Introduction

Demographic changes and increased life expectancy have led to an aging population and an increase in chronic conditions with multimorbidity. Many of these patients will require careful health care at the end of their lives to help them face advanced disease states and the end of life with dignity and as little suffering as possible (1, 2).

Within the framework of respect for patient autonomy and the patient’s right to make decisions, the use and regulation of euthanasia has been discussed in recent years. By definition, euthanasia is an active intervention that directly causes the death of a patient. In other words, it is a voluntary act that is deliberately aimed at ending the life of a sick person both by action and omission (3).

Etymologically, euthanasia means “good death” (4). The Royal Spanish Academy defines it as “deliberate intervention to end the life of a patient with no prospect of cure” (5). Other sources define it as the “voluntary and painless termination of a person’s life, who suffers from a terminal illness that causes great physical suffering, becoming – from their point of view – a better alternative than life” (6). The World Health Organization, for its part, defines euthanasia as “the action of a physician who deliberately causes the death of a patient” (7).

Ruling C-239 of 1997 of the Constitutional Court exhorted the Congress of the Republic to issue, as soon as possible, and in accordance with constitutional principles and considerations of humanity, the regulation on the subject of dignified death, and thus laid the foundations for work to begin on said regulation (8). Euthanasia was decriminalized in Colombia in 2014, through Ruling T-970, which established the right to a dignified death, that is, the patient’s autonomy in the decision at the end of life. The Ministry of Health and Social Protection was ordered to issue a guideline that allows the creation of an Interdisciplinary Scientific Committee in the institutions providing health services to fulfill the functions indicated in the Ruling and the creation of a medical protocol regarding the procedures to guarantee the right to die with dignity (9). Finally, the Ministry of Health and Social Protection issued Resolution 1216 of 2015, which complies with Ruling T-970, in order to regulate the guidelines set forth in said Ruling (10).

The possibility of accessing euthanasia broadens the right to make decisions within the framework of a dignified death, it respects the autonomy of patients over the process of their death, and limits the participation of third parties, and this is one of the dimensions of the fundamental right to die with dignity (11). However, there are a series of dilemmas and a general lack of knowledge on the part of the public about euthanasia, which has made it easier for the country’s population to form different concepts and positions on the subject, its application and current legislation.

The objective of this study was to explore the knowledge that university students have about euthanasia and their positions on the subject in hypothetical cases at the Pontificia Universidad Javeriana de Bogotá (PUJ) and at the Universidad del Cauca in Popayán (UC).

Materials and methods

Observational cross-sectional study conducted through a voluntary and anonymous online survey. At PUJ, the population were students over 16 years of age, belonging to the faculties of Medicine, Legal Sciences, Engineering and Architecture-Design. At UC, the students were from any of the nine faculties and enrolled in undergraduate and graduate programs.

The survey was designed using Google Forms (see appendix at the end of the article) based on two studies with similar characteristics and was adapted to the objectives of this study (2,12). It consisted of an initial consent for participation, and was divided into three sections: general respondent data, knowledge about euthanasia, and hypothetical questions about specific situations regarding whether participants would agree to a request for euthanasia or not (after providing the correct definition). The three hypothetical cases used (each with a Yes, No and Does not know answer option) were: (i) If you were terminally ill and the doctors assured you that there was nothing that could be done, you were in a lot of pain and were no longer able to perform basic activities such as eating or going to the bathroom on your own, would you agree to euthanasia?; (ii) if your mother, at the age of 80, had an incurable terminal illness and were suffering, and decided to request euthanasia from her doctor, would you agree with and support her decision? If an 8-year-old child had a terminal illness that prevented him from doing normal things for his age, such as playing or running, was in a lot of pain, and wanted to end his life, would you agree to use euthanasia?, and (iii) at the end of the survey, participants answered a question about their opinion on making it mandatory for physicians to perform euthanasia. (Would you agree that the country’s legislation should oblige all physicians to perform euthanasia, even against their will, without the possibility of abstaining, as part of the fulfillment of their work and duty to the patient?).

At PUJ, the survey link was shared through social networks (WhatsApp), while at UC it was sent through institutional mailings to all undergraduate and graduate students of the institution in April and November 2019, respectively. Convenience sampling was applied, and all subjects who voluntarily accepted participation and completed the entire survey were included. All participants participated anonymously, and access to the questionnaire was limited to one time per participant.

Measures of central tendency and standard deviations were used to summarize the numerical variables. Categorical variables were presented as simple frequencies and percentages. The answers selected for euthanasia knowledge and hypothetical questions were presented in figures and tables. The statistical package R, version 3.6.3 (13) was used for the overall analysis.

Results

A total of 758 students from both institutions participated. Of these, 232 (31%) belonged to PUJ and 526 (69%) to UC. The distribution by age, sex and faculties or programs is presented in Table 1.

Of the students surveyed, 98.5% answered that they knew the definition of euthanasia. However, only 53% selected the definition that corresponds to that proposed by the World Health Organization, and no differences were found between the two universities (Table 2). The definition of palliative care and palliative sedation was erroneously selected as euthanasia by 281 respondents (37%). Suicide was not selected frequently (10%).

In relation to the Health Sciences programs, the academic semesters that achieved the highest percentage of correct answers at PUJ (80%) and UC (75%) were the eighth and twelfth semesters (medical internship year), respectively. As a curious fact, students from graduate programs obtained only 50% of correct answers, as shown in Figure 1.

Forty-eight percent of the respondents belonged to Health Sciences and Law and Political Science programs at the two universities. Figure 2 presents the accuracy in the appropriate definition of euthanasia found in Health Sciences students compared to those of Law and Political Science students, discriminated by university.

Regarding hypothetical cases related to euthanasia, 77% of the participants stated that they would opt for it if they were in the terminal phase of an illness; it reached 82% in the case that a close relative were in a similar context. When the terminally ill person is a child, acceptance of euthanasia decreases to 52%, with 20% not accepting and 30% not considering neither of the two options (Figure 3).

Responses to the question about making it mandatory for physicians to perform euthanasia varied widely among faculties (Table 3); health sciences faculties were less in favor of making this act mandatory than law faculties.

Acceptance of euthanasia is higher among those who have had a relative who has suffered from a terminal illness (58%), compared to those who do not share this relationship. On the other hand, according to the level of religiosity, acceptance of euthanasia is perceived to decrease as it increases: for a low level of religiosity, acceptance is 58%; for an intermediate level of religiosity acceptance decreases to 53% and, finally, for a high level of religiosity acceptance of euthanasia reaches the lowest levels (39%).

Discussion

The vast majority of participants in this extensive university survey consider that they know what euthanasia is, but only 53% identified the definition proposed by the World Health Organization. Many confuse its definition with that of palliative care. When analyzing hypothetical cases, the participants present an acceptance of euthanasia greater than 50%, which decreases in students with greater or lesser religiosity and increases when they have had a close relative in end-of-life conditions.

The lack of knowledge about the definition of euthanasia among university students is significant, particularly in Latin America. A study by Ríos et al. (4) in 2017, included 3924 medical students from 17 Latin American countries and found that 53% of students aged 20-24 years were unaware of the existence of euthanasia. However, studies carried out in other latitudes, such as that of Yildirim (14), in 2019, in 300 nursing students at a university in Turkey found that 98% of respondents were aware of euthanasia and 88% had received related information at university.

The issue of euthanasia in Latin America does not follow a defined scheme, since the legal and moral nuances in each country make its prohibition evident. Colombia’s situation is exceptional, given that it has a regulatory framework that includes euthanasia as part of the right to participate in decision-making. In light of these results, the need to create spaces for information and discussion among university students and the population in general is evident.

In our study, we found that a significant proportion of participants confused the definition of euthanasia with that of palliative care. It is possible that this confusion is related to one of the “popular” names given to euthanasia, such as dignified death. A dignified death can be perceived in many ways, and perhaps this euphemism for euthanasia has led many people to confuse euthanasia with specific acts of palliative care at the end of life. However, confusion has also been encountered with other terms: in a study conducted in Ecuador in 2017, which included 188 participants among resident physicians and specialists, Berrezueta Pesantez and Saquipay Zhagui (15) found that 24% of respondents considered assisted suicide and euthanasia to be similar concepts. Another study conducted in Peru in 2015 included interns and residents from 5 institutions, and more than 68% of participants got the definition of palliative sedation, palliative care, and physician-assisted suicide correct. It is noteworthy that the vast majority of respondents in this study had received bioethics-related teaching (16).

The degree of acceptance of euthanasia in our study was higher compared to others, such as the one conducted by Gutiérrez Castillo and Gutiérrez Castillo (17), where acceptance was 44% among medical students; meanwhile, the results presented by Anneser et al. (18) show an acceptance rate among fourth-year medical students of only 19%. In our study, acceptance varies considerably depending on the different cases: 77% of the participants would agree with euthanasia on themselves in case of suffering from a terminal illness with no treatment options. This percentage rose to 82% for a very old woman and dropped to 52% in case of a terminally ill child. In our opinion, this may be due to different positions based on culture, religiosity and an individual moral perspective. There is little acceptance of death as part of existence and as a life event. However, despite the good acceptance of euthanasia in the population studied, this acceptance is lower when it is for oneself than when it is required for a terminally ill elderly third party.

On the other hand, euthanasia in children is less approved, possibly because child death has a special connotation and less acceptance. Perhaps death in children is less accepted because of the future prospects for their lives and the calamity that a terminal illness generates, or because of the apparent infrequency of occurrence of terminal illness in this population. In addition, children are considered to have less decision-making capacity, so third-party decisions on end-of-life issues may be perceived as more problematic.

In relation to religion and its impact on the acceptance of euthanasia, the findings of our study are related to the results presented by Abolfazl et al. (19). They concluded that the higher the students’ levels of religious orientation, the more opposed they were to euthanasia. Additionally, Jacobs and Hendricks (20) evaluated university students of different religions and found that 62%, mostly of Christian faith, would opt for alternative measures to help terminally ill patients, such as palliative care.

The majority of participants in our study are of the opinion that physicians should not be obliged to perform euthanasia. Only 10.5% of students in the health area said they agree with this scenario, in contrast to 23.6% and 28.3% of students in the faculty of Law and other faculties, respectively. These findings are interesting, since the fact of causing the death of a person, even if it could be considered an act of “mercy”, still implies moral and religious dilemmas. The fact of hastening death goes against the classical academic training in health sciences, which aims at curing diseases. On the other hand, it is evident that in other disciplines not related, at least directly, to the health sciences, there is greater acceptance of the obligatory nature of the performance of euthanasia by physicians. In our opinion, it may be related to a lack of knowledge of the activities of health care professionals and the context that may be involved in making decisions about a patient with advanced disease.

In medical students, a decrease in the acceptance of euthanasia was documented as they reach more advanced levels. This decrease may be subject to increased contact with patients and exposure to end-of-life situations in their care activities.

One of the limitations of this study is the use of non-probability sampling. Although a high number of people in two very different university populations (public and private, Bogotá versus Popayán, with a diversity of academic interests and levels of religiosity) participated voluntarily, this represents a great difficulty for the generalization of the results. In Colombia there are more than 290 institutions of higher education distributed throughout the national territory, which present a great cultural, social and religious diversity.

Conclusions

This study demonstrates the lack of knowledge in the study population about the definition of euthanasia established by the World Health Organization. It is very likely that this lack of knowledge exists in Colombian society in general and demonstrates the need to open spaces for information and dialogue on euthanasia, and on the different processes and forms of dignified death. Medical decisions at the end of life should be individualized depending on the patient’s cultural and religious perspectives and wishes. These conversations should take place not only in the clinical practice setting, but in every learning space in the community. Regarding the results of this study, there is a clear tendency among medical students to establish their own concept of euthanasia and a marked opposition to its mandatory practice. This tendency is reinforced as the student progresses through the semesters, a situation that is related to the increase in patient contact and clinical practice.

Funding

This study was financed with resources from the Pontificia Universidad Javeriana and the Universidad del Cauca.

Conflict of interest

All authors certify that they are aware of the journal’s conflict of interest policy and that they have no conflicts of interest related to the publication of this manuscript.

Acknowledgments

To the students of the Pontificia Universidad Javeriana and Universidad del Cauca who participated in this study. To the administrative staff of the Universidad del Cauca, for their collaboration in the dissemination of the survey.

References

Author notes

^a Corresponding author: estherdevries@javeriana.edu.co

Additional information

How to cite: Velásquez Portilla M, Espejo-Saavedra A, Navarrete Ospina F, Robledo Gómez S, Salazar Jaramillo M, Baquero García P, Buesaquillo C, Arango L, Burbano L, Andrade L, Calvache JA, De Vries E. Knowledge about euthanasia in university students in two institutions of higher education in Colombia. Univ. Med. 2021;62(1). https://doi.org/10.11144/Javeriana.umed62-1.euta

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