The social perspective of euthanasia in Spain: variables that predict attitudes towards euthanasia

: The debate surrounding whether or not euthanasia should be a legal practice has been present in Spanish society since the 90’s. Recently, the Spanish government has passed Organic Law 3/2021 on the regulation of euthanasia. In relation to this question, which has raised and continues to raise controversy among both public opinion and the political and legal world, this work explores the relation of the different variables to the attitudes of the Spanish public towards euthanasia. For this purpose, 182 people residing in Spain took part in the study. The results indicate that there are no differences with regard to the age or gender of the participants in their attitudes towards euthanasia. Those who hold religious beliefs (irrespective of their religion) hold less favourable attitudes towards euthanasia than non-believers. Political orientation also relates to attitudes towards euthanasia. Finally, trust in the country’s health system and people’s empathic concern is also related to their attitudes towards euthanasia. At this point in time, when euthanasia has only just been regulated and starts to be put into practice in this country, it is of vital importance to consider the social perspective of euthanasia.


Introduction
Euthanasia, its approval or prohibition, has generated numerous political and social debates in different countries around the world, dividing society between its detractors and those who consider it as a way to end human suffering and to die with dignity. Over the last 20 years, these practices (euthanasia and physician-assisted suicide) have gradually increased, as has the corresponding legislation in different countries (Mroz et al, 2021). One of the latest countries to legalize euthanasia is Spain; in March 2021 the Spanish government passed the euthanasia law, thereby regulating euthanasia and physician-assisted suicide. In Spain the debate surrounding the legalization of euthanasia has been present since the 1990's. At a social level, the debate about euthanasia practices was probably heightened by the Ramón Sampedro case. This case had Europe-wide repercussions due to the Alejandro Amenábar film "Mar Adentro" ("The Sea Inside"), which relates the case of this Spanish citizen (Cohen et al, 2006), a man who, after 29 years defending his right to die, organized his death with the assistance of several trusted collaborators, in such a way that each one would car-ry out a different action so that it would not constitute a crime in itself.
The surveys conducted in Spain in the last few years, in general, indicate favourable attitudes towards the regulation of euthanasia and physician-assisted suicide (de Miguel Sánchez & López Romero, 2006;Durán, 2004;Fundación B.B.V.A., 2020;Ipsos MORI, 2015;del Rosal & Cerro, 2018), both among doctors and among the general public (Bernal-Carcelén, 2020). The attitudes of the Spanish people towards euthanasia have gradually evolved in the last few years towards more favourable attitudes (Aznar, 2021;Fundación B.B.V.A 2020).
Given the debate which has arisen in practically all the European countries with regard to whether or not to legalize euthanasia, behavioural sciences have explored the variables which predict attitudes towards euthanasia. One of the variables proposed when explaining people's attitude towards euthanasia is trust. Trust could be related to the acceptance or non-acceptance of the legalization of euthanasia since one possible fear is that legalization might increase permissiveness in the cases in which euthanasia is acceptable (Cohen, et al., 2014). One of the most frequently recurring arguments or objections is the slippery slope argument (Aguiar et al., 2009;Smith, 2005;Van der Burg, 1991;Walton, 1992); the slippery slope would mean that permitting, accepting or practising a desirable or neutral action could lead us to undesirable actions. According to this argument, if we accept euthanasia, we could fall down a slope that might even lead to murder (Aguiar et al., 2009). People's fear of inappropriate use of euthanasia or other forms of ending life such as assisted suicide may increase due to a general lack of trust in other people in general (Köneke, 2014), in family members (Vilpert et al., 2020), in the legal system of the country (Vilpert et al., 2020) or in the medical system or medical professionals (Bartolomé-Peral, & Coromina, 2020;Cohen et al., 2013;Köneke, 2014).
Despite the fact that different authors have argued the possible relation between trust in doctors or in the health system and attitudes towards euthanasia and / or physicianassisted suicide (Bartolomé-Peral, & Coromina, 2020;Bernheim et al., 2014;Cohen et al., 2013), in previous research, works exist which found no relation between the trust in doctors or the health system and the attitudes towards euthanasia (Braun et al., 2017;Vilpert et al., 2020); and works that find a negative relation, as for example the work by de Buiting y cols (2012), in which people over 64 years of age were more prone to consider euthanasia as an option for themselves when they did not have sufficient trust in their doctors; or that of Raijmakers et al. (2015), in which high levels of trust in doctors indicated a lesser acceptance of euthanasia. A recent work (Bartolomé-Peral, & Coromina, 2020) finds that the data from the European Values Study indicate that the relation between trust in the health system and attitudes towards the beginning-and end-of-life depend on the country under study; for example, trust in the health system has a significant and positive effect in Spain, while in the case of Germany it is negative. However, in Köneke's work (2014), no relation is found between trust in the health system at an individual level and people's attitudes towards euthanasia, but a relation between the level of trust of the country as a whole in the health system and attitudes towards euthanasia is evidenced. His results indicate that, although the individual person may not trust the health system of his country (trust at individual level), his attitudes towards euthanasia are more favourable if he lives in a country where people in general do trust in it. For example, Cohen et al. (2014) argue that one of their results, the polarisation in attitudes towards euthanasia between the countries of Western Europe and those of Eastern Europe, might be due to the so-called "health divide between the East-West in Europe" (Carlson, 1998(Carlson, , 2004Laaksonen et al., 2001); according to the authors, the Eastern European countries face greater levels of morbidity and mortality, which may be due to the lack of finance in health care; owing to this, people might consider euthanasia as a threat that could be used to control health costs (Cohen et al., 2014). The authors (Cohen et al., 2014) put forward the idea that an alternative explanation for their results might be the religious differences in Europe. Religious beliefs, or the self-positioning in terms of religion, has been one of the variables which has been studied in greatest depth in relation to attitudes towards euthanasia. Many works have related religious attitudes to a lesser acceptance of euthanasia in different countries and contexts (Aghababaei et al., 2014;Cohen et al., 2014;del Rosal & Cerro, 2018;Fundación B.B.V.A., 2020;Hegarty, 2021;Sikora, 2009;Suárez Almanzor et al., 1997) or as one of the reasons why physicians would not provide end-of-life practices (Brown et al., 2021). It would seem that the stronger people's adherence to their religious beliefs and the more they consider religion as an important part of their lives, the greater their rejection of euthanasia as an option. This effect exists irrespective of the religion professed (Köneke, 2014). Despite this effect between religion and attitudes towards euthanasia, differences have been found among the same religious groups depending on country; for example, in the work by Cohen et al., (2014) the Catholics who lived in Spain or France showed a more permissive attitude towards euthanasia than those Catholics living in Hungary or Poland, whereby attitudes towards euthanasia seem to be determined by the culture of the country where the person resides (De Moor, 1995, cited by Cohen et al., 2014; hence the importance of the study of attitudes towards euthanasia specifically in each cultural context. Together with trust in the medical system of the country and religious beliefs, another variable that may influence attitudes towards euthanasia is trust in other people. Trust at an individual level, that is to say, trust in other people in general, could be linked to a more favourable attitude towards euthanasia and with a lesser fear of the slippery slope argument. The results of Köneke's work (2014) indicate that trust in other people increased the acceptance of euthanasia; trust may be an important cultural factor, rather than a characteristic of the individual and it would therefore be interesting to corroborate these relations in each specific context (Köneke, 2014). In the Spanish context, recent works indicate that trust in other people is at mid-level, with a score of 5.2 out of 10 (Fundación B.B.V.A., 2020).
On the other hand, in the literature on bioethics, reasons of compassion might constitute a criterion for carrying out euthanasia practices. Compassion and empathy are linked to ethical principles of personal autonomy and human dignity (Baum, 2017). The act of empathy in the face of others' suffering or misfortune is compatible with an ethical sense of humanity; according to Baum (2017, pp 6) "euthanasia highlights the moral conflict surrounding suffering or allowing another to suffer when faced with an incurable and painful illness". Empathy is the capacity to understand the other person, to put oneself in their place. Empathy is an affective response that arises from the understanding of the emotional state or condition of the other person (Eisenberg et al., 1994). The literature on empathy shows that people differ in the extent to which they are affected by the suffering of others (van Tol et al, 2012), so that empathy might be a variable that explains people's attitudes towards euthanasia.
Finally, in relation to attitudes towards euthanasia, various research works have also investigated the relation to variables such as age, gender or political orientation, both in the general population and among people working in the area of health. With regard to gender, the results found among different research studies were contradictory. Despite the fact 289 anales de psicología / annals of psychology, 2023, vol. 39, nº 2 (may) that most recent studies find no differences based on gender (Aghababaei et al., 2014;Kontaxakis et al., 2009;Rodríguez-Calvo et al., 2019;Stronegger et al., 2011;Szadowska-Szlachetka et al., 2019), some studies show that women are more supportive of euthanasia than men (Muller et al., 1996;Vega & Moya, 1992), while other work indicates that men are more supportive of euthanasia (Fekete et al., 2002;Ramírez-Rivera et al., 2006). With regard to age and attitudes towards euthanasia, it would seem that, in general, the results of different research studies indicate that acceptance of euthanasia decreases slightly as the age of the person goes up (Fekete et al., 2002;Köneke, 2014;Vega & Moya, 1992). With regard to ideological self-positioning and attitudes towards euthanasia; in Spain it seems that the further left people position themselves, the more they support the regulation of euthanasia, while, if they position themselves in line with right-wing ideologies, they show a lesser degree of support for euthanasia (del Rosal & Cerro, 2018;Fundación B.B.V.A, 2020).
The objective of this work is to investigate, in the Spanish context, the variables that predict the attitudes of the population to euthanasia: specifically, the role of sociodemographic variables, as well as the variables of political orientation and religious attitudes, the role both of the trust of the individual in the health system and in people in general, as well as the role of empathy in people's attitudes towards euthanasia practices.

Method
Participants 182 people took part, 60 men and 122 women. The age of the participants ranged from 17 to 81; the average age of the sample was 32.75 (DT = 14.09). 97.8% of the participants were Spanish nationals, 1.6% Moroccan and the remaining, .5% of Algerian nationality. With regard to their civil status, 29.1% of the participants were married, 57.7% were single, 3.8% were separated, .5% were widowed and 8.8% had a common-law partner or lived with their partner. With reference to their employment situation, 50.3% of the sample were currently working, 34.3% studying and 15.4% working and studying.

Procedure
The questionnaires were distributed through the Qualtrics programme by means of snowball sampling. 279 people filled in the questionnaire, but only 182 completed all of it and only the answers of those 182 people were therefore analysed. Participation was voluntary and anonymous. The participants were informed that by filling in the questionnaires they agreed to participate in the study. The study was conducted under the ethical standards and criteria of the Helsinki Declaration (World Medical Association, 2013).

Data analysis
This research was carried out using a cross-sectional predictive design (Ato et al., 2013). A linear hierarchical regression analysis to possible predictor variables of attitudes towards euthanasia was performed using Statistical Package for Social Sciences, IBM 26.0 (SPSS, 2010). We conducted a sensitivity and a post-hoc analysis using G * power (Faul et al., 2009). The sensitivity analysis to determine the effect size the current study could detect showed that with this sample size (N = 182), with α = .05 and 1-β = .95, the minimum effect size that we can detect for a multiple regression analysis with 10 predictors is f 2 = .14.

Instruments
The following scales and study instruments were used.

Questionnaire on socio-demographic variables
At the beginning of the questionnaire the participants were asked to provide information regarding their age, gender, nationality, their region of residence, civil status and whether, in questions of religion they considered themselves believers or not (of any religion).

Measurement of general trust and trust in the health system
General trust (trust in people) was evaluated with one item: "speaking in general terms, would you say that most people can be trusted?" (adapted to: EVS: European Values Study, 2008), with a response scale from 0 (not at all) to 5 (totally).
Individual trust in the health system was evaluated with one item: "how much do you trust the Spanish health system?" (EVS: European Values Study, 2008), with a response scale of 0 to 3, where higher scores indicate greater trust in the health system. The responses were codified as 0 = I don't trust the Spanish health system, 1 = I don't trust my country's health system very much, 2 = I have considerable trust in my country's health system, 3 = I trust my country's health system totally.

Political orientation
Political ideology was measured with one item: "what is your political orientation?", with a response format of 1 to 5 where 1 = extreme left-wing, 2 = left-wing, 3 = centre, 4 = right-wing, 5 = extreme right-wing.
Interpersonal Reactivity Index (IRI) (Davis, 1983) The version in Spanish, by Escrivá et al. (2004) was used. This questionnaire evaluates empathy from a multidimensional perspective which includes two cognitive factors and two emotional ones. It is made up of 28 items dis- tributed in four subscales which measure four different dimensions of the global concept of empathy: perspective taking, fantasy, empathic concern and personal distress. The subscale of perspective taking measures the facility and the impulse of the subject to put himself or herself in the other person's situation. The subscale of fantasy evaluates the tendency to identify oneself with fictional characters and stories. The subscale of empathic concern measures feelings such as concern, compassion and care in the face of other people's distress and the subscale of personal distress evaluates the negative feelings that arise in the subject on observing others' distress. The scale presents a response format of the Likert type from 0 to 4. The consistency of the scale for this study was α = .78. The alpha of Cronbach for the perspective taking scale was .70, for the subscale of empathic concern .58, for the subscale of fantasy .73 and .71 for the subscale of personal distress. These alpha values range from .58 to .73, values similar to those obtained in other works with a Spanish sample (Escrivá et al., 2004).

Euthanasia Attitude Scale (EAS; Tordella y Neutens, 1979)
A scale validated and adapted to the Spanish language by Onieva-Zafra et al. (2020). The EAS consists of 21 items in total, distributed in 11 items on ethical considerations, 4 items on practical considerations, 4 items on treasuring life and 2 on naturalistic beliefs. The scale presents a response format of the Likert type of 5 points, from 1 = I totally disagree to 5 = I very much agree. The consistency of the scale for this study was α =.89.

Results
With the aim of analysing the influence of the different socio-demographic variables, of individual trust in the health system and in people in general, and of empathy in attitudes towards euthanasia, a hierarchical regression analysis was carried out.
In the first step of the regression the socio-demographic variables age and gender (0 = men, 1 = women) were introduced. Furthermore, in this step the data was also introduced as to whether the person considered himself/herself a believer in any religion (0 = no, 1 = yes), as well as the political ideology with which he or she felt identified (from 1 = extreme left-wing to 5 = extreme right-wing). In the second step of the regression, the data on trust in the health system and trust in people in general were introduced. Finally, in the third step of the regression the four subscales of perspective taking, empathic concern, phantasy and personal distress were introduced.
In the first step, the results of the regression analysis indicate that there are no differences in the attitudes towards euthanasia according to the gender or age of the participants. Significant effects were found according to whether or not the people considered themselves to be believers in a religion (p = .013), whereby the participants who considered themselves to be believers held less favourable attitudes towards euthanasia than those who did not consider themselves believers. With regard to political ideology, the further right the political orientation, the lesser the acceptance of euthanasia.
In the second step of the regression, no significant effects were found with regard to trust in general of other people; however, significant effects were found in trust in the health system (p = .009); the greater the trust in the Spanish health system, the more positive the attitudes towards euthanasia.
In the third step of the regression, no significant effects were found in 3 out of the 4 empathy subscales: perspective taking, personal distress and fantasy. Significant effects were found in the empathic concern subscale (p = .003), whereby the greater the empathic concern, the more favourable the attitudes towards euthanasia.
In each one of the regression steps, the changes in the adjusted R 2 were significant. We conducted a post-hoc analysis using G*power to determine the effect size in each step of the regression. The results showed that the effect size was .16 in step 1, .22 in step 2 and .28 in step 3. Therefore, the inclusion of the variables has a medium effect size in the improvement of the prediction of attitudes towards euthanasia. .273 3.05** Personal distress -.122 -1.54 R 2 = .221; F(10, 138) = 5.18** † p < .10; *p < .05; **p < .01

Discussion
The main objective of this research was to explore which variables could contribute to explain Spanish people's attitudes towards euthanasia. Knowing these variables is a subject of great social interest, and even more so at this time when euthanasia has recently been regulated in the country and starts to be put into practice. Another of our objectives was to corroborate whether, in the Spanish context, certain variables are related to attitudes towards euthanasia in a way similar to other European contexts or if these variables differ The social perspective of euthanasia in Spain: variables that predict attitudes towards euthanasia 291 anales de psicología / annals of psychology, 2023, vol. 39, nº 2 (may) specifically in each context. In particular, investigations were made into the relation between socio-demographic variables, political self-positioning, religious beliefs, empathy, trust in people, trust in the health system and the attitudes of the population towards euthanasia.
In relation to the socio-demographic variables, no differences were found, in terms of gender, in attitudes towards euthanasia; this result corroborates previous works which also found no differences according to gender (Aghababaei et al., 2014;Kontaxakis et al., 2009;Rodriguez-Calvo et al., 2019;Szadowska-Szlachetka et al., 2019), and contradicts the results of other research works which did find such differences (Fekete et al., 2002;Muller et al., 1996;Ramírez-Rivera et al., 2006;Vega & Moya, 1992). In relation to age, previous studies indicated that acceptance of euthanasia decreases slightly the older the person (Fekete et al., 2002;Köneke, 2014;Vega & Moya, 1992;Fundación BBVA, 2020); in our work a marginal effect can be found which might point to this result, but the results are not significant, so that, in this study, age does not predict attitudes towards euthanasia. With regard to political self-positioning, the result found by del Rosal and Cerro (2018), also with the Spanish population, is confirmed insofar as political self-positioning would influence people's attitudes towards euthanasia. Our data showed the more pronounced the self-positioning in a leftwing ideology, the greater the acceptance of euthanasia.
Religious beliefs were one of the variables that has been most closely related to attitudes towards euthanasia in previous literature. The results of this work indicate that people who consider themselves believers (irrespective of the religion they profess) hold less favourable attitudes towards euthanasia that those who do not consider themselves believers. This work also confirms the findings of previous research both in our context (del Rosal & Cerrero, 2018) and in other countries (Aghababaei et al., 2014;Köneke, 2014;Rudnev & Savelkaeva, 2018).
With regard to trust, while no relation is found between trust in general in other people and attitudes towards euthanasia, a relation is found between the latter and individual trust in the Spanish health system. Our results would indicate that the greater the trust in the healthcare system, the greater the acceptance of euthanasia practices, a result that confirms previous work in other countries (Bernheim et al., 2014;Andrew et al., 2013) and the relationship found in our country by (Bartolomé-Peral & Coromina, 2020). In Spain, it seems that trust in the healthcare system plays an important role in the acceptance of euthanasia.
Lastly, the hypothesis was formulated that empathy might predict attitudes towards euthanasia. The results indicate that it is empathic concern, the capacity of the individual to react emotionally in the face of situations or negative experiences of others, which relates to more positive attitudes towards euthanasia.
In conclusion, our data indicate that neither gender nor age is related to attitudes towards euthanasia. Instead, political self-positioning, religious beliefs, individual trust in the health care system and empathic concern will help explain these attitudes. These variables should be considered when carrying out euthanasia practices and taken into account when working with the professionals who participate in this practice.

Limitations and future research
We are conscious that this study may be subject to certain limitations, principally the sample: the sample is one of convenience, selected by means of snowball sampling. The majority of the people who participated are from a specific region of Spain and there are fewer participants from the other Spanish regions. Furthermore, fewer older adults have participated than young or middle-aged people, as well as more women than men.
It would be convenient if future studies were to corroborate these results with wider samples. Despite these limitations, the work corroborates in Spain the results found in other contexts and explores the relation of empathy to attitudes towards euthanasia.