CHAPTER 11
PUBLIC OPINION ABOUT LIFE AND DEATH

LIFE AFTER DEATH

Since the dawn of history, many people have believed that human beings do not simply cease to exist upon their death. Numerous religions and cultures teach that the physical body may die and decompose, but that some element of the person goes on to what many call the "after-life." Between 1972 and 1982, when the Roper Center for Public Opinion Research asked the American public, "Do you believe there is life after death?," 70 percent said they believed in an afterlife, and 20 percent said they did not. In 1996, when the Roper Center asked the same question, 73 percent of respondents said yes, and 16 percent said no. A 2002 poll conducted by the National Opinion Research Center at the University of Chicago, as part of its General Social Survey, revealed similar results. Seventy-two percent of those polled said they believed that there is a life after death, 17 percent did not, and 11 percent were undecided. (See Figure 11.1.) Clearly, the proportion of the U.S. population believing in an afterlife appears to have remained relatively consistent over three decades.

When asked in polls conducted by the Gallup Organization about an afterlife and what that "eternal destination" might be, many Americans expressed a belief in heaven, where people who led good lives are eternally rewarded after death, and hell, where unrepentant people who led bad lives are eternally punished. From 1997 to 2004, a majority of Gallup Poll respondents—72 percent in 1997 and 81 percent in 2004—acknowledged a belief in heaven. (See Figure 11.2.) In the 2004 survey, 10 percent were unsure whether or not they believed in heaven, and 8 percent did not believe in it. In addition, a majority of respondents—56 percent in 1997 and 70 percent in 2004—acknowledged a belief that hell exists in the afterlife. (See Figure 11.3.) In the 2004 survey, 12 percent were unsure whether or not they believed in hell and 17 percent did not believe in it.

In a 1997 poll conducted by the Gallup Organization for the Nathan Cummings Foundation and the Fetzer Institute, published in "A Roper Center Data Review: Facing Death" (Public Perspective, March/April 2001; hereafter cited as Roper), 83 percent of those surveyed thought that existence in the afterlife would be a positive experience as opposed to negative or neutral. Further, nearly three-quarters (72 percent) of those who believe they will exist in an afterlife also believe they will experience spiritual growth after death.

Because so many people believe in an afterlife and anticipate a spiritual life after death, it is not surprising that more than half of respondents expressed concern about "not being forgiven by God" (57 percent), "not reconciling with others" (56 percent), and "dying when … removed or cut off from God or a higher power" (51 percent). About half (49 percent) worried about "not being forgiven by someone for something."

CONCERNS ABOUT DEATH

Americans say they are not afraid of death. In a 1999 survey conducted by the Los Angeles Times) 83 percent said they were not afraid to die. Fear of death seems to decline with advancing age. Among adults ages 18 to 44, 18 percent said they were afraid to die, while 79 percent were unafraid. Among respondents age 65 and over, only 7 percent reported a fear of death, while 90 percent said they were not afraid (Roper).

In the same survey, about half the respondents (49 percent) said that they very seldom think about death, and 10 percent claimed that they never think at all about their own deaths. A September 2000 survey found that the largest proportion of respondents (38 percent) think about their own deaths just a few times each year.

Teens are not much different from young adults in how much they think about their own deaths. In a 2004 Gallup Youth Survey, 1,302 teens aged 13 to 17 years were queried on this topic. Again, the largest proportion of respondents (35 percent) thinks "hardly at all" about their own deaths. An additional 25 percent never thinks about their own deaths, while 30 percent only sometimes thinks about it. Only 2 percent of teens "almost always" think about their own deaths. (See Figure 11.4.)

In addition to not being preoccupied with thinking about their own deaths, American teens appear to have a realistic attitude about the possibility of their dying at an early age. In a 2003 Gallup Youth Survey, 48 percent of teens aged 13 to 17 years responded that they were somewhat likely to die from a car accident before they reached adulthood. (See Figure 11.5.) This belief parallels National Center for Health Statistics data, which show that motor vehicle accidents are the leading cause of teen death. In contrast, only 24 percent of teens thought they might die at a young age from violent crime, 21 percent from disease, and 18 percent from terrorism.

Fearful Aspects of Dying

Although they may not fear death or spend much time thinking about their own deaths, Americans are fearful about some aspects of dying. In a survey published in 2001 and conducted by Yankelovich Partners, Time, and CNN, two-thirds of respondents expressed much or some concern about dying in pain. Another two-thirds said they were "very fearful" or "somewhat fearful" of leaving loved ones behind, and 43 percent of respondents were "very fearful" or "somewhat fearful" about dying alone (Roper).

The 1997 Gallup Organization survey reveals that when they think about their own death, the majority of Americans (70 percent) express some or a great deal of concern about "not having the chance to say goodbye to someone." Sixty-four percent of respondents also feared causing loved ones stress and inconvenience, and 65 percent worried about how their families or loved ones would be cared for (Roper).

The same survey found that nearly three-quarters of respondents (73 percent) fear the possibility of being in a persistent vegetative state before dying, and more than two-thirds (67 percent) are afraid they will suffer "great physical pain" before death. About half (49 percent) are concerned about having others make medical decisions for them, and 41 percent are concerned about being in the hospital while dying.

The Yankelovich Partners/ Time /CNN survey found that the majority of people (73 percent) would prefer to die at home rather than in a hospital, hospice, or nursing home. Despite these expressed wishes to die at home, less than half (43 percent) believed they were likely to die at home—28 percent thought they were likely to die in a hospital, nursing home, or hospice.

The Seriously Ill Have Different Concerns

When patients with advanced chronic illnesses were asked, in a 1999 survey conducted by Karen E. Steinhauser for the Program on the Medical Encounter and Palliative Care, whether they agreed or strongly agreed about the importance of a variety of end-of-life issues, their concerns were quite different from the general population (Roper). While dying at home appears to be a priority for many Americans, only 35 percent of the seriously ill named dying at home as a priority, making it last on their list of concerns. Their top priorities were being kept clean (99 percent), having a nurse with whom they felt comfortable (97 percent), knowing what to expect about their physical conditions (96 percent), trusting their physician (94 percent), and being free of pain (93 percent).

In this same survey, seriously ill patients also revealed that they felt it was very meaningful to have someone who would listen to them (95 percent), and more than nine out of ten said it was important to them to maintain both their dignity (95 percent) and sense of humor (93 percent). Almost all believed it was vital to name someone to make decisions for them if they became unable to make them (98 percent), and to have their financial affairs in order (94 percent). They did not wish to be a burden to their families (89 percent) or to society (81 percent). While only half of seriously ill respondents felt it was important to be able to discuss their spiritual beliefs with their physicians (50 percent), more than two-thirds (69 percent) wished to meet with a clergy member, and 85 percent valued prayer. The highest spiritual priority for seriously ill patients was coming to peace with God (89 percent).

GETTING OLDER

Living to 100

National surveys of the adult population by the Alliance for Aging Research (AAR) have found that Americans would generally like to live longer. In 2001, 6 in 10 Americans (63 percent) said they would like to live to be 100 years old. Men (68 percent) and those aged 18 to 36 (69 percent) were more likely to want to live to be 100 years old. These findings are similar to AAR studies from 1991 and 1996.

Although a majority of Americans would like to live to be 100 years old, not all expect to get their wish. Nonetheless, 90 percent of people completing an online survey, and 60 percent of those who responded by telephone to a 2001 survey by the AAR, expected to live to be at least 80 years old. More than half (62 percent) of those surveyed online said they expected to live to be at least 90 years old. Earlier AAR surveys, conducted in 1991, 1992, and 1996, also showed that more than half of the respondents (56, 58, and 51 percent, respectively) thought they would live to be at least 80 years old.

Concerns about Aging

The aging of the baby boomers and the growing number of people living longer have focused much attention on concerns that come with aging. The 2001 AAR survey mentioned in the previous paragraph found that while Americans want to live longer, more than half of respondents to the online survey were concerned about living in a nursing home (51 percent) and disease (61 percent) in old age. Becoming a financial burden to their children (45 percent) and remaining attractive (46 percent) worried less than half of those surveyed online.

Nursing Homes Get Mixed Reviews

During 2001, The NewsHour with Jim Lehrer, the Harvard School of Public Health, and The Henry J. Kaiser Family Foundation conducted a national survey about nursing homes. Among other questions, participants were asked about their willingness to move into a nursing home.

Of the 1,309 adults surveyed, slightly less than half (47 percent) said they would not like, but would accept, moving into a nursing home if they could not care for themselves at home, while 43 percent felt that moving into a nursing home would be totally unacceptable. Only 10 percent of the survey respondents felt they would accept it as the best thing for themselves. A majority felt that nursing homes are understaffed, have staff that are often neglectful or abusive of residents, and are lonely. About half (45 percent) felt that nursing homes make most people who move into them worse off than prior to the move. Further, 86 percent of respondents believed that "most people who stay in a nursing home never go home."

SUICIDE

A 2002 National Opinion Research Center survey found that 58 percent of respondents approved of suicide if a person had an incurable disease, but only a small

minority approved of it if the person had gone bankrupt (8 percent), had dishonored his or her family (9 percent), or was simply tired of living (15 percent). In comparison, the same poll from 1977 found that a much lower percentage of people (38 percent) thought suicide was acceptable if one had an incurable illness. Suicide in other situations was also found less acceptable in the 1977 survey than in the 2002 survey. (See Table 11.1.)

PHYSICIAN-ASSISTED SUICIDE

Many advocates of physician-assisted suicide believe that people who are suffering from uncontrollable pain should be allowed to end their lives with a lethal dose of medication prescribed by their physician. Dr. Marcia Angell, for example, former executive editor of The New England Journal of Medicine, claims that "those with cancer, AIDS, and other neurologic disorders may die by inches and in great anguish, despite every effort of their doctors and nurses." She believes that if all possible palliative efforts have failed to provide pain relief, then physician-assisted suicide should be permitted.

Public Support

In March 2002, 40 percent of respondents to an ABC News/Beliefnet poll thought that doctors should be legally permitted to help terminally ill patients commit suicide by giving them prescriptions for lethal drugs, compared with 48 percent who disapproved. When the survey specified that eligible patients "would have to be diagnosed as having less than six months to live, get a second opinion from another doctor, … ask for the drugs three times [and] there would be a 15-day waiting period before the prescription could be filled," a slightly higher percentage (46 percent) supported legalizing physician-assisted suicide. Still, 48 percent of respondents felt that even with these added safeguards, physician-assisted suicide should be illegal.

Personal Consideration

Just as the public is divided about the right of patients to physician-assisted suicide, so it is divided about suicide as a personal option. A 1997 survey by the Gallup Organization for the Nathan Cummings Foundation and Fetzer Institute asked whether respondents could imagine a situation where they might seek physician-assisted suicide; half (50 percent) could conceive of asking a doctor to help them painlessly end their lives (Roper).

A 1999 Los Angeles Times survey found only 12 percent of respondents said they had ever considered suicide, while 86 percent claimed never to have considered it. Nonetheless, Americans believe that suicide will claim more lives in the future. The majority (68 percent) of respondents to a 1999 Harris Interactive survey thought suicide would kill more people ten years in the future than it does today (Roper).

A greater proportion of teens than adults say they have considered suicide. When 1,985 young people aged 13 to 17 years were asked in a 2004 Gallup Youth survey whether they had "ever talked or thought about committing suicide," 22 percent responded that they had. Girls were more likely (28 percent) than boys (15 percent) to have had suicidal thoughts. (See Figure 11.6.) When asked if they had ever tried to commit suicide, however, only 4 percent of girls and 9 percent of boys had. (See Figure 11.7.)

Public Opinion on Physician-Assisted Suicide

In the United States, public opinion has changed only slightly with regard to physician-assisted suicide between 2001 and 2004. According to Gallup Values and Beliefs polls, 65 percent of those surveyed in 2001 said "yes" when asked whether doctors should be allowed by law to end a patient's life by some painless means if the patient and his family request it and the patient has an incurable disease. That percentage rose to 72 percent in 2002, stayed steady in 2003 and declined to 69 percent in 2004. In general, over two-thirds of the American public are in favor of legalizing physician-assisted suicide under conditions of incurable disease. (See Figure 11.8.)

OREGON PHYSICIAN-ASSISTED SUICIDE LAW

In 1994 Oregon became the first jurisdiction in the world to legalize physician-assisted suicide when that state passed its Death with Dignity Act. Under the act, Oregon law permits physician-assisted suicide for patients with less than six months to live. Patients must request physician assistance three times, receive a second opinion from another doctor, and wait 15 days to allow time to reconsider.

Before the Death with Dignity Act could take effect, opponents of the law succeeded in obtaining an injunction against it. Three years later, in November 1997, Oregon's legislature let the voters decide whether to repeal or retain the law. Voters reaffirmed the Death with Dignity Act. In August 1997, prior to voters' reaffirmation of Oregon's physician-assisted suicide law, about 7 in 10 people (69 percent) surveyed by the Harris Poll indicated they would approve of a similar law allowing physician-assisted suicide in their state. Asked again in 2001 whether they would favor or oppose such a law in their own state, 61 percent of respondents indicated they favored such legislation.

Using Federally-Controlled Drugs for Assisted Suicide

After the Death with Dignity Act took effect in November 1997, Thomas Constantine of the Drug Enforcement Administration (DEA) announced that "delivering, dispensing, or prescribing a controlled substance with the intent of assisting a suicide" would be a violation of the federal Controlled Substances Act (PL 91-513). Then-Attorney General Janet Reno overruled Constantine.

In October 2000, U.S. Attorney General John Ashcroft overturned Reno's ruling in an attempt to again allow the DEA to act against physicians who prescribe lethal doses of controlled substances under Oregon's physician-assisted suicide law. In December 2001 the Harris Poll asked adults nationwide whether they considered Attorney General Ashcroft's effort to overrule the proposition right or wrong. More than half of respondents (58 percent) believed his action was wrong. On April 17, 2002, U.S. District Judge Robert E. Jones agreed, noting that "[t]o allow an attorney general—an appointed executive …—to determine the legitimacy of a particular medical practice … would be unprecedented and extraordinary." Jones's ruling reaffirmed the Death with Dignity Act. The Justice Department appealed the ruling to the Ninth Circuit Court of Appeals. On May 26, 2004, the court upheld Jones's ruling against Ashcroft.