The incorporation of the provision of aid in dying to the common portfolio of services of the National Health System, after the approval of the Organic Law for the Regulation of Euthanasia (LORE), raises the need to investigate the knowledge of medical professionals about the processes of application of this procedure.
Material and methodsA self-administered online questionnaire of 25 questions was distributed among 2,386 medical practitioners involved in the clinical training of the students enrolled in the Degree in Medicine at the University of Granada.
Results436 medical professionals (50.2% women) answered the survey. The specialty of Family and Community Medicine contributed the highest number of participants (20.4%). Around 60% of the physicians did not know the legal requirements that must be met by the patient requesting aid in dying or the role of the responsible physician and the consultant physician. 33.5% of the respondents declared that they would request conscientious objection if necessary and only 14.4% stated that they had received any specific training course in their workplace. More than 80% of the specialists did not consider themselves prepared to deal with this procedure.
ConclusionsThe results of this study indicate that the level of knowledge of the medical professionals surveyed about key aspects of LORE may still be insufficient, pointing out the need to reinforce their training to offer a better response to euthanasia contexts and ensure adequate access to this service for patients.
La incorporación de la prestación de ayuda para morir a la cartera común de servicios del Sistema Nacional de Salud, tras la entrada en vigor de la Ley orgánica de regulación de la eutanasia (LORE), plantea la necesidad de indagar sobre el conocimiento de los profesionales médicos acerca de los procesos de aplicación de este procedimiento.
Material y métodosSe distribuyó un cuestionario online autoadministrado de 25 preguntas entre 2.386 facultativos médicos vinculados con la formación clínica de los estudiantes del grado en Medicina de la Universidad de Granada.
ResultadosEl cuestionario fue respondido por 436 profesionales médicos (50,2% mujeres). La especialidad de Medicina Familiar y Comunitaria fue la que aportó un mayor número de participantes (20,4%). Alrededor del 60% de los encuestados desconocía los requisitos legales que debe cumplir el paciente que solicita la prestación de ayuda para morir o el papel del médico responsable y el médico consultor. El 33,5% de los participantes manifestó que solicitaría la objeción de conciencia llegado el caso. Solo el 14,4% afirmó haber recibido formación específica en su lugar de trabajo. Más del 80% de los especialistas aún no se consideraban preparados para abordar este procedimiento.
ConclusionesLos resultados de este estudio indican que el nivel de conocimiento de los profesionales médicos encuestados sobre aspectos clave de la LORE podría ser todavía insuficiente, señalando la necesidad de reforzar su formación para ofrecer una mejor respuesta ante contextos eutanásicos y asegurar el adecuado acceso de los pacientes a esta prestación.
With the enactment of Organic Law 3/2021, of 24 March, on the regulation of euthanasia (LORE),1 Spain became the seventh country in the world to decriminalise and regulate this procedure.2 Since 25 June 2021, the provision of assistance in dying has been incorporated into the Basic Portfolio of Services of the National Healthcare System as one more provision in end-of-life care, establishing access to euthanasia as a new individual right, underpinned by the respect for patient autonomy.3,4
In Andalusia, the effective implementation of the LORE did not begin until 5 months after its entry into force, when this autonomous region established its Guarantee and Evaluation Commission.5 According to the annual reports published by the Commission,5,6 between 2022 and 2023, the Andalusian public healthcare system received 137 requests for assistance in dying, resulting in 92 cases opened and 53 procedures carried out (38.7%). In Spain as a whole, up to 31 December 2023, a total of 1515 requests were processed and 697 procedures were carried out (46%).7
Providing assistance in dying entails significant medical, legal and social implications, giving rise to conflicting positions in various sectors of society, including the medical profession.8,9 At this point, the individual right to conscientious objection on the part of healthcare professionals who are directly involved also comes into play, as this is recognised explicitly by the LORE in its article 16.1 Nevertheless, as outlined in the Manual of Good Practices in Euthanasia,10 this right should not, under any circumstances, compromise the initiation of the procedure and, consequently, patients' access to this provision.
The LORE is a very complex and recently implemented law, making it essential to provide healthcare professionals with the appropriate training for its understanding and application.3,5–7,11 In this regard, some authors have criticised the LORE for focusing on legal procedures without ensuring that affected professionals receive the necessary training, thus missing the opportunity to promote changes in undergraduate education that could contribute to address these deficiencies.12
The objective of this study was to analyse the level of knowledge of the LORE among medical professionals working in healthcare institutions affiliated with the University of Granada (UGR), their position regarding the application of this provision, and the involvement of their workplaces in providing the necessary professional training, by means of a self-administered online survey.
Material and methodsA questionnaire (see appendix) comprising 25 questions was designed and then underwent an internal validation process among the authors, followed by external validation among a sample of 10 volunteer physicians. The first 5 questions collected sociodemographic information about the participants: sex, age range, medical specialty, years of professional practice and workplace. The subsequent questions were multiple-choice with a single answer (“yes,” “no” or “don't know/no answer”) and explored their general knowledge of the LORE, their opinion about participating in the procedure of euthanasia and their professional experience related to the application of this provision. The final 5 questions used a rating scale to ascertain the assessment by these medical professionals of their level of knowledge about euthanasia following the entry into force of the LORE, the dissemination of this provision in their workplace, the training received, their level of competence and the resolution of doubts and issues. The study obtained approval from the Human Research Ethics Committee of the UGR, with registration number 3114/CEIH/2022.
Between January and March 2023, the survey was sent via e-mail to 2386 medical practitioners who, upon request, had been appointed by the Andalusian Public Health System as clinical tutors to supervise clinical placements of UGR medical students at health centres located in the provinces of Granada (77.6%), Almeria (14.3%) and Jaen (8%). A database containing the contact e-mail address, medical specialty and workplace of these professionals, with no other personal information, was used to contact the subjects. The e-mail informed participants about the objectives and goals of the study, and included a link to complete the survey in Google Forms. At the outset, participants were required to provide their express consent to take part in the study and were assured about the anonymity of their responses throughout the entire process, in accordance with current Spanish legislation on personal data protection.13
Responses were analysed statistically using the program SPSS, version 28.0 (IBM Corp., Armonk, NY, USA). A descriptive analysis of the data was conducted, as well as a study of frequencies and percentages of the responses. The bivariate analysis employed the Pearson χ2 test. A value of P < .05 was considered statistically significant.
ResultsA total of 436 medical professionals completed the survey, of which 219 were female (50.2%) and 217 were male (49.8%). The most common age range was that comprising between 30 and 45 years (50.2%), which accounted for 61.6% of the total females and 37.8% of males surveyed (of these, 43% were in the age range between 50 and 65 years). In terms of their medical specialties, family and community medicine accounted for the highest number of participants (20.4%), followed by internal medicine and obstetrics and gynaecology (7.3%). Regarding the years of professional practice, 20.6% had between 6 and 10 years of experience, representing 25.6% of the total females and 15.9% of males (in the latter case, the group with 36–40 years of experience accounted for 16.4%). Public hospitals were the main place of work of participants, with 79.6%. Table 1 shows the distribution of percentages of specialties of the professionals who were sent the survey, compared to those who responded, as well as the total rate of response (18.3%) and the distribution by medical specialty.
Response rates by medical specialty.
| Medical specialty | Surveys sent | Surveys responded | Rate of response |
|---|---|---|---|
| n (%) | n (%) | ||
| Allergology | 8 (0.3) | 1 (0.2) | 12.5 |
| Pathological anatomy | 17 (0.7) | 7 (1.6) | 41.2 |
| Anaesthesiology and resuscitation | 138 (5.8) | 15 (3.4) | 10.9 |
| Angiology and vascular surgery | 25 (1) | 6 (1.4) | 24.0 |
| Digestive system | 70 (2.9) | 15 (3.4) | 21.4 |
| Cardiology | 62 (2.6) | 11 (2.5) | 17.7 |
| Cardiovascular surgery | 5 (0.2) | 1 (0.2) | 20.0 |
| General and digestive system surgery | 121 (5.1) | 25 (5.7) | 20.7 |
| Oral and maxillofacial surgery | 14 (0.6) | 3 (0.7) | 21.4 |
| Orthopaedic surgery and traumatology | 78 (3.3) | 13 (3.0) | 16.7 |
| Paediatric surgery | 18 (0.8) | 1 (0.2) | 5.6 |
| Plastic, aesthetic and reconstructive surgery | 5 (0.2) | 1 (0.2) | 20.0 |
| Thoracic surgery | 16 (0.7) | 1 (0.2) | 6.3 |
| Medical-surgical dermatology and venereology | 45 (1.9) | 10 (2.3) | 22.2 |
| Endocrinology and nutrition | 18 (0.8) | 5 (1.1) | 27.8 |
| Haematology and haemotherapy | 35 (1.5) | 7 (1.6) | 20.0 |
| Family and community medicine | 585 (24.5) | 89 (20.4) | 15.2 |
| Physical medicine and rehabilitation | 36 (1.5) | 11 (2.5) | 30.6 |
| Preventive medicine and public health | 6 (0.3) | 0 | 0 |
| Intensive care medicine | 80 (3.4) | 16 (3.7) | 20.0 |
| Internal medicine | 125 (5.2) | 32 (7.3) | 25.6 |
| Nuclear medicine | 27 (1.1) | 4 (0.9) | 14.8 |
| Nephrology | 25 (1.0) | 5 (1.1) | 20.0 |
| Pulmonology | 48 (2.0) | 12 (2.8) | 25.0 |
| Neurosurgery | 22 (0.9) | 4 (0.9) | 18.2 |
| Neurology | 44 (1.8) | 7 (1.6) | 15.9 |
| Obstetrics and gynaecology | 153 (6.4) | 32 (7.3) | 20.9 |
| Ophthalmology | 48 (2.0) | 6 (1.4) | 12.5 |
| Medical oncology | 38 (1.6) | 11 (2.5) | 28.9 |
| Radiation oncology | 26 (1.1) | 8 (1.8) | 30.8 |
| Otolaryngology | 43 (1.8) | 7 (1.6) | 16.3 |
| Paediatrics | 167 (7.0) | 25 (5.7) | 15.0 |
| Psychiatry | 106 (4.4) | 21 (4.8) | 19.8 |
| Radiodiagnostics | 73 (3.1) | 9 (2.1) | 12.3 |
| Rheumatology | 16 (0.7) | 0 | 0 |
| Urology | 25 (1.0) | 10 (2.3) | 40.0 |
| Other specialty | 18 (0.8) | 5 (1.1) | 27.8 |
| Total | 2386 (100) | 436 (100) | 18.3 |
In terms of the level of knowledge of the LORE among the professionals surveyed (Table 2), 65.1% said they were aware of the modalities of provision of assistance in dying regulated by this law. The requirements that a patient should meet in order to receive the provision were known by 58.7%, while the requirements for a request were known by 42% of respondents. A similar percentage (41.5%) were aware of the role of the responsible and consulting physicians, while the number of respondents who said they knew the role of the Guarantee and Evaluation Commission was lower, at 37.2%. In total, 72% of respondents said they knew whether it was possible or not to delay or withdraw the request, although only 19.7% knew to whom patients should resort in case of a denial. The procedure to exercise conscientious objection was known by 23.9% of participants. No significant differences were found between the responses to these questions provided by males and females, except for the possibility of delaying or withdrawing the request, with a higher ignorance about the regulation (which does not allow a delay of the request, but does accept its repeal or withdrawal) on the part of surveyed males (27.6% vs. 17.8%; P < .01). In terms of age, as shown in Table 2, there were statistically significant differences between the responses provided by those aged under and over 45 years, with a higher percentage of affirmative responses among the older group.
Knowledge of the LORE by the medical professionals surveyed according to their age group.
| Yes | No | DK/NA | Total | ||
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n | ||
| Do you know the modalities of provision of assistance in dying regulated by the LORE? | |||||
| Age group⁎ | <45 years | 141 (59.7) | 32 (13.6) | 63 (26.7) | 236 |
| >45 years | 143 (71.5) | 26 (13) | 31 (15.5) | 200 | |
| Total of the sample | 284 (65.1) | 58 (13.3) | 94 (21.6) | 436 | |
| Do you know the requirements that a patient should meet in order to receive the provision of assistance in dying? | |||||
| Age group⁎ | <45 years | 124 (52.5) | 100 (42.4) | 12 (5.1) | 236 |
| >45 years | 132 (66) | 59 (29.5) | 9 (4.5) | 200 | |
| Total of the sample | 256 (58.7) | 159 (36.5) | 21 (4.8) | 436 | |
| Do you know the requirements to request the provision of assistance in dying? | |||||
| Age group⁎⁎ | <45 years | 77 (32.6) | 145 (72.5) | 14 (5.9) | 236 |
| >45 years | 106 (53) | 86 (43) | 8 (4) | 200 | |
| Total of the sample | 183 (42) | 231 (53) | 22 (5) | 436 | |
| Do you know the role of the responsible and consulting physicians in this context upon a request for euthanasia? | |||||
| Age group⁎ | <45 years | 83 (35.2) | 143 (60.6) | 10 (4.2) | 236 |
| >45 years | 98 (49) | 90 (45) | 12 (6) | 200 | |
| Total of the sample | 181 (41.5) | 233 (53.4) | 22 (5) | 436 | |
| Do you know the functions carried out by the Guarantee and Evaluation Commission? | |||||
| Age group⁎⁎ | <45 years | 69 (29.2) | 158 (66.9) | 9 (3.8) | 236 |
| >45 years | 93 (46.5) | 93 (46.5) | 14 (7) | 200 | |
| Total of the sample | 162 (37.2) | 251 (57.6) | 23 (5.3) | 436 | |
| Do you know if a patient may delay or withdraw a request for provision of assistance in dying at any time? | |||||
| Age group | <45 years | 162 (68.6) | 61 (25.8) | 13 (5.5) | 236 |
| >45 years | 152 (76) | 37 (18.5) | 11 (5.5) | 200 | |
| Total of the sample | 314 (72) | 98 (22.5) | 24 (5.5) | 436 | |
| Do you know who the patient should resort to in case their request is denied by the responsible physician? | |||||
| Age group⁎ | <45 years | 34 (14.4) | 192 (81.4) | 10 (4.2) | 236 |
| >45 years | 52 (26) | 136 (68) | 12 (6) | 200 | |
| Total of the sample | 86 (19.7) | 328 (75.2) | 22 (5) | 436 | |
| Do you know the procedure to be followed in order to exercise conscientious objection to the provision of assistance in dying? | |||||
| Age group⁎⁎ | <45 years | 42 (17.8) | 189 (80.1) | 5 (2.1) | 236 |
| >45 years | 62 (31) | 126 (63) | 12 (6) | 200 | |
| Total of the sample | 104 (23.9) | 315 (72.2) | 17 (3.9) | 436 | |
DK/NA: don't know/no answer.
Regarding the issues related to participation in the procedure of euthanasia (Table 3), 49.5% of respondents said they were prepared to carry out the role of responsible physician, with 43.3% being prepared to administer or prescribe the drugs intended to provide assistance in dying. In total, 33.5% said that they would declare conscientious objection, while only 11.9% had disseminated information about this provision among their patients. No statistically significant differences were found among the responses provided by males and females to these questions. However, statistically significant differences were observed between age groups and are shown in detail in Table 3. Regarding the professional experience in relation to this procedure, 7.8% of respondents said they had received a request for the provision of assistance in dying. These professionals mostly belonged to the specialties of family and community medicine, internal medicine and medical oncology, as shown in Table 4.
Opinion of surveyed physicians about their participation in the procedure of euthanasia according to their age group.
| Yes | No | DK/NA | Total | ||
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n | ||
| Would you be prepared to fulfil the role of responsible physician if the case arose? | |||||
| Age group⁎ | <45 years | 139 (58.9) | 55 (23.3) | 42 (17.8) | 236 |
| >45 years | 77 (38.5) | 95 (47.5) | 28 (14) | 200 | |
| Total of the sample | 216 (49.5) | 150 (34.4) | 70 (16.1) | 436 | |
| Would you be prepared to administer drugs aimed at providing assistance in dying? | |||||
| Age group⁎ | <45 years | 127 (53.8) | 73 (30.9) | 36 (15.3) | 236 |
| >45 years | 62 (31) | 106 (53) | 32 (16) | 200 | |
| Total of the sample | 189 (43.3) | 179 (41.1) | 68 (15.6) | 436 | |
| Would you declare conscientious objection to administering euthanasia? | |||||
| Age group⁎ | <45 years | 56 (23.7) | 134 (56.8) | 46 (19.5) | 236 |
| >45 years | 90 (45) | 81 (40.5) | 29 (14.5) | 200 | |
| Total of the sample | 146 (33.5) | 215 (49.3) | 75 (17.2) | 436 | |
| Have you disseminated the possibility of obtaining this type of assistance among your patients? | |||||
| Age group | <45 years | 27 (11.4) | 200 (84.7) | 9 (3.8) | 236 |
| >45 years | 25 (12.5) | 164 (82) | 11 (5.5) | 200 | |
| Total of the sample | 52 (11.9) | 364 (83.5) | 20 (4.6) | 436 | |
DK/NA: don't know/no answer.
Distribution of respondents who said they had received a request for euthanasia, according to their medical specialty.
| Medical specialty | n (% within the specialty) |
|---|---|
| Anaesthesiology and resuscitation | 1 (6.7) |
| Angiology and vascular surgery | 2 (33.3) |
| Cardiology | 1 (9.1) |
| Haematology and haemotherapy | 1 (14.3) |
| Family and community medicine | 13 (14.6) |
| Physical medicine and rehabilitation | 2 (18.2) |
| Internal medicine | 6 (18.8) |
| Neurosurgery | 1 (25) |
| Medical oncology | 3 (27.3) |
| Radiation oncology | 1 (12.5) |
| Psychiatry | 2 (9.5) |
| Urology | 1 (10) |
On the one hand, 14.4% of physicians reported having received training on euthanasia at their workplace, while 18.8% said they had received specific instructions on how to handle a request for euthanasia at their centre or service. Regarding the level of satisfaction with the dissemination of information about the provision of assistance in dying at their workplace (Table 5), 4.3% of participants reported feeling satisfied (score of 4 or 5), compared to 82.6% of respondents who expressed dissatisfaction (score of 1 or 2) over this issue. In relation to the training provided by their service or workplace (Table 5), physicians who reported being fully satisfied (score of 5) accounted for 2.5% of the total samples. By comparison, 63.5% of respondents considered this training totally insufficient (score of 1), with this option being the most common response among all medical specialties. Lastly, the assessment of the level of satisfaction of respondents regarding the resolution of doubts and issues raised at their workplace (Table 5) showed that 7.6% of physicians were satisfied (score of 4 or 5) with this matter, compared to 69.2% who reported dissatisfaction (score of 1 or 2). The detailed results by medical specialty are presented in Table 5.
Assessment of the level of satisfaction regarding dissemination, training provided and resolution of doubts and issues by their service or workplace regarding the provision of assistance in dying, according to the medical specialty of respondents.a
| 1 | 2 | 3 | 4 | 5 | NA | Total | |
|---|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | n | |
| Assessment of the level of dissemination provided by their service or workplace regarding the provision of assistance in dying | |||||||
| Family and community medicine | 39 (43.8) | 24 (27) | 16 (18) | 5 (5.6) | 3 (3.4) | 2 (2.2) | 89 |
| Internal medicine | 15 (46.9) | 10 (31.3) | 6 (18.8) | 1 (3.1) | 0 | 0 | 32 |
| Obstetrics and gynaecology | 19 (59.4) | 11 (34.4) | 2 (6.3) | 0 | 0 | 0 | 32 |
| General and digestive system surgery | 18 (72) | 6 (24) | 0 | 1 (4) | 0 | 0 | 25 |
| Paediatrics | 10 (40) | 6 (24) | 7 (28) | 2 (8) | 0 | 0 | 25 |
| Psychiatry | 13 (61.9) | 5 (23.8) | 2 (9.5) | 0 | 1 (4.8) | 0 | 21 |
| Other | 142 (67) | 42 (19.8) | 21 (9.9) | 3 (1.4) | 3 (1.4) | 1 (0.5) | 212 |
| Total of the sample | 256 (58.7) | 104 (23.9) | 54 (12.4) | 12 (2.7) | 7 (1.6) | 3 (0.7) | 436 |
| Assessment of the level of satisfaction with the training provided by their service or workplace regarding the procedure of euthanasia | |||||||
| Family and community medicine | 46 (51.7) | 17 (19.1) | 12 (13.5) | 10 (11.2) | 4 (4.5) | 0 | 89 |
| Internal medicine | 18 (56.3) | 8 (25) | 3 (9.4) | 1 (3.1) | 1 (3.1) | 1 (3.1) | 32 |
| Obstetrics and gynaecology | 21 (65.6) | 9 (28.1) | 2 (6.3) | 0 | 0 | 0 | 32 |
| General and digestive system surgery | 20 (80) | 3 (12) | 2 (8) | 0 | 0 | 0 | 25 |
| Paediatrics | 12 (48) | 6 (24) | 6 (24) | 0 | 1 (4) | 0 | 25 |
| Psychiatry | 13 (61.9) | 5 (23.8) | 2 (9.5) | 0 | 1 (4.8) | 0 | 21 |
| Other | 147 (69.3) | 37 (17.5) | 14 (6.6) | 9 (4.2) | 4 (1.9) | 1 (0.5) | 212 |
| Total of the sample | 277 (63.5) | 85 (19.5) | 41 (9.4) | 20 (4.6) | 11 (2.5) | 2 (0.5) | 436 |
| Assessment of the level of satisfaction with the resolution of doubts and issues raised at their service or workplace in relation to the provision of assistance in dying | |||||||
| Family and community medicine | 36 (40.4) | 17 (19.1) | 20 (22.5) | 11 (12.4) | 3 (3.4) | 2 (2.2) | 89 |
| Internal medicine | 15 (46.9) | 6 (18.8) | 8 (25) | 2 (6.3) | 0 | 1 (3.1) | 32 |
| Obstetrics and gynaecology | 17 (53.1) | 8 (25) | 6 (18.8) | 0 | 1 (3.1) | 0 | 32 |
| General and digestive system surgery | 13 (52) | 9 (36) | 3 (12) | 0 | 0 | 0 | 25 |
| Paediatrics | 12 (48) | 3 (12) | 7 (28) | 2 (8) | 0 | 1 (4) | 25 |
| Psychiatry | 7 (33.3) | 7 (33.3) | 4 (19) | 0 | 2 (9.5) | 1 (4.8) | 21 |
| Other | 109 (51.4) | 43 (20.3) | 42 (19.8) | 8 (3.8) | 4 (1.9) | 6 (2.8) | 212 |
| Total of the sample | 209 (47.9) | 93 (21.3) | 90 (20.6) | 23 (5.3) | 10 (2.3) | 11 (2.5) | 436 |
NA: No answer.
Regarding the set of questions scored via a scale, which included the opinion of participants about their level of knowledge and competence in relation to the provision of assistance in dying (Table 6), 42.7% considered that the increase in their level of knowledge about euthanasia since the entry into force of the LORE deserved the minimum score (1). Only 5.3% of respondents selected the maximum score (5). Those who considered themselves totally competent (score of 5) in the application of this provision accounted for 5.7% of the total samples. On the other hand, 45.4% of the physicians surveyed selected the minimum score (1) to reflect their level of competence. Table 6 shows the distribution of responses to these questions by medical specialty.
Assessment of respondents regarding their level of knowledge and competence in relation to the provision of assistance in dying, by medical specialty.a
| 1 | 2 | 3 | 4 | 5 | NA | Total | |
|---|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | n | |
| Assessment of the increase in level of knowledge in relation to the procedure of euthanasia following the entry into force of the LORE | |||||||
| Family and community medicine | 22 (24.7) | 18 (20.2) | 21 (23.6) | 18 (20.2) | 10 (11.2) | 0 | 89 |
| Internal medicine | 18 (56.3) | 2 (6.3) | 5 (15.6) | 3 (9.4) | 4 (12.5) | 0 | 32 |
| Obstetrics and gynaecology | 13 (40.6) | 10 (31.3) | 4 (12.5) | 2 (6.3) | 3 (9.4) | 0 | 32 |
| General and digestive system surgery | 14 (56) | 4 (16) | 5 (20) | 1 (4) | 1 (4) | 0 | 25 |
| Paediatrics | 11 (44) | 5 (20) | 5 (20) | 4 (16) | 0 | 0 | 25 |
| Psychiatry | 2 (9.5) | 4 (19) | 11 (52.4) | 3 (14.3) | 1 (4.8) | 0 | 21 |
| Other | 106 (50) | 39 (18.4) | 42 (19.8) | 21 (9.9) | 4 (1.9) | 0 | 212 |
| Assessment of the level of competence in relation to the application of the provision of assistance in dying | |||||||
| Family and community medicine | 24 (27) | 24 (27) | 16 (18) | 18 (20.2) | 6 (6.7) | 1 (1.1) | 89 |
| Internal medicine | 17 (53.1) | 1 (3.1) | 8 (25) | 4 (12.5) | 2 (6.3) | 0 | 32 |
| Obstetrics and gynaecology | 18 (56.3) | 8 (25) | 3 (9.4) | 2 (6.3) | 1 (3.1) | 0 | 32 |
| General and digestive system surgery | 14 (56) | 1 (4) | 8 (32) | 1 (4) | 1 (4) | 0 | 25 |
| Paediatrics | 12 (48) | 5 (20) | 4 (16) | 3 (12) | 1 (4) | 0 | 25 |
| Psychiatry | 6 (28.6) | 9 (42.9) | 4 (19) | 0 | 2 (9.5) | 0 | 21 |
| Other | 107 (50.5) | 39 (18.4) | 31 (14.6) | 19 (9) | 12 (5.7) | 4 (1.9) | 212 |
| Total of the sample | 198 (45.4) | 87 (20) | 74 (17) | 47 (10.8) | 25 (5.7) | 5 (1.1) | 436 |
NA: no answer.
The LORE assigns coordination of the procedure to provide assistance in dying to medical staff.1 The role of family doctors is crucial in this regard, since patients tend to resort to them in order to present a request for euthanasia, thus making this the main specialty of responsible physicians.3,5–7 However, the profile of consulting physicians differs, as it is focused on the specialty of the main ailment suffered by patients requesting this assistance in dying.3,5–7 Nevertheless, family doctors usually assume this role in the case of patients with multiple pathologies, complex chronic patients and those with geriatric syndromes.1,3,5–7 In this study, 20.4% of participating physicians were family and community medicine specialists, with the rest divided into more than thirty other medical specialties (Table 1), including some which may be involved most frequently with the provision of this assistance (neurology, oncology, internal medicine).3,5–7 The rate of response of these specialities was below 20% in the case of family and community medicine and neurology, while the rates for internal medicine, medical oncology and radiation oncology were over 25% (Table 1).
It is striking that around 60% of respondents were not aware of key aspects of the LORE, including the legal requirements that patients should meet in order to request the provision, the role of the responsible and consulting physicians and the functions of the Guarantee and Evaluation Commission (Table 2). Likewise, more than 75% of participants reported not knowing the procedure to exercise their right to conscientious objection, despite this being expressly recognised by the LORE (Table 2). In a previous study by Pujol-Fontrodona et al.,14 based on a survey conducted in 2022 among 1446 Spanish physicians, less than 25% of respondents said they knew the LORE in detail. These results highlight that the dissemination of this law among healthcare professionals, as well as the provision of continuous training regarding assistance in dying, contained in the LORE itself,1 have not been sufficient. In our study, less than 20% of the physicians surveyed had received specific training on euthanasia or concrete instructions on how to manage a request at their workplace or service.
In Andalusia, a total of 1340 conscientious objectors were registered up to December 2023, with the provinces where surveyed physicians worked having the lowest number of registered objectors.5,6 Nevertheless, it is also important to consider that, in real practice, ad hoc objection is admitted and applied, meaning that a professional who is not included in the register could still express their objection to any specific request.15 In this regard, 33.5% of the professionals surveyed expressed that, if the situation arose, they would declare themselves as conscientious objectors (Table 3). Similar percentages were recorded in surveys conducted among physicians working in the provinces of Vizcaya (2018, 28.3%),16 Las Palmas (2019, 28.6%),17 Tarragona (2019, 31%),18 Madrid (2019, 37.6%)19 and Zaragoza (2021, 33%).4 In the study by Pujol-Fontrodona et al.,14 16.6% of respondents said that they were already registered or were planning to register as objectors. In our study, professionals aged 45 and above reported having a better knowledge of the LORE (Table 2), but were more reluctant to participate in the process, instead being more inclined to request conscientious objection compared to younger physicians (45% vs. 23.7%; P < .001) (Table 3). This observation goes hand in hand with the fact that older respondents tended to express a more unfavourable opinion of euthanasia, both within the medical collective14 and in society in general.20
In total, 49.5% of participants in our survey were prepared to fulfil the role of responsible physician, with 43.3% of them prepared to administer or prescribe drugs aimed at providing assistance in dying (Table 3). The disparity in percentages observed could be interpreted as the result of a lack of knowledge by medical professionals regarding the specific functions assigned to this key figure (Table 2), which include, among others, carrying out the provision of assistance in dying together with the care team.10 Furthermore, it could also indicate that some professionals are prepared to assume the role of responsible physician, as long as they are not the members of the care team in charge of administering the drug to the patient. Nevertheless, less than 10% of respondents reported having received a request for the provision of assistance in dying (Table 4), despite belonging to the specialties most involved in the procedure.3,5–7 In the study of Pujol-Fontrodona et al.,14 86.7% of respondents declared not having participated in the process of euthanasia so far.
In our study, 61.5% of the surveyed professionals considered that their level of knowledge of euthanasia since the entry into force of the LORE had hardly improved (Table 6). In this regard, more than 80% expressed their dissatisfaction with the level of information and specific training provided by their workplace or service (Table 5). In terms of their level of competence to apply this assistance, only 16.5% of respondents considered themselves prepared, including the 26.9% of family and community medicine specialists and the 18.8% of internal medicine specialists surveyed (Table 6). Faced with this lack of training, less than 8% expressed satisfaction with the response provided by their workplace to doubts and issues raised regarding the provision of this assistance (Table 5). This percentage was slightly higher (15.7%) among family and community medicine specialists, but lower still in other specialities frequently involved in the process, such as internal medicine (6.2%). Once again, these results indicate that, faced with a request for euthanasia, physicians do not have the necessary training to fulfil it with full guarantees, as has been pointed out by other authors.21 This lack of information and training generates uncertainty among medical professionals, contributing to their reluctance to participate in the procedure of euthanasia, which in turn could hamper patients' access to this provision.9,22 In this sense, it is important to consider other factors, including a lack of time by healthcare professionals and their intense administrative workload.9,11,22 Professional training should not only encompass the technical aspects of the procedure but also an understanding of the ethical and legal framework regulating it.11 Moreover, it is essential for these professionals to develop skills related to communication, deliberation and emotional and psychological accompaniment, so as to ensure high-quality care, while respecting at all times the rights and preferences of patients.11
In terms of the limitations of the study, it is worth noting that, due to the availability of access, the survey was disseminated among medical professionals included in the database of clinical tutors for the training of undergraduate medical students at the UGR, which included subjects from specialties that are only exceptionally involved in the provision of euthanasia. Thus, participation in the survey may have generated less interest among these professionals (Table 1). For this reason, it would be advisable to broaden the sample size, in order to more precisely reflect the level of knowledge and training of professionals working in Andalusia and other Spanish regions regarding the application of this provision, as well as to obtain a more representative sample of certain medical specialties which are frequently involved in this procedure, such as neurology and geriatrics.
ConclusionsThe provision of assistance in dying generates significant dilemmas and debates in society, including among the medical community itself. The results of this study appear to indicate that the dissemination of the LORE among physicians and the training received by them for its knowledge and application may still be insufficient. Another relevant conclusion is that, although older professionals declared having a higher level of knowledge of the LORE, they also tended to express more reluctance to participate in the procedure of euthanasia, and they were more predisposed to declare themselves conscientious objectors. Therefore, it seems essential to increase the efforts to provide adequate training for professionals, taking into consideration the complexity of the procedure to be followed and the guarantees that must be observed. Understanding which aspects of the LORE are difficult to interpret and generate uncertainty among medical professionals will contribute to ensure adequate access to the provision for patients, preventing unjustified delays that could violate the rights of those who request it.
FundingOpen access funding: University of Granada/CBUA.
The authors have no conflict of interests to declare.
The authors would like to express their gratitude to the Andalusian doctors who participated in this study. We would like to thank the University of Granada/CBUA for funding the open access publication.
Supplementary material.
Please cite this article as: González-Herrera L, Márquez-Ruiz AB, Miguel-García E, Valenzuela-Garach A. Study on the knowledge of the organic law for the regulation of euthanasia among medical professionals in eastern Andalusia. Revista Española de Medicina Legal. 2025. https://doi.org/10.1016/j.remle.2025.500490.
