OMEGA, Vol. 52(3) 263-287, 2005-2006

RACIAL DIFFERENCES IN ATTITUDES

TOWARD EUTHANASIA

JASON WASSERMAN, MA

JEFFREY MICHAEL CLAIR, PH.D.

FERRIS J. RITCHEY, PH.D.

University of Alabama at Birmingham

ABSTRACT

This article examines racial differences in attitudes toward euthanasia. Many

researchers assert distrust of medicine as a substantive explanation for less

favorable attitudes toward euthanasia among African Americans, although

quantitative measurement has been unsuccessful in showing this. In this

article, spiritual meaning, perceived capacity for discrimination (distrust),

individual experiences with physicians, and access to healthcare are hypothe-

sized as intervening variables in the relationship between race and attitudes

toward euthanasia. With a distinction between individual and collective

experiences with discrimination we use path analysis to test previous asser-

tions that African American distrust of medicine leads to more negative

attitudes toward euthanasia. Results indicate that while African Americans

exhibit higher levels of distrust of medicine, this is not related to attitudes

toward euthanasia, which seem predominantly to be a spiritual matter. Our

findings have implications for legislative policy, treatment interventions,

doctor-patient relations, and sociological understanding of the interaction of

race, spirituality, experience, and attitudes.

INTRODUCTION

This article examines racial differences in attitudes toward euthanasia. Spiritual

meaning, perceived capacity for discrimination (distrust), individual experiences

263

� 2006, Baywood Publishing Co., Inc.

with physicians, and access to healthcare are hypothesized as intervening

variables in the relationship between race and attitudes toward euthanasia. Our

model broadly tests the theoretical assumption that personal experiences influence

attitudes, but personal experiences involve more than overt acts of discrimination.

Personal experiences include the frustrations of encountering structural barriers

inherent in institutionalized racial and class discrimination. Both individual

experience with discrimination and the collective, cultural experiences of African

Americans as a minority group are characteristically negative. Institutional dis-

crimination leads to collective, cultural distrust of institutions in general. For the

institution of medicine, in particular, distrust is rooted in barriers to healthcare

access, receipt of lower tier medicine, and a history of unethical practices in

medical research (e.g., the Tuskegee syphilis study). Our focus is on how these

factors affect attitudes toward euthanasia, which continues to be a prominent and

controversial issue for medicine. Our findings have implications for legislative

policy, treatment seeking interventions, doctor-patient relations, and sociological

understanding of the interaction of race, spirituality, experience, and attitudes.

Technological advances have radically extended end of life trajectories and

brought about a host of new ethical and socio-medical issues that need to be

addressed. Many patients spend their final days in extreme pain. Proponents

of euthanasia argue that death with dignity necessarily entails respecting the

autonomy of the patient. Currently, patient autonomy is constrained within the

parameters of traditional medical norms, societal diversity in values and

ideologies, and the complexities of legal restraints.

Ethical acceptance of euthanasia, however, is an altogether different enterprise

than moving forward with the practical task of reconciling abstract moral judg-

ments with concrete social policies. There are a number of legitimate, pragmatic

social concerns that interfere with broadening patients’ controls over end-of-life

decisions. Of particular interest is public support for euthanasia, particularly

across different sectors with different medical experiences. Ultimately, public

policy will sink or swim on the basis of public opinion, so attitudes toward

euthanasia are of great importance to the practical debate.

Empirical research has become increasingly important as policy reform moves

to the forefront. This is exemplified by a number of high profile cases, such as the

enacting of legislation permitting physician-assisted suicide (PAS) in Oregon,

and in national policies from countries such as the Netherlands, where voluntary,

active euthanasia was legalized in 2002. Recent events suggest that euthanasia

will retain an important place in the political landscape, as at the time of this

writing, the U.S. Supreme Court is reviewing Oregon’s “Death with Dignity

Act,” at the behest of the Bush administration. The President and Congress also

intervened in unprecedented ways in the highly publicized case of Terry Schiavo.

Studies have shown that African Americans are significantly less supportive

of euthanasia than their white counterparts (Blackhall et al., 1999; Caralis, Davis,

Wright, & Marcial, 1993; DeCesare, 2000; Finlay, 1985; Garrett, Harris, Norburn,

264 / WASSERMAN, CLAIR AND RITCHEY

Patrick, & Danis, 1993; Jorgenson & Neubecker, 1980; Klessig, 1992;

Litchenstein, Alcser, Corning, Bachman, & Doukas, 1997; McKinley, Garrett,

Evans, & Danis, 1996; Rao, Staten, & Rao, 1988; Shavers, Lynch, & Burmeister,

2000; Singh, 1979; Wade & Anglin, 1987; Weiss, 1996). Causal explanations

have varied, although religious commitment has consistently been a strong

indicator. Many also assert distrust of medicine as a substantive explanation, but

the single effort by McKinley et al. (1996) to measure it quantitatively was

unsuccessful (Blackhall et al., 1999; Caralis et al., 1993; Finlay, 1985; Garrett

et al., 1993; Lichtenstein et al., 1997; Rao et al., 1988). Our goal is to test the

assertion that distrust is related to attitudes toward euthanasia. We also attempt to

improve on measurements of relevant variables to better understand the interplay

of the concepts at work.

LITERATURE REVIEW AND THEORETICAL

CONSIDERATIONS

Racial differences pervade many phenomena in American healthcare, such

as organ donation and participation in clinical trials (Callender et al., 1991;

Crawley, 2001; Creecy & Wright, 1990; Minniefield & Muti, 2002). There

is some empirical evidence that distrust is an influential factor in these areas

(Callender et al., 1991; Creecy & Wright, 1990; Corbie-Smith, Thomas, &

St. George, 2002; Corbie-Smith, Thomas, Williams, & Moody-Ayers, 1999;

Crawley, 2001; Minniefield & Muti, 2002). Similarly, racial differences exist

with regard to palliative care and euthanasia. While there has been some descrip-

tive work in the literature that highlights these differences, theoretical under-

pinnings and causal evidence for the disparity are conspicuously absent. Often,

substantive assertions for racial differences in attitudes toward euthanasia seem

derived directly from research on organ donation and participation in clinical

trials. But factors at work in these areas may not function the same way regarding

euthanasia. With the goal of assembling a set of variables relevant to attitudes

toward euthanasia, we examine the literature with reference to the broad issues

of racial distrust and its affect on medical issues.

Individual and Cultural Experiences

Past experiences with institutions typically influence how individuals view

institutional life. Risk theories of interpersonal exchange show that once trust is

violated, individuals’ attitudes become more conflict-oriented and their actions

less cooperative (see for example, Kee & Knox, 1970). Thus, those who have had

more positive experiences with institutions tend to have a more positive view

of them. Conversely, negative past experiences with institutions negatively affect

the amount of trust an individual has in them. But negative experiences may

have a greater impact on attitudes than positive ones since positive experiences,

ATTITUDES TOWARD EUTHANASIA / 265

particularly with doctors, are expected. Thus, negative individual experiences

with physicians would be more remarkable and, therefore, may tend to be more

influential.

The concept of experience is typically thought of in individual terms—what a

person has seen, felt, participated in, been victimized by, etc. But while group

experience might be seen simply as the aggregate of these individual experiences,

the experience of a group also can have a profound effect on individuals who

belong to it. For example, knowledge of the Tuskegee Syphilis experiment

significantly affects willingness to participate in clinical trials among African

Americans (Shavers et al., 2000; see also Corbie-Smith et al., 1999, 2002). This

is not a result of having experienced the actual events, but rather identification

with those who did. The personal experiences of any one individual with the

institution of medicine do not fully reflect the way that “experience” has con-

tributed to trends in attitudes toward that institution. The collective racial iden-

tity of African Americans and their shared cultural experiences also shape

attitudes. In identifying with the history of discrimination in healthcare, African

Americans may tend to distrust the institution when it comes to their own medical

treatment. We call this “perceived capacity for discrimination.” Regardless of

the actual discrimination that any one individual may experience, he or she may

still expect a greater likelihood of experiencing discrimination as a member of

a minority group.

McKinley et al. (1996) represent the only attempt to create a quantitative

measure of distrust to be used as a correlate to attitude toward life sustaining

treatment (a variable that consistently functions inversely with attitudes toward

euthanasia on all predictors except gender). The researchers concluded that while

they still believed that distrust was causally linked to the difference in support,

their scale did not adequately capture the concept. This may reflect that the

questions were too oriented toward the respondent’s cognitive rationality. Items

such as “How much do you trust doctors,” may yield higher trust scores than

items that measure affective dimensions of distrust. For example, Lupton (1996)

argues that how much doctors show that they care about a patient, invest personal

interest and time, and how well they relate on an inter-personal level are deter-

minant features of patient attitudes toward them. Insofar as distrust is an emotion it

may not be well measured by questions directed at cognitive processes rather

than emotional sentiments.

Abrums (2000) study of black, Christian women in Seattle, Washington gives

support for the notion that minority groups have a culturally distinct sense of

distrust in the medical system. Many study subjects shared personal stories of

medicine-gone-wrong, but a majority of the women seemed also to feel that they

were in a high risk group for abuse simply because they were African American.

They tended to view the medical system as characteristically a white institution

to which they must relinquish control of their bodies and this feeling of vulner-

ability made them extremely uneasy (Abrums, 2000).

266 / WASSERMAN, CLAIR AND RITCHEY

Socioeconomic Status

Socioeconomic status represents a predisposing characteristic that affects

experience. Education has been examined in a number of studies and shown to

be positively correlated with attitudes toward euthanasia (Blackhall, Murphy,

Frank, Michel, & Azen, 1995; Blackhall et al., 1999; Caralis et al., 1993; DeCesare

2000; Finlay, 1985; Garrett et al., 1993; Jorgenson & Neubecker, 1980; Rao et al.,

1988; Singh, 1979). Blackhall et al. (1999) found “years of schooling” to be

significantly negatively correlated to desire for life-support. Essentially, the more

educated a person, the less positive their “general attitude” toward life-support

tended to be. Garrett et al. (1993, p. 364) found similar results but note that years of

education had little effect on desire for treatment among the African American

subgroup.

A number of studies also have shown that income and occupational prestige are

either positively correlated with attitudes toward euthanasia or negatively cor-

related with attitude toward life-support (Blackhall et al., 1995, 1999; DeCesare,

2000; Jorgenson & Neubecker, 1980; McKinley et al., 1996; Rao et al., 1988;

Singh, 1979). Rao et al. (1988) found a significant, positive correlation between

both respondent prestige and spousal prestige and support for euthanasia among

the black subgroup, but not among the white subgroup. Adams, Bueche, and

Schraneveldt (1978) found a significant positive correlation between SES and

attitudes toward euthanasia.

Caralis et al. (1993, p. 161), however, found no significant influence of socio-

economic status (measured as, “education level coupled with yearly salary”)

on the racial difference in support for euthanasia or desire for life-sustaining

treatment. They noted that, “Previously identified ethnic and racial differences

remained, regardless of socioeconomic status” (Caralis et al., 1993, p. 161). In

so far as income denotes quality of healthcare, this seems to suggest that there is

something external to individual experiences with medicine that affects attitudes

toward euthanasia for African Americans.

While a number of socioeconomic factors might function as good predictors

of attitude toward euthanasia, they are likely only indirectly related. “Access

to healthcare” better operationalizes SES as an experiential concept. This is

supported by the correlation of having insurance and type of insurance (public

and private) to attitudes toward life sustaining treatment (Blackhall et al., 1995,

1999; Garrett et al., 1993).

Religiosity and Spirituality

While a good deal of the existing research has addressed religiosity as a

correlate of attitudes toward euthanasia or life sustaining treatment, the measure-

ments typically did not tap into cultural differences in religion, such as the

meaning of suffering or fatalistic beliefs about God’s control of the universe

(Blackhall et al., 1999; DeCesare, 2000; Finlay, 1985; Garrett et al., 1993;

ATTITUDES TOWARD EUTHANASIA / 267

Jorgenson & Neubecker, 1980; Lichtenstein et al., 1997; McKinley et al., 1996;

Rao et al., 1988; Singh, 1979; Wade & Anglin, 1987; Weiss, 1996). Researchers

often only used a single-item indicator (e.g., “How important is religion in your

life” (e.g., Lichtenstein et al., 1997)). Nonetheless, studies consistently show that

religiosity measures are negatively correlated with attitudes toward euthanasia

and also a reduction in the racial difference when controlling for religiosity.

There are a few notable exceptions to these standard religiosity measures.

Finlay (1985, p. 554) found that, “a general ‘death attitudes’ variable, intervenes

between a religious morality attitudes and euthanasia attitude per se.” This hints

at the fact that the religious beliefs affect attitudes toward euthanasia, but the

differences across racial groups were not analyzed. In conjunction with tradi-

tional measures of religiosity, Rao et al. (1988) found a single-item indicator of

a profound religious experience showed a racial disparity, significantly affecting

support among whites, but not among blacks. This finding suggests that spiritual

differences exist across racial groups. Finally, Abrums’ (2000) empirical evidence

shows the need for more robust measures of religiosity such as spiritual meaning,

particularly as it relates to health and illness. The African American women in

the study exhibited a fatalistic attitude toward health and illness, believing that

God was the locus of control over the body.

Other Variables Related to Attitudes toward Euthanasia

Research has tended to show a negative correlation between age and attitudes

toward euthanasia (DeCesare, 2000; Finlay, 1985; Jorgenson & Neubecker, 1980;

Rao et al., 1988; Singh, 1979). This may be due to the increasing relevance of

death with increasing age, a positive correlation of age with religiosity, or an

increased likelihood of negative experiences with medicine due to more overall

encounters. With respect to gender, females also tend to be less supportive

of euthanasia (DeCesare, 2000; Finlay, 1985; Jorgenson & Neubecker, 1980;

Litchenstein et al., 1997; Singh, 1979). This may also reflect a gender correlation

with religiosity (Finlay, 1985).

Some research has addressed correlations of other attitudinal variables on

attitudes toward euthanasia. Attitude toward euthanasia has been correlated with

support for freedom of expression and attitude toward premarital sex (Finlay

1985; Singh 1979). These relationships are likely the result of a positive relation-

ship of social liberalism to attitudes toward euthanasia.

While race primarily is a social construct rather than a biological fact, it is a

useful cultural distinction when addressing issues of experience in American

society. Experience with discrimination in American society is a racial reality

more so than any other nominal category. That there are real consequences to

being African American makes race a reality, although a socially constructed

one (Root, 2000). Since our study concerns attitudes that arise from experience,

race is very much a salient concept for research.

268 / WASSERMAN, CLAIR AND RITCHEY

Theoretical Premise

To cite distrust as a substantive explanation for the relationship between race

and attitudes toward euthanasia is to take on two assumptions. First, one must

assert that the experience of race causes a tendency to distrust medicine. Secondly,

one must assert that attitudes toward medicine are related to attitudes toward

euthanasia. While this is intuitively appealing, the latter does not necessarily

follow from the former. Our purpose here is to empirically assess both of these

assumptions. Some qualitative literature has provided evidence that the under-

standing of distrust is an important pursuit, but quantitative measurement is

needed. The basic theoretical premise is that attitudes arise from experiences, both

individual and cultural. We attempt to measure both and discern the relationships

of these and other variables, discussed above, in order to understand the racial

difference in attitudes toward euthanasia.

HYPOTHESES

Based on previous research and the idea that attitudes toward euthanasia come

from both individual and cultural experiences with medicine, we make several

initial bivariate predictions. The first is simply the overall premise that race is

correlated with attitude toward euthanasia:

H1: Race (1 = African American) is negatively correlated with attitudes

toward euthanasia. That is, African Americans have more negative atti-

tudes toward euthanasia.

We delineate two aspects of experience, individual and cultural, and we predict

that they are related to each other in that individual experience with physicians

affects perceived capacity for discrimination. For example, it is likely that an

African American patient with a negative individual experience with physicians

is more likely to see medicine as a potentially discriminating institution. Thus

we predict:

H2: Individual experience with physicians is negatively correlated with

perceived capacity for discrimination.

Since we expect that race is relevant to both kinds of experience, we predict:

H3: Race (1 = African American) is negatively correlated with indi-

vidual experience with physicians.

H4: Race (1 = African American) is positively correlated with perceived

capacity for discrimination.

We use “access to healthcare” as a more conceptually specific indicator of

experience than other, typical SES measures and make the prediction that:

ATTITUDES TOWARD EUTHANASIA / 269

H5: Access to healthcare is positively correlated with individual experi-

ence with physicians.

We predict that more specific dimensions of religiosity which tap into concepts

such as the meaning of life-events in a spiritual context and God’s control in the

universe will provide a more robust understanding of how religion functions in

regard to attitudes toward euthanasia. We use a measure (discussed below)

developed by the Fetzer Institute called “Spiritual Meaning” (Pargament, 1999).

H6: Spiritual meaning is negatively correlated with attitudes toward

euthanasia.

As religiosity has been shown to explain at least part of the racial difference in

attitudes toward euthanasia, we hypothesize that:

H7: Race (1 = African American) is positively correlated with spirituality.

As mentioned, perceived capacity for discrimination is related to race (H4) and

individual experience with physicians (H2). But if distrust of medicine is related

to attitudes toward euthanasia, the following prediction also should be true:

H8: Perceived capacity for discrimination is negatively correlated with

attitudes toward euthanasia.

Individual experiences with physicians also should be directly related to atti-

tudes toward euthanasia. We therefore predict:

H9: Individual experience with physicians is positively correlated with

attitudes toward euthanasia.

Gender discrimination and gender’s relationship to spirituality may be factors

influencing attitudes toward medicine and euthanasia. We first derive from the

literature the hypothesis (H10) that females tend to be more religious (see for

example Finlay, 1985). H11 and H12 follow a logic similar to that proposed

for race, that females are more likely than males to see medicine as a discrim-

inatory institution and less likely to have had positive individual experiences

with physicians.

H10: Gender (1 = female) is positively correlated with spiritual meaning.

H11: Gender (1 = female) is positively correlated with perceived capac-

ity for discrimination.

H12: Gender (1 = female) is negatively correlated with individual experi-

ence with physicians.

We also might include the prediction of a direct path from gender to attitudes

toward euthanasia as derived from previous literature. However, we leave this

out since our goal is to test the theoretical assertion that attitudes arise from

270 / WASSERMAN, CLAIR AND RITCHEY

experiences. To this end we believe that the three hypotheses we have offered

are sufficient.

A theoretical path model is provided in Figure 1. This diagram displays all of

the relationships proposed above.

METHODS

Sample

Our sample is comprised of students from five introductory sociology classes

at a large, urban state university in the southeastern United States. While this

sample is certainly convenient, it also is methodologically useful since it provides

many implicit controls. First, ages have a relatively small range. The mean age in

our sample is 21.70 years, with a standard deviation of 5.72 years. This is slightly

lower than the mean age for undergraduate students at the university, since first

and second-year students are overrepresented in the sampled introductory level

classes (77.8% combined). The small range of ages minimizes correlations with

other variables, reflecting the fact that age, in many respects, is relatively constant.

Second, much previous research on euthanasia examines samples of individuals

65 years or older. Use of a younger group contributes to a gap in the literature.

Third, experience with death affects attitudes toward euthanasia. Younger persons

have relatively few such experiences. The younger sample effectively controls

for personal experience with death and this allows a greater focus on the variables

of interest, particularly race, spirituality, and distrust. Fourth, the more total

experiences a person has had with medicine, the more likely they are to have

had a negative experience. Since negative experiences may resonate more than

positive ones with regard to individual perception, this is an important implicit

control in our population. Fifth, previous research reveals that education is

positively correlated with attitudes toward euthanasia. Education was not found

to correlate for our sample, reflecting the fact that it is essentially held constant.

Finally, it is important to note that selectivity issues should affect both the

white and African American subgroups similarly. Since our goal is to analyze

differences between these groups, not to estimate overall support, our sample

is adequate.

The initial data set contained 211 cases. Respondents who did not mark

“African American” or “White, Anglo” for their race or who failed to complete

one or more consecutive pages were removed from the data set. For the remain-

ing respondents, random non-responses were coded as the mean score of that

respondent on the scale in which the item was nested. For the two respondents

who did not write in their age, the mean age of the sample was imputed. A final

total of 176 respondents comprise the final data set.

African American women comprise a significantly higher proportion of the

data set, (Chi Square = 4.34; p < .05). This is due to their overrepresentation in

ATTITUDES TOWARD EUTHANASIA / 271

272 / WASSERMAN, CLAIR AND RITCHEY

Fig

ure

1.

Att

itu

des

tow

ard

eu

than

asia

—th

eo

reticalp

ath

mo

del.

one particular class. A one-way ANOVA of all independent variables on soci-

ology class showed significant differences only on spirituality (p < .01). A post

hoc test revealed that significant between-group variation was the product of

higher levels of spirituality in Instructor 2’s spring 2004 class. Further impli-

cations of this are discussed below.

Procedure

Scales developed by the researchers and those borrowed from previous

research were first pretested in the population. Measurement and reliability

are discussed below and unpublished scales developed by the researchers are

available upon request. A questionnaire was constructed and distributed to the

sampled classes. A standardized set of instructions were read to each class as

they followed on a written copy attached to the front of their questionnaire.

Students were instructed that the survey was not a test, that it was completely

anonymous, and were told to raise their hands if they had questions about

any particular item.

Measures

The Dependent Variable,

Attitudes toward Euthanasia

Much previous work on attitudes toward euthanasia uses National Opinion

Research Center (NORC) data, which employed a two-item scale. These are

methodologically problematic because they are multi-barreled and narrowly

restricted to the scope of medical policy rather than questions about the act

of euthanasia itself. Our Attitudes toward Euthanasia (ATE) scale is designed to

systematically address a number of issues central to the discussion of euthanasia,

including standards for the practice, decision-making, and distinctions between

active and passive versions of the practice (see Wasserman, Clair, & Ritchey,

2005 for a detailed discussion). The ATE scale is comprised of 10 items with

summary scores initially ranging from 10 to 50. Since the distribution was

positively skewed we truncated to eliminate extreme scores resulting in a maxi-

mum score of 38 (with 38 = 38 and above). The Cronbach’s alpha reliability

coefficient is .87 and item-to-scale correlations range from .481 to .670.

Race

Respondents indicated race by marking one of the following choices: “White,

Anglo,” “African American,” “Asian,” “Hispanic,” and “Other.” As noted, only

whites and African Americans are included in the analysis, with 0 = white and

1 = African American.

ATTITUDES TOWARD EUTHANASIA / 273

Distrust: Perceived Capacity for Discrimination

The Perceived Capacity for Discrimination scale is composed of six items and

measures distrust of medical institutions. Summary scores range from 6 to 30.

The Cronbach’s alpha reliability coefficient is .88 and item-to-scale correlations

range from .596 to .767.

Spiritual Meaning

Spiritual meaning is measured using a scale developed by the Fetzer Institute

(Pargament, 1999). The scale contains 20 items and taps issues such as the

meaning of general life-events and connectedness to God. In so far as the scale

measures spiritual meaning that arises from religious beliefs, it provides a nice

bridge from prior research on religiosity to a more robust measure of spirituality.

The distribution for this variable was negatively skewed. A reflected square root

transformation was performed to modify extreme scores. The modified scale was

then reflected again so that higher scores on the scale indicate higher levels of

spiritual meaning. Summary scores range from 91.1 to 99.1. The Cronbach’s alpha

reliability coefficient is .98 and item-to-scale correlations range from .343 to .932

Access to Healthcare

Access to healthcare is measured with a scale containing 6 items that uses many

standard questions about perceived financial cost of going to the doctor, difficulty

in getting appointments, and access to dental care, which is considered a privilege

of those with a high degree of access. Initial scores were negatively skewed

and ranged from 6 to 30. The final truncated scale ranged from 15 to 30. The

Cronbach’s alpha reliability coefficient is .83 and item-to-scale correlations range

from .432 to .698.

Individual Experience with Physicians

Individual experience with physicians was measured with a 10 item scale

adapted from Ritchey, Yoels, Clair, and Allman (1995). The scale contains

questions that tap a respondent’s personal experience with doctors (as opposed to

cultural experience). Scores range from 19 to 50. The Cronbach’s alpha reliability

coefficient is .83 and item-to-scale correlations range from .369 to .736.

Age and Gender

Age is self-reported. To eliminate attenuation from a few extremely high

scores, age is truncated resulting in a final range of 18 to 25 years. Gender is

coded 0 = male, 1 = female.

Means and standard deviations of the variable used in the analysis are pre-

sented Table 1.

274 / WASSERMAN, CLAIR AND RITCHEY

Analysis

First, we examine bivariate relationships for our hypotheses. Then we use a

path analysis to summarize the viable relationships that remain. Ultimately,

this will provide some basis for interpreting the causes of racial differences in

attitudes toward euthanasia.

RESULTS

As a preliminary phase of the analysis, t-tests and chi-square tests were per-

formed for all of the variables on race (Table 1). The means for attitudes toward

euthanasia, perceived capacity for discrimination, spiritual meaning, and age were

significantly different for whites and African Americans. A chi-square analysis of

race by gender showed that African American females were overrepresented. But

ATTITUDES TOWARD EUTHANASIA / 275

Table 1. Means and Standard Deviations of Variables by Race

(n = 176)

Variable

Total

(n = 176)

White, Anglo

(n = 81)

African

American

(n = 95)

Difference

(p)

Attitudes toward

euthanasiaa

Perceived capacity

for discrimination

Spiritual meaning

Access to healthcarea

Individual experience

with physicians

Agea

Gender

(proportion female)

23.68

(6.79)

16.36

(5.15)

95.74

(1.91)

23.02

(4.27)

35.05

(5.33)

20.61

(2.21)

.61

(—)

24.82

(7.34)

14.11

(4.64)

94.99

(2.19)

23.51

(4.18)

34.52

(5.06)

21.15

(2.41)

.53

(—)

22.71

(6.16)

18.27

(4.79)

96.38

(1.36)

22.61

(4.32)

35.50

(5.53)

20.15

(1.91)

.68

(—)

.040

.000

.000

.165

.224

.002

.037b

aVariables have been truncated.bChi-square test

a t-test for all variables on gender showed significant differences for males

and females on spiritual meaning only.

African Americans were significantly less supportive of euthanasia, exhibiting

a mean score of 22.71, while whites had a mean score of 24.82 (p < .05). A Levene

test of the homogeneity of variances showed a smaller standard deviation for

African Americans on this variable that was nearly significant (p = .058), sug-

gesting there may be less variation in this sub-group.

African Americans had significantly higher spiritual meaning scores, with a

mean score of 96.38, compared to a mean score of 94.99 (p < .001) for whites.

A Levene test of the homogeneity of variances showed that African Americans

had a significantly smaller standard deviation with respect to spiritual meaning

(p < .001). In other words, not only were African Americans more spiritual, but as

a group they were more tightly distributed with respect to this variable.

Finally, African Americans exhibited significantly higher scores on perceived

capacity for discrimination with a mean score of 18.27 as compared to 14.11

(p < .001) for whites. This means that African Americans were more likely to

view medicine as a potentially discriminating institution.

Zero-Order Correlations

Zero-order correlations are presented in Table 2. Table 3 presents a summary of

findings for our hypotheses. As predicted, African Americans have less positive

attitudes toward euthanasia (H1). We predicted a significant negative correlation

between individual experience with physicians and perceived capacity for dis-

crimination (H2), which is supported by the data. Although we predicted a

significant, negative relationship between race (1 = African American) and indi-

vidual experience with physicians (H3), this was found not to be the case. As (H4)

predicted, there was a positive correlation between race and perceived capacity for

discrimination. As (H5) predicted, access to healthcare is significantly, positively

correlated with individual experience with physicians.

A significant negative correlation was found between spirituality and attitudes

toward euthanasia (H6). Contrary to our prediction perceived capacity for dis-

crimination was not significantly related to attitudes toward euthanasia (H8) and

individual experience with physicians is significantly, but negatively, correlated

with attitudes toward euthanasia (H9).

Finally, with respect to gender, females exhibited higher scores for spiritual

meaning (H10), but were not more likely to view medicine as a discriminatory

institution (H11) or have had negative individual experiences with physicians

(H12).

To better decipher relationships among predictors of attitudes toward

euthanasia, we posit a path analysis model. Results are described below and

inform us that many of the bivariate correlations are nullified when certain,

dominant variables are controlled for.

276 / WASSERMAN, CLAIR AND RITCHEY

Tab

le2

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ivari

ate

Co

rrela

tio

ns

ofV

ari

ab

les

12

34

56

78

1R

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ATTITUDES TOWARD EUTHANASIA / 277

Path Analysis

We use path analysis because our goal is to test assertions in previous research

of a relationship between distrust and attitudes toward euthanasia, rather than

locating the best predictors of attitudes toward euthanasia. While “attitudes toward

euthanasia” is indicated by the zero order correlation with race, the significance is

eliminated when we control for other variables. Our theoretical model asserts that

the racial differences in attitudes toward euthanasia are the product of indirect

relationships primarily with spirituality and both individual and cultural experi-

ences. A stepwise regression of attitudes toward euthanasia on spiritual meaning,

278 / WASSERMAN, CLAIR AND RITCHEY

Table 3. Summary of Predicted and Observed Correlations

Hypothesis

Predicted

direction

Empirical

direction

H1

H2

H3

H4

H5

H6

H7

H8

H9

H10

H11

H12

Race � Attitudes toward Euthanasia

Individual Experience with Physicians �

Perceived Capacity for Discrimination

Race � Individual Experience with Physicians

Race � Perceived Capacity for Discrimination

Access to Healthcare � Individual Experience

with Physicians

Spiritual Meaning � Attitudes toward Euthanasia

Race � Spiritual Meaning

Perceived Capacity for Discrimination �

Attitudes toward Euthanasia

Individual Experience with Physicians �

Attitudes toward Euthanasia

Gender � Spiritual Meaning

Gender � Perceived Capacity for Discrimination

Gender � Individual Experience with Physicians

–

–

–

+

+

–

+

–

+

+

+

–

–

–

nsa

+

+

–

+

nsa

–

+

nsa

nsa

anot significant

perceived capacity for discrimination, and individual experience with physicians,

shows that all other variables can be explained away by spiritual meaning.

Removing non-significant paths results in the model displayed in Figure 2.

Because gender is positively related to spiritual meaning, and African American

females are overrepresented in the sample, we control for gender in assessing the

relationship of race to spiritual meaning. Still, race remains significantly related

to spiritual meaning. Thus, it would seem that the contribution that race makes

toward explaining the variation in attitudes toward euthanasia is really the product

of an indirect relationship mediated by spiritual meaning.

This conclusion is further supported in Table 4, which shows the decomposition

of effects on attitudes toward euthanasia. Of primary interest here is that the

indirect effect of race nearly equals the zero-order correlation suggesting that

spiritual meaning is the dominant mediating variable, which explains the racial

differences in attitude toward euthanasia. The direct effect of spiritual meaning

on attitudes toward euthanasia remains equal to the zero-order correlation since

all other paths were not significant when spiritual meaning is in the model.

While our purpose is to interpret the aforementioned relationships, rather than

predict attitudes toward euthanasia, it is still necessary to point out that the

explanatory power of spiritual meaning on attitudes toward euthanasia is modest.

Spiritual meaning explained roughly 15% of the variation in the dependent

variable.

To cite distrust as an explanation of the racial difference in attitude toward

euthanasia requires the assumptions that both 1) distrust of medicine exists among

African Americans, and 2) that it is related to attitudes toward euthanasia. Our

research finds empirical support for the former, but not the latter assertion.

Evidence of this comes from the relationships of race and individual experience

with physicians to perceived capacity for discrimination. As expected, results

indicate that both race and individual experience with physicians are significantly

related to perceived capacity for discrimination, the former relationship being

positive and the latter negative. Both relationships persist when controlling for the

other variable. This means that African Americans score higher on the perceived

capacity for discrimination scale, which fits intuitive notions of distrust of

ATTITUDES TOWARD EUTHANASIA / 279

Table 4. Analysis of Effects on Attitudes toward Euthanasia

Direct effect

(�)

Indirect

effect

Total

effect

Zero-order

correlation

Spiritual meaning

Race

–.399***

—

—

–.146

–.399***

–.146

–3.99***

–.155*

*p < .05. **p < .01. ***p < .001.

280 / WASSERMAN, CLAIR AND RITCHEY

Fig

ure

2.

Att

itu

des

tow

ard

eu

than

asia

—fin

alp

ath

mo

del.

healthcare. Furthermore, as one would expect, those having more positive

individual experiences with physicians score lower on perceived capacity for

discrimination. These relationships support the validity of the perceived capacity

for discrimination scale. Nonetheless, there was no significant correlation between

perceived capacity for discrimination and attitudes toward euthanasia. That

euthanasia tends to be viewed as a spiritual rather than a pragmatic concern is

further evidenced by an ANOVA of a separate question directly referencing

euthanasia and trust of physicians factored on race. Statistics from our sample

show no racial difference in mean score for the item, “If euthanasia were legalized,

I would worry that some doctors might not do everything they can to save me if I

am sick or injured.”

Table 5 shows the decomposition of effects on perceived capacity for

discrimination.

Access to healthcare is strongly, positively correlated with individual experi-

ence with physicians, which, in turn, is strongly correlated with perceived capacity

for discrimination. But access to healthcare and race are not significantly related

(likely due to the nature of our sample) and the indirect effects of race on perceived

capacity for discrimination are small compared with strong direct effects. This

suggests that the relationship of race and perceived capacity for discrimination

is robust. Similarly, individual experiences with physicians have a moderately

strong direct effect on perceived capacity for discrimination nearly equaling the

zero-order correlation even when race is controlled. This suggests that the direct

effect is robust. As a model, race and individual experience with physicians

account for roughly 29% of the variation in perceived capacity for discrimination.

Interestingly, when controlling for age and access to healthcare, race

(1 = African American) has a significant positive effect on individual experiences

with physicians. This is contrary to our initial hypothesis that race is negatively

ATTITUDES TOWARD EUTHANASIA / 281

Table 5. Analysis of Effects on Attitudes toward Euthanasia

Independent variable

Direct effect

(�)

Indirect

effect

Total

effect

Zero-order

correlation

Individual Experiences

with physicians

Race

Access to healthcare

Age

–.367***

.438***

—

—

—

–.065

–.124***

–.079

—

.373

–.124***

–.079

–.326***

.404***

–.226**

–.165*

*p < .05. **p < .01. ***p < .001.

correlated with individual experiences with physicians. This finding may be

explained by the fact that individuals commonly have negative attitudes toward

doctors in general, but often express satisfaction with their own doctors (Clair

& Allman, 1993). This interpretation is supported by our finding of a negative

effect of race on perceived capacity for discrimination, a measure of attitude

toward medicine as a whole. Since the individual experiences scale references

respondents’ perception of their doctors of the past and present, this positive

relationship may be the result of positive past interactions of African Americans

with their own physicians. In light of this result, the negative effect of race on

perceived capacity for discrimination seems all the more striking: It suggests the

existence of cultural distrust even in the face of positive individual experiences

with physicians. That the direct effect of race on perceived capacity for dis-

crimination is positive while the indirect effect of the relationship mediated by

individual experience with physicians is negative, further suggests that there is

a disconnect between a person’s view of their own doctors and their view of

medicine in general (Clair & Allman, 1993).

Finally, it is necessary to note that while we did not hypothesize age as related to

any variables, largely because we did not expect a large amount of variation in the

distribution of the variable, it does show zero-order correlations with perceived

capacity for discrimination and spiritual meaning. This is likely due to the fact

that the African American stratum of the sample is slightly, but significantly,

younger than the white stratum. As age is strongly correlated with access to

healthcare and race, its correlation with perceived capacity for discrimination and

spirituality are likely the product of an indirect relationship mediated by these

two variables. Furthermore, while age does not show a significant zero-order

correlation with individual experience with physicians, when controlling for race

and access to healthcare, the coefficient for age on individual experience with

physicians becomes significant.

It is important to address the significant correlation of age and access to

healthcare. While the correlation is bidirectional, substantively we feel that the

effect of age on individual experience with physicians is spurious and likely the

result of its correlation with access to healthcare. While the age range in our

sample is limited, the years included represent a transitional time period. The

younger individuals in the sample are more likely to still be covered by their

parents’ insurance, whereas the older individuals may be more likely not to

have insurance.

LIMITATIONS

Our sample is not randomly selected. There are a number of potential selectivity

issues in sampling undergraduate college students. However, we do not feel that

these totally compromise the validity of our findings. In fact, in some cases we find

the particulars of our sample to be beneficial, as discussed above. Nonetheless,

282 / WASSERMAN, CLAIR AND RITCHEY

testing the relationships in the model in a representative population is necessary

in future research.

Insofar as path analysis employs regression as a statistical technique, it assumes

no specification error in the model. Thus, with any study employing regression as

an analytic tool, a potential hazard exists that the model has not been properly

specified. We are cautious that considerations such as income, having insurance,

and type of insurance also might have significant effects on attitudes toward

euthanasia, but these concepts are represented to some extent in the model by

access to healthcare. Race and SES measures also tend to be highly correlated, but

we find no significant correlation between race and access to healthcare in our

sample. This is likely because our sample is comprised of students who have

health insurance options not afforded to the general public. Further, our purpose

here is to specifically test the assertion that attitudes toward euthanasia come from

distrust of institutional medicine. While our overall model explains a compara-

tively small amount of the variation, we feel that we have adequately achieved

what we set out to do.

CONCLUSION

Understanding racial differences in attitudes toward euthanasia is important for

moving forward with end-of-life policy reform. We attempt to build on previous

research in a number of ways. First, we use a new measure of attitudes toward

euthanasia, which systematically incorporates its multifaceted dimensions includ-

ing the active/passive distinction, standards of acceptability, and designations

of decision-making (Wasserman et al., 2005). Second, we attempt to quantify

distrust, and there is evidence that our perceived capacity for discrimination

scale is valid. Third, our finding that distrust is ultimately not related to attitudes

toward euthanasia counters previous assertions made throughout the literature.

Finally, we use a more robust and meaningful measure of spirituality, which

buttresses prior conclusions about the dominant role of religious or spiritual

beliefs.

Researchers have seemingly derived distrust of medicine as a substantive

explanation for the racial difference in attitudes toward euthanasia from studies

which have shown a correlation between distrust and willingness to donate organs

or participate in clinical trials (Callender et al., 1991; Corbie-Smith et al., 1999,

2002; Creecy & Wright, 1990; Minniefield & Muti, 2002). Our research points

to the fact that while distrust may limit African American participation in these

areas, it does not function in the same way with regard to attitudes toward

euthanasia. Both clinical trials and organ donation are situations where medicine

perceptively makes immediate gains from the use of patients. These concerns may

be present with euthanasia—patients may worry that their lives will be terminated

prematurely to save money, for example—but the possible gains to medicine may

seem less obvious, and people may not associate them as readily. Further, new

ATTITUDES TOWARD EUTHANASIA / 283

research by David Wendler and Ezekiel Emanuel has found that, given the

opportunity, African Americans are as likely as their white counterparts to par-

ticipate in clinical trials, suggesting that perhaps distrust has been overestimated

in this arena as well (Weiss, 2006). This is informative for both future research

and policy reform because it provides some indication as to what the salient

concerns of the public are (and are not). McKinley et al. (1996) interpreted the

lack of a relationship between distrust of medicine and attitude toward life-

sustaining treatment as a potential measurement problem. Our research suggests

that perhaps no significant relationship exists. Ultimately, this research shows

that while race is relevant to one’s attitude toward medicine, euthanasia is largely

seen as an abstract moral and spiritual issue, unrelated to both individual and

cultural experience with medicine.

While our conclusion that spirituality is the dominant explanatory variable

is similar to previous work, the methodology we used to arrive at this conclusion

provides greater confidence in the statistical assessment. The scale we used to

assess spirituality makes improvements over past studies because it allows for

inferences about particular beliefs. Traditional religiosity measures such as

church attendance or self-reported religious importance may measure concepts

such as social integration rather than spiritual beliefs. This is important since

beliefs about the meaning of suffering appear to be particularly influential on

attitudes toward euthanasia.

Perceived capacity for discrimination was not correlated with euthanasia,

although our scale does appear to have tapped the concept of distrust, or at least

some dimension of it. This is supported by the fact that, as hypothesized, it is

both correlated positively with race and negatively correlated with individual

past experiences. However, future research is needed in this area since it also

is possible that there are different dimensions of distrust that are correlated

with attitudes toward euthanasia. Future studies might attempt to assess cultural

experience in other ways, particularly by developing scales more directly related

to the history of African American interaction with medicine. While this has

been done with Tuskegee, it is important to tap into the real and mythic knowledge

about other pieces of history. Nonetheless, our scale makes a methodological

contribution toward quantitatively measuring a concept that has largely been the

domain of qualitative work.

While we feel that our variable, perceived capacity for discrimination, measures

a dimension of cultural experience, it is important to extend this measure to

assess what might be called a “learned distrust” component of cultural experi-

ence. Weber (1946) posits a building of culture through repeated actions

that may become severed from their initial impetus. For our purposes, African

Americans may learn distrust from the actions of their families and peers,

independent of knowledge of particular events. If an individual’s parents avoid

going to the doctor, they will likely have the same tendencies. While the

experience of events, past and present, play a role, perhaps even a dominant one,

284 / WASSERMAN, CLAIR AND RITCHEY

distrust may exist independently of them. This is a potential area for future

research on distrust.

While it us ultimately spiritual beliefs that guide their attitude toward

euthanasia, our findings suggest that improving access to healthcare would both

make individual’s experiences with medicine better and also decrease the belief

in medicine as a discriminatory institution.

Finally, our results suggest that policies aimed at legalizing euthanasia need to

primarily attend to spiritual beliefs. This is not good news for right-to-die activists

since challenging moral matters would seem much more difficult than solving

pragmatic problems. These results do suggest that a focus on carefully crafting

policies to protect patients and inspire trust, while not unimportant, may be less

important than arguing for the acceptability of the practice on moral and religious

grounds. In academic philosophy, the debate about the general morality of

euthanasia is something of a dead issue. Nonetheless, our research points to the

fact that the morality of the act may not be so decided among the public.

ACKNOWLEDGMENTS

We would like to thank Kenneth J. Doka and two anonymous reviewers for

their helpful comments. In memory of James Rachels, whose writing and per-

sonal guidance helped inspire this work.

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Direct reprint requests to:

Jason Wasserman, M.A.

Department of Sociology

University of Alabama at Birmingham

1212 University Boulevard

237 Ullman Building

Birmingham, AL 35294-3350

e-mail: JasonW@uab.edu

ATTITUDES TOWARD EUTHANASIA / 287