Cultural disparity in End-of-Life Ethics

Introduction

People’s moral appraisals can influence judgments of causation and intention, as illustrated by doing/allowing judgments (Cushman et al., 2008): actions perceived as morally bad are more likely to be judged as actively causing harm rather than passively allowing it to occur.

The distinction between “doing” and “allowing” is of great importance in the “End of Life” debates, taking the form of “killing” vs. “allowing to die”. An experiment run in Spain (Rodríguez Arias et al., 2020) found evidence that indeed moral appraisals influence both behaviour description and causal attribution. Specifically, when physicians behave according to the patient’s wish to die, their behaviour was described in passive terms and their causal role in the death of the patient was disregarded, whereas when they acted against the patient’s will the physicians attributed themselves a bigger causal role and their behavior was depicted in active terms. These findings seem consistent with the normative power of consent (Raz, 1986) and more specifically with two fundamental moral principles in bioethics: autonomy, understood as the capacity to consent, and the harm that can be inflicted upon the individual (Beauchamp & Childress, 2019).

However, these principles do not operate in a vacuum, rather they are subject to shaping by cultural, social or political nuances specific to a country’s shared history (Karumathil & Tripathi, 2022).

Our research

From this perspective, the present study examines the differences in moral judgments relating to terminal care decisions in two countries with markedly different historical trajectories: Spain and Romania. More specifically, it explores how people perceive the concepts of “killing” vs. “allowing to die” in different end-of-life scenarios. This research provides a cross-cultural analysis of attributions of causation and intention. It reveals how patient autonomy and resulting harm influence these attributions differently in two national contexts, Spain and Romania.

We used, with the authors’ consent, the data from the previously published study conducted in Spain (n = 306; (Rodríguez Arias et al., 2020)) and recruited a total of 236 participants from Romania.

Participants were randomly assigned to a 2 between- (patient’s End-of-life will: Concordant vs. Discordant) × 4 within- (Scenario: Withholding treatment, Withdrawing treatment, Terminal Sedation, and Euthanasia) subject design. In each experimental condition, participants read four scenarios in which a doctor either endorsed or opposed a terminally ill patient’s wishes regarding end-of-life decisions: Withholding treatment (not connecting a respirator), Withdrawing treatment (disconnecting a respirator), Terminal Sedation (administering sedatives to relieve suffering until death), and active Euthanasia (injecting a lethal muscle relaxant). Following this reading, for each scenario participants answered two binary questions about the act vs. omission frame of the action (i.e. the doctor ended vs. killed), one question about the agency and casualty (i.e. the doctor vs. the illness caused the death, Cronbach’s alpha of the three questions = .80), and one categorical question regarding the labeling of the action (either letting the patient die, facilitating the death, or killing the patient). Following the main task, participants completed measures assessing their general attitudes toward the moral and legal permissibility of euthanasia.

Preliminary results

We examined the degree to which participants attributed causal responsibility to the physician. Across both Conditions and Scenarios this attribution varied substantially. Euthanasia and Terminal Sedation elicited significantly higher causal attribution than Withholding and Withdrawing treatment. Discordancy between the physician act and the patient will consistently amplified causal attribution across all four scenarios.

In Spain, the discordancy between the physician act and the patient will consistently elicited higher causal attribution than the concordance between the two across all four scenarios, with larger and more uniform effects: Withholding, Withdrawing, Terminal Sedation, and Euthanasia.

In Romania, the Condition effect was present but substantially weaker and varied considerably across scenarios: it was largest for Withholding, moderate for Euthanasia and Terminal Sedation, and almost negligible for Withdrawing.

These results suggest that while Spanish participants’ causal attributions were strongly and uniformly driven by patient will being respected, i.e., their consent, regardless of the type of act, Romanian participants showed a more nuanced sensitivity in which the nature of the act, particularly whether it involved direct harm, modulated the influence of consent framing.