Social values as an independent factor affecting end of life medical decision making
Research shows that the physician’s personal attributes and social characteristics have a strong association with their end-of-life (EOL) decision making. Despite efforts to increase patient, family and surrogate input into EOL decision making, research shows the physician’s input to be dominant. Our research finds that physician’s social values, independent of religiosity, have a significant association with physician’s tendency to withhold or withdraw life sustaining, EOL treatments. It is suggested that physicians employ personal social values in their EOL medical coping, because they have to cope with existential dilemmas posed by the mystery of death, and left unresolved by medical decision making mechanisms such as advanced directives and hospital ethics committees.
KeywordsEnd of life Social values Medical decision making Israel
Medical advances have both extended the human lifespan, and created difficult ethical dilemmas for patients, families, and doctors concerning which life-prolonging treatments to employ, withhold, or withdraw. Research has shown that, in practice, most end-of-life (EOL) medical decisions are made by physicians (Lang and Quill 2004; Buford 2008). Procedures that encourage the input of the patient in the decision making process, either through advance directives specifying patient treatment preferences, or through the input of surrogates, have proven to be only partially effective (Parks and Winter 2009; Torke et al. 2008; Perkins 2007). Given the dominant role of the physicians in EOL decision making, it is important to identify the factors that influence the physician’s EOL decision making process.
Research has shown a strong association between both the doctor’s personal attributes and their social attitudes and practices, with their actual EOL decision making (Silverman 1996; Cohen et al. 2008; Baume et al. 1995; Vincent 1999). Personal physician attributes have been shown to be associated with a tendency to withhold or withdraw (rather than continue) life prolonging treatments. These include male gender, older age, more medical experience, medical specialty (oncological related, rather than surgical) and personal experience with terminal illness (which strengthens the tendency to withhold or withdraw treatments) (Hinkka et al. 2002a, b; Lipp 2008; Christakis and Asch 1995). In addition, social cultural factors such as a more conservative, tradition-based religious affiliation and practice have been shown to be strongly associated with a tendency to continue (rather than withhold or withdraw) life prolonging treatments (Cohen et al. 2008; Baume et al. 1995; Carmel 1996; Christakis and Asch 1995; Hinkka et al. 2002a, b; Hardart and Truog 2003). Also, physicians practicing in non-Western, traditional national societies with strong, patriarchic, extended family institutions are more likely to continue life prolonging treatments (Hipshman 1999; Asai et al. 1997; Mobeireek et al. 2008; Sittisombut et al. 2009).
The significance of religiosity and nationality implies that the specific social values that the physician applies in EOL decisions may derive from a more overriding, comprehensive set of social values. Social values are culturally defined standards by which people assess the correctness, desirability, goodness and beauty that serve as broad guidelines for a range of areas of social living (Macionis 2003). Seemingly, the social values that the physician applies in EOL decision making are similar to the set of social values that s/he applies in other areas of behavior. EOL decision making thus does not occur in a neutral, value-free vacuum, nor is it strictly case specific.
This study examines the relationship between medical EOL decision making and social values using the conceptual framework of political philosophy. Political philosophy tenets that a significant factor in ethical decision making is an individual’s conscious values, defined as their rational, cognitive understandings concerning the proper relation between the individual and civil society (in contrast to psychology that focuses on elucidating inner subjective drives and motivations). These premises make political philosophy an appropriate conceptual framework for studying the role of values in medical decision making as medical institutions are social settings in which rational, cognitive thought processes of diagnosis and treatment predominate. Similarly the subject of ethical decision making is a field in which it is presumed that rational analysis and choice play a dominant role.
The political philosophical analysis of Leo Strauss provides us with a comprehensive conceptual framework for examining our research question of social values and EOL decision making. He argues that social values are not simply a collection of random, relative social preferences, but rather are derived from basic philosophical understandings concerning the nature of people and society. These basic philosophical understandings, in turn, frame the debate on ethical dilemmas. The basic political and cultural developments of modernity, Strauss argues, can be understood as a conflict between liberal and conservative understandings concerning the proper relation of the individual to the civil society with which s/he interacts (Bloom 1987).
According to Strauss, liberalism is defined by the following philosophical understandings concerning a person’s place in civil society: (1) Political and ethical choices should be primarily based on ideas and data that can be understood and quantified by human faculties (as opposed to ideas and data whose source is divine revelation). (2) In a similar manner, social change should be developed and promoted by rational, utilitarian problem solving methods. (3) The problem-solving process of the individual conscience should be free to be the ultimate arbiter of ethical decision making. And (4) the individual’s bond to civil society should be based on freely (democratically) assumed mutual obligations between the individual citizen and civil society (Green 1993; Tarcow and Pangle 1987).
In contrast, conservatism is defined by the following philosophical understandings: (1) Political and ethical choices may significantly incorporate ideas and data derived from sources that are not completely knowable and quantifiable by human faculties, such as divine revelation emanating from a transcendent spiritual realm, or a historical tradition of a collective national group. (2) Social planning and development should emphasize respecting, and taking into account, religious or collective group tradition and precedent. (3) Individual ethical decision making should be coordinated with, and at times subordinated to, divine revelation or collective group tradition. And (4) the mutual obligation between citizen and civil society are, in many ways, a product of a historical, or a ‘natural-organic’ bond between the individual and his civil society (Green 1993; Tarcow and Pangle 1987).
Interestingly, Strauss’s theoretical political analysis defining liberalism and conservatism corresponds to recent findings of research in the field of social psychology that shows that liberal social values give priority to concerns of individual psycho-social suffering, and the equality and fairness of the social order, while conservative social values give priority to collective loyalties, multi-generational hierarchical bonds, and issues of spiritual purity (Haidt et al. 2009). Strauss’s philosophical political analysis defining the preferred social structures of liberal and conservative social values also corresponds to recent findings in the field of evolutionary psychology/anthropology, a school that holds that political orientations are natural dispositions molded by evolutionary forces. Many of these studies define and measure liberalism-conservatism using the RWA (right wing authoritarianism) scale and genetic and neurological testing. These studies argue that conservatism is best understood as a genetically/evolutionary derived personality disposition that finds self fulfillment in collective, hierarchical social structures that are religious and ethnocentrically oriented, and intolerant of sexual freedom. Liberalism, in turn, is best understood as an evolutionary derived personality disposition that finds individual fulfillment in non-hierarchical, mutually reciprocal social structures which encourage individual creativity, family and societal egalitarianism, sexual freedom, and openness and tolerance of strangers. These liberal and conservative personality dispositions strongly correlate with specific political attitudes on a spectrum of current socio-political issues (Tuschman 2013).
Our research thus hypothesizes that, (1) a physician’s social values will be related to his/her EOL decision making; (2) social values will be related to EOL decision making independent from the variable of religiosity. (3) A physician’s EOL ethical decision making will be associated with his political philosophical understandings, and corresponding social values, concerning the domains of a person’s proper place in civil society. (4) Thus we predict that physicians who hold an overriding set of conservative social values would less likely to withdraw or withhold life sustaining treatments, and physicians who hold an overriding set of liberal values will be more likely to withdraw or withhold life sustaining treatments.
A conservative set of social values discourages a withholding/withdrawing of treatment because conservative values consider private emotional and physical suffering in a wider context of spiritual, supernatural factors (for example, considerations of a spiritual afterlife, and shared proprietorship on life with a divine being). Also conservative social values balance or subordinate individual conscience decision making to legal or societal custom precedents of a religious or collective group tradition.
Liberal social values allow for a withdrawing/withholding of life sustaining treatments because they give priority to considerations of individual, here-and-now physical and emotional suffering (not placing them in a supernatural, spiritual context), and give priority to here-and now rational, utilitarian problem solving, and individual conscience decision making (with very limited regard for social custom precedents of a religious or a collective group tradition).
This study was conducted in Israel, a relevant place to study dilemmas of decision making in bio-social ethics as Israeli physicians must often cope with medical dilemmas of patients and families whose social values are significantly different from their own. Israeli society is very multi-cultural, spanning the range of sub cultures from Western modernity, to non-Western traditionalism. Its medical education is on a high Western, modern level. Most physicians are secular and liberal in their social perspective (Wenger and Carmel 2004a, b). In contrast, large segments of the Jewish population are immigrants or first generation descendents of immigrants, from non-Western countries and from the former, communist Soviet Union. Others practice religion in a strictly observant, fundamentalist manner. There is also not the same degree of separation of church and state that is prevalent in North America and Europe. The Israeli religious establishment directly intervenes in many areas of medical practice and in the delivery of health services. A recent study of religion and medical ethics focusing on Israel details how health and EOL decision making, in both the civil and individual spheres, is the result of a convergence of competing psycho-social forces. These forces include religious legal norms, religious customs and popular practices, economic and social power interests, and the personalities of the participants. The study shows that in both the secular/civil and religious communities competing liberal-leaning and conservative-leaning social values play a significant role in how civil and religious statues will be implemented in practice (Barilan 2014).
The study aims to help clarify how social values that are derived from differing political philosophical understandings of human nature and societal change may influence decisions concerning the prolonging or withdrawing of life sustaining medical treatments.
Procedure and sampling
The sample consisted of physicians from three major medical centers in three different areas in Israel and included oncologists, geriatricians, internists and obstetrician-gynecologists (OB/GYNs). These represent the specialties that are most likely to be engaged in real time EOL medical decisions that are made in hospital settings. Respondents were informed, before answering the questionnaire, that this was a study on medical ethics dilemmas, which examines the relationship between social values and moral dilemmas. It was also explained that the questionnaires were anonymous and that the findings would not be used beyond the purposes of the study. The questionnaires were distributed within the framework of staff meetings and conferences. Out of 115 questionnaires distributed, 112 (97 %) came back fully completed.
The average age of the respondents was 42 (SD = 12) years old.; 96 % were Jewish. With regard to religiosity, 67 % defined themselves as secular. Sixty-two percent were men and thirty-eight percent were women. Overall, 76 % of all respondents had personally dealt with one or more of the dilemmas presented in the questionnaire in their own families—51 % reported that they had dealt with terminal illnesses and 38 % with advanced dementia.
The research tool
The researchers developed and pre-tested two original scales in order to investigate the association between the two main variables of our research hypothesis, social values, and EOL medical ethical decision making. A preliminary version of the instruments was given to 15 physicians who filled it out and made comments and suggestions as to how to improve the questionnaire. The questionnaires were the revised accordingly.
Independent variable: social values
Social value scale
1 Total dis agree ment
5 Full agreement
Criteria for planning social change
1. Despite the rapid pace of technological change, it is preferable that social change (family, society) progress in a conservative manner
2. Many segments of society live in distress and poverty, and it is important that the government itself takes responsibility to rapidly execute social change in order to help them
3. It is important that the status of women change in accord with progressive social change
4. Traditional precedents should play an important role in planning social changes
5. Social research and progress in the social sciences are the most constructive and meaningful basis for planning successful social change
6. Change in the status of women should be not only in accord with social change, but it is important to give weight to traditional precedents
Individual free choice with regard to medical ethical questions
1. The individual conscience and the right to self determination should be the highest authority and the final word with regard to questions of medical ethics concerning an individual’s own body
2. The proprietorship on individual life is shared between man and G-d
3. The individual is the sole proprietor on his body
4. Medical ethical decisions should take into account the welfare of the individual patients, but also be coordinated with precedents of religious law
5. With regard to medical ethical questions, in my own personal life, I would not make a decision without consulting a religious leader
6.With regard to medical ethical questions, it is important that the individual see himself as a link in a collective tradition (nation, religion, or ethnic group)
7. It is important that the individual have full freedom to fulfill his life in accord with his personal philosophy
Criteria for deciding the ‘Good’ and the ‘Bad’ with regard to the personal welfare of the individual
1. There exists a spiritual reality that is truer in its essence than the material physical reality that we are able to know through our senses and reason
2. We must recognize and know the reality and essence of our existence primarily through the use of our reason in a scientific and rational manner
3. Every individual has a soul that is derived from an eternal spiritual world
4. Even if there is some type of spiritual reality, it cannot be an ultimate authority for deciding what is ‘good’ and ‘bad’, and what is ‘true’ and ‘not true’
5. The most meaningful basis for deciding ‘good’ and ‘bad’, ‘true and not true’ is divine revelation
6. In understanding what constitutes ‘personal welfare’, we want to focus on the person’s emotional and material needs because it is not possible with any degree of truthfulness to know what constitutes the spiritual welfare of the individual
The source of moral authority
Liberal social values emphasize that ethical choices should be based primarily on human reasoning, while conservative social values emphasizes the role of divine revelation, or the historical tradition of a collective, national or religious group.
An item presenting a liberal social value: “In determining what constitutes individual well-being we want to concentrate on individual physical and emotional well-being, because there is no objective basis for establishing the truth of what constitutes spiritual well-being”.
An item presenting a conservative social value: “There exists a spiritual reality that is more basic and truer than the reality that we can recognize by means of our senses and intelligence”
The proper nature of social development and change
Liberal social values emphasize that social change should give primacy to rational, utilitarian problem solving methods, while conservatism argues that social change must give proper consideration to religious or collective, national tradition.
An item presenting a liberal social value: “Many segments of our population find themselves in distress and need, and it is important that the government takes responsibility to plan and execute social change in order to help them”.
An item presenting a conservative social value: “Social development with regard to the status of women should not only take into consideration societal changes, but also should give weight to the precedents of collective tradition”.
The scope of individual conscience decision making
Liberal social values grant almost complete ethical freedom to the individual conscience, while conservatism argues that the individual must sometimes be subordinated to divine law or collective precedent.
An item presenting a liberal social value: “It is important that the individual have the freedom to decide and determine the way of life that is most appropriate to him”
An item presenting a conservative social value: “With regard to ethical decision making it is appropriate that the individual see himself as a link in a collective chain of tradition (religion, nationality, or ethnic group)”.
Dependent variable: end of life medical decision making
End of life medical decision making—factor analysis, factor loadings, Cronbach’s alpha internal consistency, averages and standard deviations
With regard to a patient’s terminal illness and three month life expectation…
1.Non-use of antibiotics for coherent, independent patient
2.Non-use of feeding tube for patient
3.I myself would refuse antibiotics
4.I myself would refuse feeding tube
5.Civil approval of physician assisted suicide
With regard to non-communicative demented patient…
6.Permissible for government to legislate allowing physicians to withhold artificial feeding
7.Permissible for government to legislate allowing physicians to withhold mechanical breathing
8.It is ethically moral to withhold artificial feeding
9.It is ethically moral to withhold mechanical breathing
10.I myself would not want artificial feeding
11.I myself would not want mechanical breathing
“It is ethical for a person with advanced dementia, and infection, not to receive life sustaining nutrients through a feeding tube”.
“It is ethical for the state to legalize physician assisted suicide if the person with a terminal illness desires it”.
“If I was coherent and sick with a terminal illness, like an advanced case of cancer, and became ill with pneumonia, I would refuse to take strong antibiotic medicines”.
Religiosity was reported by each respondent according to four categories, most commonly used in Israel: ultra-orthodox, religious, traditional, and secular. Other attributes studied were age, ethnic background, medically specialty, medical professional status, and personal experience coping with terminal illness.
Factors bearing upon attitudes toward medical dilemmas in matters of life and death
Hierarchical linear regression was used in order to examine the explained variance of attitudes toward life and death medical dilemmas on a liberal-conservative continuum, against the doctors’ age, status (specialists, residents and interns), religious self-definition (ultra-orthodox, religious, traditional, and secular) and social values (liberal to a conservative continuum).
Linear regression: predicting attitudes toward medical dilemmas in matters of life and death
Unstandardized regression coefficient B
Standard error S.E.B
Standardized regression coefficient β
STEP I: general background
Summary of step I
F(2,91) = 4.10, R2 = .083, p < .05
STEP II: religiosity
Summary of Step II (aggregated)
F(3,90) = 4.62, R2 = .133, p < .01
STEP III: social outlook
Summary of step III (aggregated)
F(4,89) = 5.06, R2 = .185, p < .001
The background variables, age and status, jointly explain 8.3 % of the variance in attitudes toward medical dilemmas in matters of life and death. The older the doctor, the more liberal his opinion (β = .344, p < .01). Religiosity explained another 5 % of the variance in attitudes toward medical dilemmas in life and death matters, so that the more religious the doctor, the more conservative his opinion, (β = .236, p < .05). Social values explained an additional 5.3 % of the variance in the attitudes beyond the effect of background and religiosity (β = .366, p < .05). The findings indicate that the more liberal the doctor, the more likely s/he was more inclined to withhold or withdraw life sustaining treatments. Over all, age, religiosity and social values explained 18.5 % of the variance in attitudes toward medical dilemmas in life and death matters.
The findings of this study showed that social values and religiosity each independently explain a significant part of the variance in physician attitudes to EOL medical decision making. Physicians who hold a more liberal set of social values, and define themselves as religiously non-observant, are more likely to withhold, or withdraw, life-prolonging treatments. These findings concerning the role of religiosity replicate the findings of previous studies (Hipshman 1999; Mobeireek et al. 2008; Sittisombut et al. 2009), as does the finding that the older and more medically experienced the doctor, the more liberal his/her opinion(Hinkka et al. 2002a, b).
Our study goes beyond these factors by clarifying the role of a comprehensive set of social values, expressed in the physician’s basic, political philosophical understandings concerning the proper role of the individual in society and their relationship to EOL decision making. Social values, independent of religiosity, affect EOL medical decision making. Seemingly, one of the resources that physicians use to cope with EOL medical dilemmas is their personal, philosophical understandings concerning the proper role of the individual in society.
Why do physicians use their personal set of social values to cope with the task of EOL decision making? Socially and emotionally coping with the EOL has always been a very complex, challenging task. Modern medicine’s ability to prolong life has made this task even more overwhelming for families, medical professionals and society. Procedures and mechanisms have been developed over the last 20 years to help these involved parties cope better. For example, tools such as advanced directives and surrogate decision making have been developed in order to insure individual autonomy in the decision making process. Hospitals and governmental regulatory bodies have instituted hospital review and ethical committees, and concepts such as ‘futility of care’, ‘quality of life’, ‘meaningful survival ‘ and ‘medically ineffective treatments’ in order to more effectively balance family preferences and overall societal needs and resources. Finally, medical education has developed curricula for teaching palliative care, and skills of crisis communication and ethical decision making.
These tools have made significant advances in helping the involved parties better cope with the task of EOL decision making. They have helped ascertain and define the primary issues, and created procedures that better coordinate the coping efforts of family and medical staff. However, despite these advances, EOL decision making remains a formidable coping task. First, the literature reports that it is very difficult to implement the coping procedures described above and bring about meaningful input of families and surrogates (Parks and Winter 2009). The result is that the physician maintains a central role in the decision making process. Second, these coping mechanisms define and channel, but do not resolve, the existential/philosophical questions created by the EOL (Perkins 2007). For example our findings show when EOL decision making requires defining the proper boundaries between individual ethical choice and the obligations of a collective tradition, and determining the physical versus the spiritual dimensions of ‘suffering’ and ‘futility’ physicians refer to their personal set of social values, and not to objective, measurable criteria. The basic concepts of medical ethics are defined differently by liberal and conservative value systems.
Thus the procedural coping mechanisms described above leave the physician in a decisive decision making position, but with the basic social value questions that comprise the decision making process unresolved. In order to cope with these dilemmas, and make a decision, physicians must employ the coping resource of his personal set of social values concerning the questions of proper social change, the divine or human source of knowing ‘good’ and ‘true’, and the boundaries of individual ethical free choice.
Our above explanation of the independent effect of social values on EOL medical decision making finds considerable support in the literature. The key related subjects are (1) the limited efficacy of the institutional coping tools that have been developed to define and coordinate family and societal EOL medical decision making, (2) developments in medical education, (3) the role of differing social values in multi cultural medical settings, and (4) the unresolved existential/philosophical questions created by the EOL.
Recent research has highlighted the inefficacy of advanced directives and surrogate decision making. For example, <25 % of the USA population has authorized directives. Many patients refuse to write ADs because they do not want to think about the future (Wu et al. 2008). In time of medical crisis, ADs are frequently unavailable or are not enlightening, given the complexity of the acute medical situation. Research has also questioned the moral authority of the ADs, showing that authors do not recall their previous choices, do not understand AD texts, change their opinions overtime, and are greatly influenced by the specific, psycho-social context at the time of the authorization (Parks and Winter 2009; Kressel and Chapman 2007).
Similarly, surrogate decision-making, by designated family members or representatives, has proven to be an insufficient medical ethical coping mechanism. Surrogates are frequently unaware that they have been authorized, or are not aware of the specific directives that have been authorized. The surrogate’s ability to play an active role in decision-making is often limited because of distance and competing considerations of family and work. When surrogates are asked to either recall or affirm the patient’s unwritten, but stated, preferences, they find this to be a difficult task. When patient preferences are unclear, not available, or inapplicable, the surrogate must determine what actions are in the patient’s best interest, a task found by many to be traumatic. They frequently do not understand the medical facts and questions at stake, lack a concrete frame of reference of values for decision-making, find communication with doctors to be difficult or lacking and are fearful of creating family conflict (Torke et al. 2008; Vig et al. 2007; Braun et al. 2009). In brief, while advanced directions and surrogates may be effective for some patients, the physicians remain a dominant, pivotal figure in EOL decision making, and their personal social values continue to be relevant and have impact.
Similarly, attempts to resolve medical futility disputes between society’s limited medical resources and family desires for ongoing medical care by establishing hospital ethical committees, appointing third party arbitrators, and legislating statutes based on concepts such as “futility of care” and “meaningful survival” have also only been partly effective. It has not been possible to establish a medically proven definition of futility, and ethics committees and legislative statues have been shown to be biased to the interests of the medical establishment, and not those of the patients (Burkle and Benson 2012; Lofmark and Nilstun 2002; Kressel and Chapman 2007). Thus, also on the societal level, a conclusive mechanism resolving the complexity of EOL dilemmas has yet to be developed. The physician’s personal social values thus continue to be relevant and have impact on EOL decision making.
Medical education in the last 20 years has succeeded in developing curriculum to help physicians cope with EOL medical issues. The curriculum include teaching principles of palliative care, crisis and family communication skills, procedures for empowering patient autonomy and non biased clinical decision making, and analysis of the ethical issues of withholding or withdrawing medical care in cases of ‘futility of care’ (Bickel-Swenson 2007; Sulmasy et al. 2008; Sullivan et al. 2003). However, these curriculum developments have not included teaching the differing liberal-conservative social understandings that our findings have shown to have an impact on EOL decision making. Students do not have sufficient opportunity to systematically study the subject of social philosophy, and learn how to professionally apply the social values that they bring from other areas of their life (politics, religion) to the specific area of EOL medical ethical decision making. Nor do they have sufficient opportunity to develop the degree of self awareness concerning their personal set of social values that will enable them to non-judgmentally work with families having a very different set of liberal-conservative social values.
The fact that medical education has not sufficiently trained physicians to cope with differing social values in a multicultural medical setting is shown in recent research on physicians treating immigrant populations, or ethnic, racial groups whose social culture radically differs from that of the physician (Santonocito et al. 2013; Hielmk et al. 1999; Politi and Street 2011; Perron et al. 2003). Physicians find it difficult to ‘translate’ their advice concerning proper medical compliance into the specific cultural values (language) of their patients. Without proper cultural ‘translation’ patients have difficulty coping with health problems (such as heart, respiratory, diabetes, and blood pressure) that require a high degree of daily, disciplined medical compliance and life style change.
Physicians employ the coping tool of personal social values because of the limited efficacy of the coping procedures described above, and because EOL medical decision making means coping with the existential mystery of death. The EOL is existentially greater than all the coping tools that human society can create. The basic existential philosophical questions remain unresolved. The central EOL operational coping concepts such as the role of individual conscience decision making, medical futility, suffering and quality of life are defined differently by liberal and conservative social values. The role of the existential dimensions of the EOL is highlighted by Perkins, in his article “Controlling Death: The False Promise of Advance Directives”. (Perkins 2007) He argues, for example, that advanced directives offer only limited benefit because life and death, citing Albert Camus, are largely unpredictable. People lack control over it and should acknowledge that. Less emphasis should be placed on advanced directives. Rather, more emphasis should be given to training physicians in the communication skills that will enable them to recognize and accept varying social cultural approaches to death, to provide non formulaic, individual dare, and to provide supportive preparation for death’s harsh and unpredictable reality.
In brief, EOL medical decision making means coping with the existential mystery of death. The medical procedures of the past 20 years have succeeded in defining issues and coordinating family, physician and societal coping procedures, but have left unresolved the basic type of existential issues that are addressed by social values. Physicians thus find it necessary to also employ their personal values when called upon to make challenging medical decisions.
Limitations of the study
The main limitation of the study is that it examines one particular definition of religiosity and social cultural outlook, in a particular country. For example, the scale measuring the physician’s tendency to withhold or withdraw life-prolonging treatments is based on Jewish religious (Halacha) medical law (Steinberg 2003). However this limitation should be understood in the light that previous studies have shown that the role of religiosity in Israel on EOL decision making is similar to that of conservative, traditional religiosity in America and Europe (Wenger and Carmel 2004a, b), and thus a certain generalization from our findings may be permitted.
The second limitation is that social values are only one of many forces influencing EOL decision making on a civil and individual level. As cited above, case studies in Israeli Jewish bio-ethics demonstrate the ongoing influence on EOL decision making of religious legal norms, religious customs and popular practice, economic and social power statuses, and the psycho-emotional attributes of the involved personalities. Our study did not investigate this spectrum of competing forces (Barilan 2014).
The third limitation is that the study examined attitudes concerning specific EOL decisions, but did not gather data on the decisions taken in practice. However, most research shows there to be a significant correlation between EOL attitudes and EOL practice (Silverman 1996; Cohen et al. 2008). Thus, this connection suggests that our findings concerning social cultural factors and attitudes to EOL decision-making should also increase understanding with regard to the possible influence of these factors on EOL practice itself.
Implications for practice
Our study shows that social values have a significant effect, independent of religiosity, on EOL medical decision making. This research should contribute to the knowledge base of curriculum for training medical students and physicians in the ethical decision making. It will encourage medical educators to teach about differing philosophical understandings concerning the proper role of man in society, and how these differing understandings relate to the specific dilemnas of EOL medical decision. It will enable physicians to gain greater professional self awareness concerning their own, and their patient’s particular set of social values, and concerning the possible efficacy of self disclosure of such values when counseling patients. (Politi and Street 2011; Hielmk et al. 1999)
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