Does experience affect physicians’ attitude towards assisted suicide? A snapshot of Swedish doctors’ opinions

be used in decisions regarding AS. Similarly, 44% could not consider performing AS and 27% were indecisive on the question. A majority (41%) thought that a physician should be responsible for approving applications for AS. Discussion. — A few more physicians express a positive attitude toward AS than against it, but many cannot express a certain opinion. In our material, no side in the ‘‘debate’’ for or against AS reaches the majority. The most junior physicians are the most uncertain ones.


Introduction
Assisted dying is a highly controversial topic that has legal, clinical, ethical as well as religious aspects to take into consideration.The term assisted dying is a term that covers both physician-assisted suicide (PAS) and assisted suicide/dying in general (AS,) as well as voluntary active euthanasia.PAS is defined as a physician, upon a person's voluntary and competent request, intentionally helping a person to terminate their life by providing substances for self-administration [1,2].
The topic of physician-assistant suicide PAS has been a long-going debate in several countries.Several papers have been published in the last few years and Sweden recently had two cases of PAS bringing the topic to public debate and discussion [3,4].
A slight ongoing change of attitude in regards to PAS has been noticed internationally as well as in Sweden [5][6][7].In general, the topic often elicits strong emotions, many strongly in favour and many vigorously opposing.Meanwhile, it also seems like several surveys demonstrate weaker support for PAS from physicians compared to the general public [1,5,8].
This paper aims to provide a snapshot of Swedish physicians' opinions regarding AS, including their opinion concerning experience and to evaluate whether a correlation between opinion and experience exists.

Material and methods
Swedish Medical Association has currently 56 000 members, with about 80% of Swedish physicians being members.The poll was conducted through a panel of members consisting of 6800 members (12% of the member count).The panel is representative of the association's members in age and gender (Fig. 1).The poll is an email-alerted online poll where the responder does not get to know about the topic beforehand.
No economic compensation was given, but all respondents participated in a lottery for a gift card.The poll itself consisted of multiple-choice questions regarding AS.The questions assessed the responders' attitudes on whether AS should be legal in Sweden and further linked the response to their self-assessed experience in working with palliative health care.The definition of AS was further subdivided into assisted suicide and euthanasia.The questions are presented in detail in Table 1.
A hypothetical scenario regarding who should conduct AS (public care, certain highly specialized centres) was further assessed together with the responder's willingness to write statements or certificates to be used in the decision of eligibility for AS.One of the questions also assesses the responder's willingness to take part in a board that declines or accepts a patient's request for AS.
The potential medicolegal situation was further assessed with questions regarding who should determine whether a patient would be eligible for AS.
The results were collected through SurveyMonkey (www.surveymonkey.com/mp/audience)online polling and data extracted from the online version.

Statistical analysis
The statistical analysis was performed using the R statistical software (The R Foundation for Statistical Computing, Vienna, Austria).The statistical methods used are Kendall's rank correlation coefficient including Stuart-Kendall Tau to assess variables with multiple outcomes.Each question has further been analyzed using the Chi 2 -test.P-values below 0.001 were considered significant.

Results
The response rate was 49% (3332/6800 panel members) and the response rate was slightly higher for female members (52%).The panel's demographics in relation to the members of SMA are demonstrated in Fig. 1.
The questions and the proportion of answers are presented in Table 2. On the question regarding whether AS and/or euthanasia should be legalized 41% of the respondents stated positive answers.The most positive group was the physicians with slight/some experience working with dying patients.The most inexperienced had the highest amount of indecisive answers.Physicians with extensive experience in working with dying patients stated most strongly against AS and/or euthanasia (45%).
When cross-evaluating the questions ''Are you experienced in working with dying people?''and ''Should euthanasia or AS be legal according to Swedish law?'' a Kendall correlation analysis gave a negative correlation of -0,086 with  No, by some court of law or a governmental agency outside health care a z-value of -5.4 resulting in a very significant finding (P < 0.0005).This is to be interpreted as a strong correlation between experience and negative attitude towards AS.The correlation between the view of legalization of AS and age as well as the correlation between age and experience is illustrated in Fig. 2. A significant correlation (P < 0.001) was also found between age and experience with the following factors: a negative attitude towards legalization of AS, considering AS to not comply with medical ethics, experience and unwillingness to perform PAS if it would be to become legalized.Here 50% of the group of physicians with the most experience in palliative care stated that AS would not be compatible with medical ethics.
More than half of the respondents (54%) stated that AS if it would be legal, should be performed within specific health care units.Approximately the same proportion (48%) were willing to write a statement on health status, knowing that it would be used in decisions regarding AS.Similarly, 44% could not consider performing AS and 27% were indecisive on the question.A majority (41%) thought that a physician should be responsible for approving applications for AS.

Discussion
AS is an emotive, often differentiating, topic with a long history.In 1937 Switzerland became the first country to legalize assisted suicide, provided that there was no selfish motive by the person assisting [8,9] Assisted dying has been legalized in many parts of Europe and North America [1,10].At the moment, there is legal provision for variants of assisted dying at least in the Netherlands, Belgium, Switzerland, Luxembourg, Spain, Germany, Canada, Colombia, New Zealand, Australia and eleven states in the United States of America [1,11,12].States considering law reforms are Ireland, England and Scotland [11].The pace of legalization of assisted dying seems to be increasing and around 2% of the world's population are said to live in areas that provide assisted dying [2].In general, it seems like PAS has gained support in Western Europe whereas some decline in support has been noticed in the United States of America and Eastern Europe [8].Currently in Sweden, AS is not provided by health care.The Swedish Medical Association's ethical code states that a physician should never take part in measures that aim to facilitate death.This ethical code complies with the World Medical Association (WMA) code of medical ethics and the WMA declaration of euthanasia [13,14].End-of-lifesustaining treatments and palliative sedation are available in Sweden.
However, recently the question of changing the country's legislation has been raised by the general public, representatives of physicians' groups as well as the Swedish Association for Medical Students.Two recent cases of AS in patients with severe Amyotrophic Lateral Sclerosis occurred and further sparked the discussion [3,4].In 2020 two Swedish surveys regarding AS were performed.The Swedish Medical Society did a postal questionnaire-based survey where the results were compared to a similar study from 2008 [7,15].This paper described an increase in the acceptance of AS (from 34,9% to 47.1%) and that one-third of the respondents were prepared to prescribe the needed drugs [7].
Our data represent the opinions of members of the Swedish Medical Association.Upon comparison with the Swedish studies, our study has a larger cohort of respondents but the Swedish Medical Society's study has a slightly higher response rate [16].Both response rates are similar to other published studies [5,7].Upon comparison, both of the Swedish studies had rather similar rates of accepting AS (47.1% vs 40%).
In 2020 the British Medical Association (BMA) conducted a questionnaire where half of the surveyed members believed that there should be a change in the law to permit doctors to prescribe life-ending drugs [6].Of the participants, 40% were in the view that BMA should actively oppose attempts to legalize AS.Out of the study population, 45% were not prepared to actively participate in the process of prescribing life-ending drugs.Approximately half, 54%, were unwilling to actively participate in the process of administering drugs for AS, should it be legalized [6].The discrepancy between willingness to endorse AS and willingness to practice AS is seen in our material, and has been described in other surveys [17,18].The area of the emotional impact of AS on participating clinicians is not well researched and the hesitancy could perhaps partly be explained by aspects of responsibility as well as the impact on the clinicians [11,[18][19][20].A recent review displayed that a significant amount (30-50%) of physicians participating in AS experienced emotional burden and discomfort [19].
When treating dying individuals, physicians, patients and next of kin value accurate prognostic information [21].In the event of the legalization of AS, a majority in our study wishes for specialized health care units.This expectation for sub-specialized knowledge is similar to findings reported by an Australian study which also states that doctors are less positive toward assisted dying when compared to other healthcare workers [21].An extensive review describes no difference in prognostic ability between different types of clinicians other than the finding that a multidisciplinary estimate seems to be more accurate than the prediction of an individual physician [22].This prognostic ability seems to increase with increased experience, but no specific subgroup of clinicians seems to outperform the others [22].This is quite interesting considering that our results show that hesitancy towards AS increases with experience in working with patients in palliative care.Intuitively one might expect the opposite, the most experienced being the most certain.The correlation between experience and negative attitude towards AS has been described before and is visualized in our survey [7,18,21,23,24].Some studies have described that oncological speciality, religious faith, female gender and younger age are independent factors associated with reluctance to AS [5,18,[23][24][25].The close link between ethics and religious belief is not surprising and has in some studies been shown to be one of the main reasons for opposing AS [20].The geographical areas where AS has been legalized tend to be countries with a greater degree of atheism and secularity [20].The view on AS has also been described to be quite similar among religions, with Christianism, Judaism, Islam and Confucianism being against it, Hinduism having no clear view with both Hindu philosophies against and in favour of AS [20,26,27].Buddhism seems to be the religion providing the most positive framework for AS, but in general, all religions speak against the moral acceptability of AS [20].Unfortunately, our study does not cover questions regarding respondents' religious views.
A few more physicians express a positive attitude toward AS than against it, but many cannot express a certain opinion.In our material, no side in the ''debate'' for or against AS reaches the majority.The most junior physicians are the most uncertain ones.
The issue of AS is complex, involving many interacting societal as well as bioethical aspects, and the variations in practice and law are extensive.However, dying is an inevitable part of life.The medical community should continue to have a dialogue within itself as well as with politicians and the public regarding the balance between a person's autonomy and safeguarding as well as the importance of evaluating and optimizing palliative care and patient care at the end of life.

Limitations
This kind of questionnaire study has several limitations.The questionnaire does not address topics of medical speciality, and religious views and the results have not been linked to gender.The response rate is around 50% and the panel is self-recruited and does not reflect a random sample of Swedish medical doctors.This could imply that the panel might consist of members that are more opinionated and more interested in controversial topics.The questions were not designed to cover and in-depth describe the experience of the members of the panel.Hence analysis of the effect of experience cannot be made concerning age or fields of expertise.

Conclusions
According to our questionnaire, 40% of Swedish physicians are positive about the legalization of AS.Meanwhile many are uncertain and 39% do not consider AS to comply with medical ethics.The hesitancy towards AS shows a significant increase with experience in palliative care as well as with age.

Fig. 1 .
Fig. 1.Age-distribution-panel and members of Swedish Medical Association.

Fig. 2 .
Fig. 2. Attitude of euthanasia and PAS linked to experience.

Table 1 Questionnaire
Answer options Are you experienced in working with dying people?Yes Yes, some No or little Should euthanasia or PAS be legal according to Swedish law?Yes, PAS Yes, PAS and euthanasia I don't know No Is PAS compatible with medical ethics Yes No I don't know If PAS was to be legalized, should it be executed within health care?Yes Yes, but only at specific health care units I don't know No If PAS was legalized, would you participate by writing a statement on health status knowing that this statement would be used in assessing eligibility for PAS?

Table 2
Responses grouped according to experience