Do Turkish physicians support euthanasia / death tourism?

Tourism academics and practitioners have carried out important studies on euthanasia tourism, which is a new research area, both nationally and internationally. Studies focusing on suicide tourism and euthanasia tourism in the literature have gained momentum since the 2000s. The first known study on the subject was addressed by Miller (1997) in the “Ethics and Medicine” journal under the title “Euthanasia tourism”. These are critical studies on whether euthanasia or assisted suicide is a type of tourism and limited studies that measure the perceptions and attitudes of physicians towards euthanasia and assisted suicide tourism.

Academic discussions on suicide tourism and euthanasia tourism have continued with studies conducted by Amujo and Otubanjo (2012), Bowen and Clarke (2009), Hall (2011), Higginbotham (2011), Huxtable (2009) and Miller and Gonzalez (2013). There are numerous studies that deeply analyse the concept of euthanasia tourism (Hall, 2011; Higginbotham, 2011; Miller & Gonzalez, 2013) and discuss whether it is a type of tourism that defines the boundaries of tourism (Beaver, 2002; Cooper & Hall, 2008, Goeldner & Ritchie, 2009; Hall et al., 2004).

There have been very limited studies attempting to determine the attitudes of physicians towards euthanasia tourism. Only one attitude scale study developed by Akın et al. (2022) is available on this subject. However, there are numerous studies that attempt to determine the views and attitudes of physicians towards euthanasia. There are studies indicating that physicians support and believe that euthanasia should be legal, such as Azizoğlu (2014), Asai et al. (2001), Cuttini et al. (2004), Dopelt et al. (2020), Fried et al. (1993), Glebocka et al. (2013), Gonçalves (2010), McGlade et al. (2000), Rivera et al. (2000), and Subba et al. (2016). However, there are also studies indicating that physicians do not support euthanasia, such as Mayda et al. (2005) and Özkara et al. (2002).

According to some US doctors, euthanasia or physician-assisted suicide is seen as an absolute necessity in patients with uncontrollable pain or weak physical function (Emanuel et al., 1998). A large majority of doctors in Victoria also support the legalisation of active voluntary euthanasia (Neil et al., 2007). Italian hospital doctors and general practitioners support euthanasia or assisted suicide for terminally ill patients (Grassi et al., 1999). There are many studies that have determined the attitudes of Australian doctors towards voluntary euthanasia. Some Australian doctors show a positive attitude towards the legalisation of voluntary euthanasia (Löfmark et al., 2008; Stevens & Hassan, 1994; Wilson et al., 1997), while others have expressed their opposition and lack of support (Cartwright et al., 2002; Munday & Poon, 2019; Sheahan, 2016).

The majority of UK doctors in most studies oppose the use of both active voluntary euthanasia and physician-assisted suicide. Several studies have found that religious beliefs/affiliation are a statistically significant factor in influencing doctors’ attitudes (Lee et al., 2009; Seale, 2009).

According to Dopelt et al. (2020), physicians specialising in internal medicine and, according to Glebocka et al. (2013), those specialising in intensive care and oncology units have more positive attitudes towards euthanasia compared to physicians working in other units. In addition, physicians have more positive attitudes towards euthanasia as their work experience increases (Dopelt et al., 2020). Subba et al. (2016) reported that male physicians with an average age of 37.9 and Cuttini et al. (2004) found that male physicians had a more positive attitude towards voluntary euthanasia in their studies. In addition, studies (Georges et al., 2008; McGlade et al., 2000) have shown that general practitioners and assistants (Rivera et al., 2000) exhibit a negative attitude towards euthanasia and are reluctant to participate in such actions.

The study was guided by an extended version of the Theory of Planned Behaviour (TPB). The TPB was found suitable for predicting and understanding the behaviour of healthcare professionals, such as physicians and nurses from various fields of clinical practice (Bosnjak et al., 2020). TPB was developed by Ajzen (1991), and it is one of the most widely implemented theories for understanding individuals’ social behaviour (Bosnjak et al., 2020).

Intention represents one’s motivation to adopt a given behaviour. The intention to implement a particular behaviour is determined by three direct factors: personal attitudes toward the behaviour, subjective norms, and perceived behavioural control (Ajzen, 1991). Attitude towards a behaviour is the positive or negative assessment of the individual’s behaviour performance (Ajzen, 2023). Attitudes were evaluated by using their two components, cognitive and affective attitudes, as suggested by Triandis (Triandis, 1980). Subjective norms reflect the social influence on the individual (Ajzen, 2023). Perceived behavioural control refers to people’s evaluation of their ability to adopt a given behaviour (Lavoie et al., 2014).

The efficacy of the TPB (Emanuel, 2002) in predicting intentions to adopt various health behaviours, including among health professionals, and the key role of intentions to predict behaviours have already been established in several meta-analyses (Armitage & Conner, 2001; Conner & Sparks, 2005). Socio-demographic and contextual variables may affect the intention to adopt euthanasia behaviour in terms of the number of end-of-life patients that nurses and doctors care for annually, whether they have relatives receiving palliative treatment, length of experience, age, gender, religious belief, attitude towards the legalisation of euthanasia, and external factors (Lavoie et al., 2014). Considering the Theory of Interpersonal Behaviour there is evidence that professional and moral norms are determinants of healthcare professionals’ intentions to adopt various behaviours (Côté et al., 2012). Lee and Kang (2020) found that attitudes and perceived control predict nurses’ intention to care for patients with infectious diseases, where perceived control was the strongest predictor.

The aim of the study is to examine the attitudes of Turkish physicians towards euthanasia tourism and to investigate the differences in these attitudes according to demographic variables. The hypothesis established in the study is as follows:

H1. The attitudes of Turkish physicians towards euthanasia tourism vary according to demographic variables.

In this study, the survey method, which is a quantitative research method, was used. The design of the study is appropriate for a general survey model, as the study aims to make estimates and generalisations about the population through sampling. According to Karasar (2012), studies aimed at determining the specific characteristics of a group are called survey research, and singular or relational scans can be performed with these models.

In this study, the Attitudes Towards Euthanasia Tourism Scale, developed by Akın et al. (2022) was used. The Euthanasia Tourism Attitude Scale (ETAS) is a scale designed to determine the level of attitudes of healthcare professionals towards euthanasia tourism. The scale, which consists of 26 items with three of them (questions: 6, 7, 8) being reverse worded, is a five-point Likert scale and has a three-factor structure. The first factor consists of 13 items and represents Euthanasia Perception, the second factor consists of 10 items and represents Euthanasia Prediction, and the third factor consists of 3 items and represents Social Values.

The prepared survey form was applied to physicians in the Marmara Region, where medical tourism is most intense in Turkey. In determining the number of surveys planned to be administered to physicians, Hair et al.’s (2019) widely used to reach maximum sample volume in limited universes, the non-clustered single-stage random probability sampling method based on population proportions was used. It was observed that the sample size to be reached should be at least 384; it was intended to reach at least 420 people in case of missing data. Between 01.11.2022–01.12.2022, a survey form was applied face-to-face and one-on-one to 424 physicians reached by the convenience sampling method, and the data collection process was completed. The data collected in accordance with the purpose were processed with the help of the SPSS package program and basic statistical analyses such as reliability analysis, frequency distribution, mean, standard deviation, and skewness-kurtosis were performed; Number, percentage, mean±standard deviation and minimum–maximum values were used for descriptive variables. The average scores and frequency values obtained from the scales were examined according to the demographic characteristics of the participants. Before conducting any difference analyses, it was investigated whether the data met the normality assumption through skewness–kurtosis coefficients, and it was found that the skewness–kurtosis coefficients were within the range of ±2 for each item. The fact that the kurtosis and skewness coefficients are between +2 and −2 emphasizes that the data show a normal distribution (Pallant, 2020). Therefore, parametric techniques were used in the analysis of the data. When examining the differences in average scores obtained from the attitude scale towards euthanasia tourism based on demographic variables, independent samples t-test was used for dichotomous variables, and ANOVA was used for variables with more than two categories. The statistical significance level of 0.05 was accepted in interpreting the obtained results.

The population of the research is the Marmara Region of Turkey where medical tourism is intense, and the sample consists of physicians working in healthcare facilities located in Kocaeli and Istanbul.

Of the physicians participating in the study, 223 (52.6%) are male and 201 (47.4%) are female. A number of 266 (62.7%) of the participants are married, while 158 (37.3%) are single. Additionally, 186 (43.9%) are graduates of a bachelor’s degree, and 238 (56.1%) are medical specialists. Of the physicians, 148 (34.9%) work in state hospitals, 169 (39.9%) work in medical faculties, and 107 (25.2%) work in private hospitals. Of the physicians participating in the study, 163 (38.4%) are between 22–39 years old, 157 (37%) are between 40–59 years old, and 104 (24.5%) are 60 years old and above. Of the participants, 64 (15.1%) have an income between 20,000 ₺–30,000 ₺, 55 (13%) have an income between 30,001 ₺–40,000 ₺, and 305 (71.9%) have an income of 40,001 ₺ and above. When looking at the physicians’ perceptions of their income, 237 (55.9%) stated that their income is less than their expenses, 153 (36.1%) stated that their income is equal to their expenses, and 34 (8%) stated that their income is greater than their expenses. Of the physicians participating in the study, 157 (37%) have 0–10 years of work experience, 114 (26.9%) have 11–20 years of work experience, and 153 (36.1%) have 21 years or more of work experience. In addition, 168 (39.6%) of the physicians are faculty members, 125 (29.5%) are medical specialists, and 131 (30.9%) are assistants. 85 (20%) physicians work in the emergency department, 89 (21%) work in internal medicine units, 152 (35.8%) work in surgical units, 67 (15.8%) work in intensive care units, and the remaining 31 (7.3%) work in other clinical units.

The attitudes of Turkish physicians towards euthanasia tourism were examined and the average scores obtained were presented in Table 1.

When the average scores of Turkish physicians’ attitudes towards euthanasia tourism were examined, it was seen that their overall perspective on euthanasia tourism was positive. It was seen that the accepted idea among the sub-dimension was in the social values dimension, while the dimension with the lowest average score was the perception level of euthanasia. The majority of the physicians believe that the culture, lifestyle, and religion have an influential role in the fact that euthanasia is not legal in Turkey. They also expressed that the legalisation of euthanasia in Turkey would increase travel and tourism revenues to the country.

The majority of physicians expressed that individuals should be given the right to die, and they particularly support euthanasia in cases of terminal illnesses that cause unbearable suffering and have no medical cure or treatment. As a result, they have also stated that they can respond positively to euthanasia requests from domestic and foreign tourists. Only a small percentage of the physicians have stated that they are against euthanasia they consider euthanasia equivalent to murder or suicide. The physicians, despite expressing their support for euthanasia and euthanasia tourism, stated that they do not think euthanasia will be legalised in Turkey within the next decade.

An independent sample t-test was conducted to examine the differences in Turkish physicians’ attitudes towards euthanasia tourism based on gender, marital status, and education level, and the results were presented in Table 2.

When the results were examined, it was observed that the attitudes of Turkish physicians towards euthanasia tourism were more positive among males and singles, but this difference was not statistically significant. However, it was determined that the perspectives of physicians who specialise in medicine towards euthanasia tourism were more positive compared to general practitioners, and this difference was statistically significant in the sub-dimensions of general attitude, perception and prediction towards euthanasia. When it comes to the dimension of social values, no statistically significant difference was found. One of the reasons for this is that the culture, lifestyle, and religion that prevail among almost all physicians in Turkey are believed to have a strong influence on the fact that euthanasia is not legal in Turkey.

ANOVA (F test) was conducted to examine the differences in Turkish physicians’ attitudes towards euthanasia tourism by age, income level and clinic, work experience, and position in the institution, and the results were presented in Tables 3 to 7.

When examining the difference in attitudes of Turkish physicians towards euthanasia tourism according to age, it was found that older physicians have a more positive view towards euthanasia tourism compared to younger physicians, and that the attitude towards euthanasia tourism increases positively with age. It was determined that this difference is statistically significant in the sub-dimensions of general attitude towards euthanasia, as well as perception and prediction of euthanasia. When examining the dimension of social values, on the other hand, the opposite situation was observed. It was found that the idea that euthanasia is not legal in Turkey due to the influence of culture, way of life, and religion was more common among young doctors in the dimension of social values.

When examining the differences in Turkish physicians’ attitudes towards euthanasia tourism by income level, it was found that physicians with higher incomes have more positive attitudes towards euthanasia compared to those with lower incomes, and that as income increases, attitudes towards euthanasia tourism also tend to become more positive (see Table 4). This difference was also found to be statistically significant. The results indicate that the idea of being able to easily participate in euthanasia tourism without financial concerns is dominant among physicians with high income levels.

When examining the attitudes of Turkish physicians towards euthanasia tourism in relation to their work experience, it was found that physicians with 11–20 years of work experience had a more positive view of euthanasia compared to physicians with 0–10 years of work experience, and this difference was statistically significant (see Table 5). However, the differences in the sub-dimensions of euthanasia prediction and societal values were found to be statistically insignificant.

When the differences in Turkish physicians’ attitudes towards euthanasia tourism were examined according to their positions within the institution, it was determined that the perspectives of professors and specialist physicians towards euthanasia were more positive compared to assistants, and this difference was identified to be significant (see Table 6). This difference was found to be statistically significant except for the social values sub-factor. The fact that professors and specialist physicians carry out numerous critical surgeries, encounter many patients in critical condition and in intensive care whose pain cannot be relieved, may have contributed to their having a more positive (supportive in nature) view towards euthanasia compared to assistants.

When the differences in attitudes of Turkish physicians towards euthanasia tourism according to the clinic where they work were examined, it was determined that physicians working in intensive care and surgical units had more positive attitudes towards euthanasia compared to physicians working in other units (see Table 7). The situation of physicians working in intensive care, surgical units, encountering more seriously ill, painful patients compared to physicians working in other units, can lead them to think more positively about euthanasia.