in-ten (42%) Americans have had a relative or close friend suffer from a terminal illness or a coma. For a majority of these people ­ 23% of the general public ­ the issue of withholding life-sustaining treatment for their relative or loved one arose. Both of these findings are on par with the results from a 1991 Kaiser Foundation/Harvard School of Public Health/Boston Globe survey.

Overall, 10% of the public has actually helped in making decisions about how much medical treatment should be given to a terminally ill or comatose friend or relative. Women over age 50 are more likely to report having made these important medical decisions than are people in other age groups; 15% of all women in this age group have made such a medical decision recently. College graduates (14%) and those with higher incomes (15% for those with family income of more than $75,000) are more likely than others to have made such medical decisions.

End-of-Life Planning

Older Americans are much more likely than younger people to have given considerable thought to their end-of-life treatment options. This is reflected as well in the age differences among those who have a living will. While over half of senior citizens (54%) say they have a living will ­ compared with just 25% in 1990 ­ far fewer people in other age groups have living wills.

There also are striking differences in the ways in which people who have recently experienced the terminal illness of a friend or relative ­ and those who have not ­ approach end- of-life issues. Generally, those who have faced such situations are much more likely to have thought about their own end of life treatment and planned accordingly.

And those who have taken on a more significant role on behalf of a gravely ill relative or friend ­ by helping decide on their medical treatment ­ are even more active in thinking about and planning for their own end-of-life treatment.

Fully 64% of those who have recently helped make decisions about the medical treatment of a terminally ill or comatose friend or relative say they have given a great deal of thought to their own preferences in such circumstances. That compares with 45% of those who have had a relative or close friend recently suffer from a terminal illness or coma, but did not participate in treatment decisions; and just 28% of those who have had no recent experience with the serious illness of a close friend or relative.

Similarly, nearly half of those who helped determine medical treatment of a gravely ill loved one (46%) have their own end-of-life wishes written down. That compares with about a third (32%) of those who have experienced the illness of a close friend or relative but did not take part in the decision making, and just 24% among those with no recent experience with a loved one facing death.

Talking About Treatment

Americans for the most part turn to family members when discussing their wishes for end-of-life medical treatment. Nearly four-in-ten (37%) say they have discussed these matters with their spouse, up from 30% in 1990. Among married people, 70% have talked with their spouse about their plans for medical treatment in such circumstances.

While fewer young people than older Americans have discussed their end of life treatment wishes with anyone, they are more likely than other age groups to talk with a parent ­ 30% have done so, the highest percentage in any age group. People ages 65 and older, by contrast, are much more likely than younger people to have discussed their end of life treatment plans with one of their children (40%).

Since 1990, there has been a sizable drop in the percentage of Americans who say, in an open-ended format, that they have discussed their wishes for end-of-life medical treatment with ‘no one.’ Just 19% say that currently, while another 10% say they have given no thought to their end-of-life treatment. That compares with 44% in 1990 who either had talked with no one, or had given no thought to their care.

Talking With Spouses and Parents

Roughly equal numbers of married men (70%) and women (69%) say that they have had a conversation with their spouse about their wishes for end-of-life treatment. But women are much more likely than men to have had a conversation with their mother about her treatment.

Nearly two-thirds of women (65%) say they have had a conversation with their mother about her end-of-life treatment wishes. Only about half of men (48%) have talked with their mothers about such issues. Far fewer women have talked with their fathers about their end-of-life medical decisions. And men are no more likely to have discussed these issues with their fathers than with their mothers (45% father/48% mother).

Views on Aging

A plurality of Americans view the prospect of having more free time as what they look forward to most about getting old, while health concerns are seen as the biggest negative. Among the positives, about a third (35%) say that not having to work or having more free time is what they look forward to most, while 19% mention being able to spend time with their children, grandchildren and other family. Smaller percentages say having good health and being active (10%), travel (4%), and being able to experience changes in the world (2%) are what they most look forward to about old age.

The public expresses a broader array of worries about getting old. Health concerns ­ including worries about cancer and other diseases, mental health, and insurance worries ­ are mentioned most frequently (39%). Roughly one-in-five (19%) worry most about not having enough money in old age and 8% voice concern about losing their ability to care for themselves and being a burden on others. These worries have changed only modestly over the past 15 years.

Nearly a third of those ages 65 and older (31%) say ‘nothing’ when asked what worries them most about getting old. Only about one-in-ten or fewer in other age categories express no worries about getting old. Health concerns are mentioned most frequently by people ages 50-64. Compared with other age groups, those ages 18-29 express a relatively high level of concern over dying. One-in-ten of those under 30 say that their biggest worry about getting old is dying; far fewer people in older age categories, especially those ages 65 and older (2%) express that concern.

Making the Century Mark

Roughly four-in-ten Americans (43%) say they would like to live to be 100 years old, while 47% say they would not like to live to be that old. These findings have not changed much since 1990, when 39% said they would like to live to be 100.

However, there has been an increase since 1990 in the percentages of African Americans, young people and women who say they would like to live to 100. Nearly two-thirds of blacks (65%) say they would like to live to see the century mark, up from 53% in 1990. That compares with just 39% of whites who want to live to 100.

More than half of those under age 30 (55%) say they would like to live to be 100, up from 44% in 1990. By comparison, just 36% of those ages 50 and older want to live that long. More women also express a desire to live to 100 than did so 15 years ago (39% vs. 31%); still, more men than women continue to say they want to live to 100. In addition, people who register the highest levels of personal happiness are more likely than those who are less happy with their lives to want to live to 100 (51% vs. 40%).