The public’s viewpoint on the right to hastened death in Alberta, Canada:

findings from a population survey study

Donna M. Wilson RN PhD Professor1, Stephen Birch DPhil Professor

2, Rod MacLeod PhD FAChPM Professor3,

Nurin Dhanji RN BScN Research Assistant1, Jane Osei-Waree MN Student Research Assistant

1 and Joachim Cohen

PhD Professor4

1Faculty of Nursing, University of Alberta, Edmonton, AB, Canada, 2Department of Clinical Epidemiology and

Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada,3Department of General Practice and Primary Health Care, School of Population Health, University of Auckland,

Auckland, New Zealand and 4End-of-Life Care Research Group, Ghent University & Vrije Universiteit, Brussels,

Belgium

Accepted for publication 22 August 2012

CorrespondenceDonna M. WilsonFaculty of Nursing, University ofAlberta, Edmonton, ABCanada T6G 1C9Tel.: (780) 492 5574Fax: (780) 492 2551E-mail: donna.wilson@ualberta.ca

What is known about this topic

• Few population surveys or opinionpolls have been conducted and pub-lished so as to provide readily avail-able and credible information onpublic views of assisted suicide andeuthanasia.

• Legislation permitting euthanasiaand ⁄ or assisted suicide has come toexist in a growing number ofcountries.

• Assisted suicide and euthanasiaremain highly controversial.

What this paper adds

• This population-based surveyrevealed majority public support forthe right to hastened death in oneprovince of Canada.

AbstractA research study was conducted to determine public opinion in Alberta,

a Canadian province, on the controversial topic of death hastening.

Questions on the right to hastened death, end-of-life plans and end-of-life experiences were included in the Population Research Laboratory’s

annual 2010 health-care telephone survey, with 1203 adults providing

results relatively representative of Albertans. Of all 1203, 72.6% said yes

to the question: ‘Should dying adults be able to request and get help

from others to end their life early, in other words, this is a request for

assisted suicide’? Among all who provided an answer, 36.8% indicated

‘yes, every competent adult should have this right’ and 40.6% indicated

‘yes, but it should be allowed only in certain cases or situations’. Over50% of respondents in all but one socio-demographic population sub-

group (Religious-other) were supportive of the right to hastened death.

However, multinomial regression analysis revealed that the experiences

of deciding to euthanise a pet ⁄ animal and developing or planning to

develop an advance directive predicted support, while self-reported reli-

giosity predicted non-support. Finding majority public support for death

hastening suggests that legalisation could potentially occur in the future;

but with this policy first requiring a careful consideration of the modelof assisted suicide or euthanasia that best protects people who are highly

vulnerable to despair and suffering near the end of life.

Keywords: assisted suicide, euthanasia, hastened death, population survey,

public opinion poll

• However, approximately one half ofall those in favour of the right tohastened death indicated that itshould be allowed in only certainsituations.

• Majority public support suggestslegalisation could occur in thefuture; a public policy first requir-ing a careful consideration of themodel of assisted suicide and ⁄ oreuthanasia that best protects peoplewho are highly vulnerable to des-pair and suffering near the end oflife.

Assisted suicide and euthanasia cannot be performed legally in Canada.However, ongoing discussion of decriminalising death hastening has

occurred since Sue Rodriguez’ 1992–1993 request to the Supreme Court of

Canada for help in ending her life with amyotrophic lateral sclerosis

(ALS) at a time of her choosing. The narrow (5–4) ruling against her dem-

onstrated much legal, if not also societal, support at that time for her posi-

tion. It is ironic that although the Criminal Code was not amended then to

permit death hastening, Sue Rodriguez was widely reported as having

been euthanised and the person or persons who ended her life were neverprosecuted. Other cases of hastened death have since occurred in Canada,

but few have been charged with what Mullock (2010) identified as a

‘criminally compassionate’ offence. With the exception of Robert Latimer

who was recently released from prison after serving a 10-year sentence for

200 ª 2012 Blackwell Publishing Ltd

Health and Social Care in the Community (2013) 21(2), 200–208 doi: 10.1111/hsc.12007

euthanising his daughter who had a disability, convic-tions for death hastening are almost non-

existent in Canada. Currently, a number of Canadians

are petitioning for the right to have death hastening

assistance, with a Supreme Court judge in the prov-

ince of British Columbia (BC) having ruled on June

15, 2012 that the Criminal Code prohibition on assisted

suicide violates the rights of people who cannot com-

mit suicide without assistance (2012 BCSC 886 Carterv. Canada). This ruling was immediately suspended

for 1 year to permit the Federal Government to

respond, although one petitioner received permission

to obtain assisted suicide after certain conditions have

been met. In addition, the Select Committee on Dying

with Dignity, a group initiated by the National Assem-

bly of Quebec 2010 (the government for the largely

francophone province of Quebec) has recently releasedtheir report on the open inquiry held in 2010–2011 to

gain public and professional viewpoints on legalising

hastened death in that province. This report contains

12 recommendations to improve access to and quality

of palliative care, and 12 recommendations for assisted

suicide and euthanasia to occur without sanction in

the province. Specifically, recommendation 13 states

(after translation into English), ‘the Committee recom-mends that relevant legislation be amended to recog-

nize medical aid in dying as appropriate end-of-life

care if the request made by the person meets the fol-

lowing criteria...’ (Dying with Dignity 2012, p. 1). This

report and the BC Supreme Court ruling have gener-

ated much discussion across Canada.

Canada is not the only country wrestling with the

issue of what to do when people ask for help to commitsuicide (i.e. assisted suicide) or ask for hastened death

when they can no longer commit aided or unaided sui-

cide (i.e. euthanasia). Clearly, there are people who seek

assisted suicide and euthanasia including those who tra-

vel to Switzerland as ‘suicide tourists’. There is consider-

able complexity in legislating and conducting hastened

death, however, as illustrated by the Australian situation.

In 1995, the Northern Territory government in that coun-try passed the Rights of the Terminally Ill Act, which sanc-

tioned ‘the right of a terminally ill person to request

assistance from a medically qualified person to voluntar-

ily terminate his or her life in a humane manner’. The

Act was quickly overturned by the Federal Government

(Law Council of Australia 2008) and no replacement Act

has been passed since. Hastened death is legally prac-

tised now in Switzerland, the Netherlands, Belgium,Luxembourg, and three American states (i.e. Oregon,

Washington, Montana); although with some differences

in decisional criteria and mandated death-hastening pro-

cesses (Burkhardt et al. 2006, Cohen et al. 2006). One

would expect public support to have been a prerequisite

in these jurisdictions for hastened death legalisation. Todate, no population-based polling of Canadians on the

topic of hastened death has been done and the results

published for open discussion purposes. Evidence is

needed to guide discussion and inform policy. In this

study, we assessed public opinion on the right to has-

tened death in Alberta, a Canadian province with

around 3.6 million citizens. We also examined which

socio-demographic factors and end-of-life experienceswere systematically associated with support for or

against the right to hastened death.

Research methods

Survey design

The University of Alberta’s Population Research Labora-

tory was commissioned to include a series of end-of-life

questions in their 2010 spring ⁄ summer random-digit-

dialling telephone survey, with a University of Alberta

research ethics committee approving this survey in

advance. The end-of-life questions were developed by

an international research team after a review of the litera-

ture, and the questions were piloted locally with 20experts in survey design. Minor changes were then made

to enhance public understanding of the questions and

their potential answer choices. The sampling plan for

gaining information representative of all adults living in

Alberta included: (i) a minimum of 1200 participants (the

Population Research Laboratory for population represen-

tation normally surveys this number of participants, hav-

ing determined that it is an appropriate number, hencethis number was set), (ii) proportional geographical rep-

resentation; with 1 ⁄3 of the 1200 expected respondents,

respectively, to be from the Edmonton metropolitan area,

the Calgary metropolitan area, or all other rural and

urban areas combined, (iii) equal numbers of men and

women in each of the three regions, (iv) one respondent

per household, with these numbers obtained through a

computer-generated random digit-dialling system usinglisted non-business telephone numbers for the province,

and (v) multiple call-backs or quota substitutions after

participation refusals or 14 call-backs that did not find

anyone at home. In May through July 2010, a total of

1203 anonymous adult volunteers were identified as eli-

gible and took part in the study. Each subject had been

read a script that informed them they were being asked

to take part in a research study, but they could decline toparticipate, and they could answer all or some of the

questions without repercussions. Persons who were inel-

igible to participate in the study were those who

reported they were younger than 18 years of age or a

non-resident of Alberta, as well as those who were

unwilling or unable to respond to the questions. The

Public support

ª 2012 Blackwell Publishing Ltd 201

obtained sample was representative for the total popula-tion of Alberta in terms of area of residence, gender,

being legally married or not and number of children in

the household. Albertans under 45 years of age were

underrepresented (see Table 1).

Measures

The main outcome measure used in this study was the

question on hastened death, formulated as follows:

‘Should dying adults be able to request and get help

from others to end their life early, in other words, this

is a request for assisted suicide’? Respondents could

decline to answer the question or answer yes, every

competent adult should have this right; yes, but itshould be allowed only in certain cases or situations; or

no. Information was also collected on the respondents’

gender, age, number of children in the household, edu-

cational attainment, marital status, household and indi-

vidual income (grouped into four categories),

occupation (dichotomised to health professionals or all

other occupations), working or non-working ⁄ retired,

religious affiliation, political affiliation and preferred

place of death. Religious affiliation was based on twoquestions, one asking about the religious denomination

of the respondent (19 possible categories and a category

‘other’ with a possibility to specify) and another asking

whether the respondent considers himself or herself to

be a religious person (answer possibilities on a scale

from 1, ‘strongly disagree’ to 7, ‘strongly agree’ to the

question ‘I consider myself to be a religious person’).

The political orientation of the respondent was gainedby the question: ‘If an election were held today, how

would you vote federally’? The question about the

respondent’s preferred place of death was asked as

such: ‘Where would you choose to spend your last days

of life’? The respondents could answer: hospital, hos-

pice, nursing home, own home, home of a relative or

friend and other as options.

Statistical analyses

Univariate statistics were used to describe views on theright to request and receive hastened death assistance.

Kruskal–Wallis tests were used to evaluate bivariate

associations between the acceptance of assistance in

dying and all independent variables. This test is used for

comparing ordinal variables for two or more groups.

With the outcome variable (acceptance of hastening

death) being ordinal (no, conditional yes, yes) rather than

nominal, the Kruskal–Wallis test was deemed moreappropriate than the Pearson chi square test. Statistical

significance was set at P < 0.05. All independent vari-

ables were considered candidates for construction of a

multinomial logistic regression with the hastening death

variable as the dependent variable (no as the reference

category vs. yes and conditional yes). A stepwise proce-

dure was used to select the variables, with only the sta-

tistically significant (P < 0.05) covariates allowed to stayin the final logistic regression models. Nagelkerke

pseudo-R2 was used to evaluate the variance explained

by the model. SPSS version 19.0 was used for all statisti-

cal computations.

Findings

A total of 1203 respondents participated in the survey,

50.3% of whom were women, 19% 60 years or older,

67.2% in a household without children, 71.8% with some

post secondary education and 28.5% not married

(Table 1). In response to the primary research question

of interest: Should dying adults be able to request andget help from others to end their life early; 72.6% replied

yes, 21.3% replied no, and 1.6% declined to answer and

4.6% answered ‘don’t know’. The data from all people

who did not answer this question or answered ‘don’t

know’ were removed from analysis and among the

Table 1 Socio-demographic characteristics of sample, as com-

pared with available population statistics for the Province of

Alberta

Sample Population* P-value (v2)‡

Area

Metropolitan Edmonton 33.3 31.8 0.26

Metropolitan Calgary 33.3 33.3 >0.99

Other Alberta 33.4 34.9 0.28

Gender

Male 49.7 49.6 0.95

Female 50.3 50.4 0.95

Age

18–24 5.8 13.9 <0.001

25–34 12.7 20.1 <0.001

35–44 17.2 20.2 0.01

45–54 22.9 19.7 0.01

55–64 22.5 12.5 <0.001

65+ 19.0 13.6 <0.001

Legal marital status

Not married 34.9 35.6 0.61

Married 65.1 64.4 0.61

Children in household

No children 67.2 69.5 0.08

1 or more 32.8 30.5 0.08

*Statistics based on census 2011 for area and for gender, age,

marital status, and number of children in household on census

2006 (as not yet available in census 2011); all percentages

calculated for population aged 18 and over. Statistics consulted

at http://www.statcan.gc.ca.‡P-value calculated through chi square test comparing sample

and population distributions for each presented category vs. all

others.

D. M. Wilson et al.

202 ª 2012 Blackwell Publishing Ltd

Table 2 Socio-demographic characteristics of the sample and their views of hastened death

Number in sample (Column percentage) Yes*% Yes conditionally*% No*% P-value‡

Total 1203 (100) 36.8 40.6 22.7

Area*

Edmonton metropolitan area 401 (33.3) 39.6 34.2 26.1 0.830

Calgary metropolitan area 400 (33.3) 35.8 44.6 19.6

Other Alberta 402 (33.4) 34.9 42.8 22.3

Gender* 0.290

Male 598 (49.7) 37.3 41.9 20.8

Female 605 (50.3) 36.1 39.6 24.3

Age group*

18–24 68 (5.8) 40.9 39.4 19.7 0.026

25–34 148 (12.7) 34.6 41.2 24.3

35–44 200 (17.2) 34.9 47.4 17.7

45–54 267 (22.9) 42.3 39.4 18.3

55–64 262 (22.5) 36.9 41.6 21.6

65+ 221 (19.0) 31.7 35.6 32.7

Household size

Number of children* 0.097

0 806 (67.2) 38.1 39.4 22.5

1 138 (11.5) 39.3 40.7 20.0

2 171 (14.2) 31.4 50.3 18.2

3 or more 84 (7.0) 29.5 34.6 35.9

Education* 0.004

Less than high school 97 (8.1) 27.3 33.0 39.8

Completed high school 240 (20.1) 38.5 42.0 19.5

Post secondary 859 (71.8) 37.4 41.1 21.5

Marital status* 0.230

Married or common law relationship 856 (71.5) 35.7 40.9 23.4

Not married 342 (28.5) 39.0 40.6 20.4

Income (household)* 0.025

<$50,000 149 (16.5) 31.9 40.6 27.5

$50 000–99 999 280 (31.1) 34.8 40.1 25.1

$100 000–$150 000 257 (28.5) 38.5 42.9 18.6

>$150 000 216 (23.9) 40.6 44.1 15.3

Work*

Health-care 89 (7.4) 29.6 45.7 24.7 0.240

Other sector 1114 (93.6) 37.2 40.4 22.4

Political affiliation* 0.019

Liberal 130 (11.5) 41.4 44.5 14.1

Conservative 532 (47.1) 31.8 42.9 25.2

New democratic party 54 (4.8) 42.6 40.7 16.7

Green party 56 (5.0) 42.9 42.9 14.3

Other 357 (31.6) 39.8 35.9 24.3

Religious affiliation and religiosity* <0.001

No religious denomination 325 (28.1) 54.5 38.3 7.1

Religious Catholic 163 (14.1) 17.2 47.8 35.0

Religious Protestant 164 (14.2) 21.9 38.1 40.0

Religious other� 148 (12.8) 26.4 29.3 44.3

Not religious Catholic 142 (12.2) 40.0 46.7 13.3

Not religious Protestant 133 (11.4) 42.7 46.8 10.5

Not religious other denomination 83 (7.2) 33.8 40.5 25.7

Location of death preference* 0.268

Hospital ⁄ nursing home 97 (8.6) 40.7 31.9 27.5

Hospice 165 (14.6) 35.0 42.5 22.5

Home ⁄ home of another 786 (69.8) 35.1 42.6 22.3

Other 78 (6.9) 45.3 40.0 14.7

*Numbers of categories within a variable might not add up to total because of missing values. Missing cases were lower than 5% except for income

(25.2%) and political affiliation (6.2%) and preferred place of death (6.5%). 1.6% of respondents did not answer to the question on hastening death;

4.6% responded ‘don’t know ⁄ not sure’. These are not considered in the analyses. Further evaluation of these missing cases (i.e. no answer and

don’t know) showed no significant differences for all variables in the percentage of missing cases except for age (only the group aged 65 and older

had more missing cases, i.e. 9%) and political affiliation (green party: 0%, Liberal: 1.8%, New Democrat: 1.8%, Conservative 5.5%, other 7.6%).‡P-value assessed by Kruskal–Wallis, a non-parametric test. A P-value <0.05 denotes a statistically significant difference in acceptance of

assistance in dying between the different categories of the independent variables.�This category ‘religious-other’ comprises amongst others, Christians for whom none of the listed denominations applied (52%), as well as

Muslims (9%), Hindus (4%) and Jews (3%).

Public support

ª 2012 Blackwell Publishing Ltd 203

remaining 1129 respondents, 36.8% indicated ‘yes, everycompetent adult should have this right’, 40.6% indicated

‘yes, but it should be allowed only in certain cases or sit-

uations’, and 22.6% indicated ‘no’. Table 2 illustrates rel-

atively few socio-demographic differences among

respondents regarding this hastened death right; over

50% in all but one sub-group (Religious-other) were in

favour or conditionally in favour of the right to hastened

death. However, significant differences in support werefound between age cohorts. Furthermore, less support

for hastened death was found among Albertans with

lower income and lower educational attainment, and

also among those with a conservative political affiliation

and those with a strong religious affiliation. Only 34 peo-

ple indicated having North American Aboriginal ances-

tors (2.9% of the sample). Their answers did not differ

significantly from those of non-Aboriginals (Aboriginalpersons indicated: 44.1% yes, 35.3% yes, conditionally

and 20.6% no; whereas non-Aboriginals, respectively,

answered: 36.2%, 40.9%, and 22.9%).

Table 3 presents information oriented to the respon-

dents’ previous personal experiences with death and

dying; with this information gathered as it was hypoth-

esised that select lived experiences could influence has-

tened death opinions. Of all respondents, 95% hadexperienced the death of a close friend or relative; 70%

had an experience of deciding to euthanise a pet ⁄ animal;51% had looked after a dying person; 44% had devel-

oped or planned to develop an advance directive or liv-

ing will; and 27% had been involved in a decision to stop

or not to start a life-supporting treatment. As shown,

the experience of deciding to euthanise a pet or another

animal, the experience of having prepared or made plans

to prepare an advance directive, and the experience of

deciding to stop or not start life-supporting treatment fora family member or friend were significant for a higher

level of unconditional support for the right to hastened

death.

Variables entered into the multinomial logistic regres-

sion analysis were as follows: age group, income, educa-

tional attainment, political affiliation, religious affiliation,

decisional experience of euthanising a pet ⁄ animal, deci-

sional experience with life-supporting treatments andhaving or planning an advance directive. The model was

built up stepwise, starting with age and gradually

expanding the model with additional variables. Non-

significant variables (P < 0.05) were removed from the

model. This resulted in a final model with three factors:

religious affiliation, experience of euthanising a pet ⁄animal and having or planning an advance directive

(Table 4). Answering yes instead of no to the question ofsupport for hastened death was significantly less likely

Table 3 Comparisons of data from key research question (should dying adults be able to request and get help from others to end their

life early?) and other end-of-life questions

Total N* (%) Yes N* (%)

Yes, conditionally

N* (%) No N* (%) P-value‡

Experience of euthanising a pet ⁄ animal <0.001

Yes 842 (70.4) 307 (38.8) 334 (42.2) 151 (19.1)

No 354 (29.6) 105 (31.6) 122 (36.7) 105 (31.6)

Experienced death of a close friend

or family member

0.254

Yes 1140 (94.9) 389 (36.3) 438 (40.9) 244 (22.8)

No 61 (5.1) 25 (44.6) 20 (35.7) 11 (19.6)

Have looked after a dying person 0.883

Yes 610 (50.7) 220 (38.1) 215 (37.3) 142 (24.5)

No 592 (49.3) 195 (35.4) 243 (44.1) 113 (20.5)

Had been involved in a decision to stop or not

start life-supporting treatment

0.014

Yes 326 (27.3) 133 (43.3) 112 (36.5) 62 (20.2)

No 870 (72.7) 282 (34.5) 344 (42.1) 191 (23.4)

Have an advance directive ⁄ living will, or planning one 0.023

Yes, have one now 516 (43.6) 197 (40.3) 189 (38.7) 103 (21.1)

No, but planning one 499 (42.1) 169 (35.9) 202 (42.9) 100 (21.2)

No 169 (14.3) 46 (29.9) 62 (40.3) 46 (29.9)

*Numbers of categories within a variable might not add up to the total because of missing values. 1.6% of respondents did not answer

the question on hastening death; 4.6% responded ‘don’t know ⁄ not sure’. These are not considered in the analyses. Further evaluation

of these missing cases (i.e. no answer and don’t know) showed no significant differences for all variables in the percentage of missing

cases.‡P-value assessed by Kruskal–Wallis, a non-parametric test. A P-value <0.05 denotes a statistically significant difference in

acceptance of assistance in dying between the different categories of the independent variables.

D. M. Wilson et al.

204 ª 2012 Blackwell Publishing Ltd

among respondents who reported a religion affiliation ascompared with those who indicated they did not belong

to any religious group, with those labelling themselves

religious Catholics (OR: 0.06, 95% CI: 0.03–0.11), religious

Protestants (OR: 0.06, 95% CI: 0.03–0.12), or religious in

any other religious denomination (OR: 0.08, 95% CI:

0.04–0.14) least likely to answer yes instead of no. Catho-

lics and Protestants who did not describe themselves as

religious were not significantly less likely to support theright to hastened death in certain cases or circumstances

than their non-religious counterparts. People with the

decisional experience of euthanising a pet or animal

were more likely to generally favour the right to has-

tened death (OR: 1.72, 95% CI: 1.18–2.51) and favour it in

certain cases or circumstances (OR: 1.78, 95% CI: 1.25–

2.53) as compared to people with no such experience.

Respondents with an advance directive or plans todevelop one were significantly more likely than respon-

dents with no advance directive to generally support the

right to hastened death instead of not supporting it (OR:

1.91, 95% CI: 1.12–3.26). However, those with an advance

directive or plans to develop one did not differ signifi-

cantly from those who did not have one in terms of

accepting the right to hastened death in certain cases or

circumstances vs. not accepting it (i.e. conditionalyes vs. no).

Discussion

This survey revealed majority support among a rela-

tively representative sample of adult Albertans for the

right to hastened death. As public opinion does change,often gradually over time, but sometimes rapidly in

response to a major development such as a highly publi-

cised event or issue, it will be important to repeat this

study in the future to determine if this finding of major-

ity support continues, fades, or increases over time. In

addition, it is important to recognise that this finding of

majority support cannot be generalised outside of

Alberta although past published studies across Canadahave similarly indicated considerable (often majority)

support among various health-care professional and citi-

zen groups for legalised death hastening (Kinsella &

Verhoef 1993, Verhoef & Kinsella 1993, 1996, Ogden &

Young 1998, Young & Ogden 1998, Marcoux et al. 2007,

Wilson et al. 2007). This finding of majority support can-

not also be generalised to other countries, including

countries that are similar to Canada in that they are highincome, and with ageing populations and high rates of

chronic illness. Regardless, this finding of majority sup-

port should be of considerable interest and relevance to

many individuals and groups both in and outside of

Alberta. This finding may help to explain the growing

number of petitions for legalising hastened death by

Canadians, the growing voice of death-hastening sup-

portive groups in Canada, and also the recent SupremeCourt ruling and the government report that recom-

mended legitimising assisted suicide and ⁄or euthanasia

(2012 BCSC 886 Carter v. Canada, Dying with Dignity

2012).

However, some limitations exist with this telephone

survey. As affluent individuals and households are more

likely to have more phones than socially deprived indi-

viduals and households, this telephone survey is biasedin favour of more affluent persons ⁄households. In addi-

tion, this survey did not determine why such a high level

of public support for the right to hastened death exists

among Albertans. It is possible that the social value of

compassion for ill people, which is thought to have cre-

ated and since maintained a universal publicly funded

health-care system in Canada (Wilson & Keiser 1996,

Wilson & Ross Kerr 1998), could be a factor. Majoritysupport for hastened death could also demonstrate, as

argued by Northcott & Wilson (2008) that death and

dying are no longer socially taboo subjects; with death

having moved beyond a ‘failure to rescue’ to being per-

ceived more often as an inescapable event at the end of a

long life or long illness. In Canada, <10% of deaths now

Table 4 Findings of multinomial logistic regression to evaluate

factors associated with support for hastened death (‘no’ as ref-

erence category)

Yes, but only in

certain cases

or situations Yes

OR (95% CI) OR (95% CI)

Religious affiliation

and religiosity

Not religious Reference

category

Reference

category

Religious – Catholic 0.24 (0.13–0.43) 0.06 (0.03–0.11)

Religious – Protestant 0.17 (0.09)0.30) 0.06 (0.03–0.12)

Religious – other 0.12 (0.07–0.23) 0.08 (0.04–0.14)

Non-religious Catholic 0.63 (0.31–1.30) 0.37 (0.18–0.76)

Non-religious Protestant 0.72 (0.33–1.55) 0.42 (0.20–0.92)

Non-religious other 0.28 (0.13–0.59) 0.16 (0.07–0.34)

Euthanised pet ⁄ animal

Yes 1.78 (1.25–2.53) 1.72 (1.18–2.51)

No Reference

category

Reference

category

Has an advance directive

or is planning one

Yes 1.23 (0.75–2.02) 1.91 (1.12–3.26)

No, but planning one 1.44 (0.89–2.35) 1.69 (0.99–2.88)

No Reference

category

Reference

category

Pseudo R2 (Nagelkerke): 19.5%. Bold signifies significant

differences with reference category.

Public support

ª 2012 Blackwell Publishing Ltd 205

are sudden and unexpected, with over 90% occurring atthe end of a long illness and also typically at the end of

a long life (Wilson et al. 2011). Emanuel et al. (2000)

argued that the public is becoming more supportive of

hastened death because of the increasingly common

and open practices of treatment withholding and with-

drawal. Growing interest in human rights could also be

a factor, with Canada’s 1982 Charter of Rights and Free-

doms having had 30 years of public exposure. Further-more, widespread death anxiety among the Alberta

public could be a factor, as death anxiety has been

shown to contribute to support for hastened death

(Bowling et al. 2010).

It was surprising that few differences in death hasten-

ing support were found among the surveyed groups, as

over 50% of persons in all but one sub-group (Religious-

Other) were in favour or conditionally in favour of theright to hastened death when asked directly: ‘Should

dying adults be able to request and get help from others

to end their life early, in other words, this is a request for

assisted suicide’? ‘Religious-Other’ persons comprised of

Muslims, Hindus, Buddhists and other minority reli-

gious groups. These are people with important diverse

cultural perspectives, with previous studies having

already shown considerable culture-based differences inend-of-life customs and expectations (Thomas et al.2008). However, not enough is known about minority

views on hastened death. In Canada, for instance, little if

anything is known about Aboriginal peoples’ views on

hastened death, and it cannot be assumed that there will

be a single shared viewpoint among all First Nation per-

sons. This survey, which involved 34 people, who indi-

cated North American Aboriginal ancestors did not findany significant differences between their viewpoints on

the right to hastened death as compared to those of non-

Aboriginals. The majority in both sub-groups were in

favour of the right to hastened death. Regardless, our

survey highlights the need for minority studies, a partic-

ularly urgent consideration as global migration is contin-

uing to diversify the population of Canada and many

other countries.The analysis only found self-identified religiosity was

a factor for non-support of the right to hastened death,

while having had experience in relation to euthanising a

pet or another animal, and having an advance directive

or plans for one were factors influencing support for the

right to hastened death. This is not the first study to find

religiosity influences health-care decision-making or

decisions (Cohen et al. 2008, Stempsey 2010). Decliningreligious affiliation, a trend already pronounced and

expected to continue in Canada and many other high-

income countries (Clark & Schellenberg 2008), could

therefore be a factor for ongoing increased interest in or

demand for hastened death.

It is also understandable that the experience ofdeciding to end and perhaps directly participating in

terminating a pet or another animal’s life would predict

death-hastening support. Pets are sometimes as impor-

tant as family members and friends; they may also be a

substitute for them (Adrian et al. 2009). Hastening the

death of a pet would typically constitute a very signifi-

cant event for all involved persons. However, pet eutha-

nasia is not likely to be a frequent life experience, butanimal deaths are common for farmers and ranchers.

Research has already indicated that rural Canadians rec-

ognise the dilemma that an animal’s suffering at the

end of life can be ended, but death hastening is not leg-

ally possible in Canada and thus it is not openly avail-

able for dying persons who are suffering near death

(Wilson et al. 2009a). The mechanism here may be that

the experience of having to euthanise a pet or anotheranimal out of reasons of mercy may incite more under-

standing of similar death hastening reasons for human

beings, with this a compassionate response or at least a

demonstration of awareness that a similar level of com-

passion may be needed for humans. It is also important

to note that research is increasingly indicating that life

experiences are major determinants of future action

(Singer et al. 1995, Breitbart et al. 2000, Nissen et al. 2009,Pousset et al. 2009). Experiences such as pet ⁄ animal

euthanasia should begin to be understood as prime

indicators of public opinion and possibly future action

on death hastening.

Conclusion

This study revealed majority support for death hasten-

ing among a relatively representative sample of

Albertans. Over 50% of respondents in all but one

socio-demographic sub-group (Religious-Other) were

fully or conditionally supportive of the right to has-

tened death. The regression model highlighted three

different predictors, however, with the experience of

deciding to euthanise a pet ⁄animal and having or plan-ning to have an advance directive both predicting sup-

port for the right to hastened death, whereas self-

reported religiosity predicted non-support. With the

number of deaths each year expected to increase and

double over the next two to three decades (Wilson

et al. 2009b), many more citizens will likely gain experi-

ence-based insights on death and dying. These experi-

ences and declining religiosity could contribute torising demand for death hastening legalisation. How-

ever, any such policy should include consideration of

the model that best serves terminally ill persons who

wish to have their death hastened, but one that also

protects dying people as they are highly vulnerable to

despair and other suffering near the end of life.

D. M. Wilson et al.

206 ª 2012 Blackwell Publishing Ltd

Requests for hastened death should never be a resultof absent or low quality palliative care.

Acknowledgements

The authors would like to acknowledge the Popula-

tion Research Laboratory for their excellent survey

work and CIHR funding (Institutes of CancerResearch and Health Services and Policy Research)

from a 5-year ICE grant #HOA-80057: ‘Timely Access

and Seamless Transitions in Rural Palliative ⁄ End-of-

Life Care’, awarded to Allison Williams and Donna

Wilson.

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