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
.B
ivari
ate
Co
rrela
tio
ns
ofV
ari
ab
les
12
34
56
78
1R
ace
2In
div
idu
alexp
eri
en
ce
with
ph
ysic
ian
s
3A
ccess
toh
ealth
catr
e
4A
ttitu
des
tow
ard
eu
than
asia
5P
erc
eiv
ed
cap
acity
for
dis
cri
min
atio
n
6S
pir
itu
alm
ean
ing
7A
ge
8G
en
der
1.0
0
.09
2
–.1
05
–.1
55
(*)
.40
4(*
**)
.36
2(*
**)
–.2
28
(**)
.15
7(*
)
1.0
0
.24
8(*
**)
–.1
68
(*)
–.3
26
(***)
.20
7(*
*)
.05
9
.08
2
1.0
0
–.1
58
(*)
–.2
26
(**)
.28
1(*
**)
–.3
38
(***)
.13
8
1.0
0
–.0
17
–.3
99
(***)
.07
7
–.0
47
1.0
0
.17
4(*
)
–.1
65
(*)
.00
1
1.0
0
–.2
06
(**)
.23
9(*
*)
1.0
0
–.1
32
1.0
0
*p
<.0
5(1
-taile
d).
**p
<.0
1(1
-taile
d).
***p
<.0
01
(1-t
aile
d).
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.
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: [email protected]
ATTITUDES TOWARD EUTHANASIA / 287
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