Race,Ethnicity,and Attitudes Toward Physician-Assisted Death in the United States: A Narrative Review

Abstract

Background:

Physician-assisted death (PAD) is a controversial practice, legal in mostly wealthy European countries and U.S. states with a lower-than-average proportion of Black residents. Although studies report lower support for PAD among Black Americans, a comprehensive review of the association between PAD attitudes and race and ethnicity is lacking. This narrative review sought to clarify the association between race and/or ethnicity and attitudes toward PAD, while exploring possible explanatory factors.

Methods:

A comprehensive search of PubMed, Web of Science Core Collection, and PsycINFO databases through December 2024, supplemented by citation follow-up and manual searches.

Results:

The search yielded 64 eligible studies. These studies varied in sampling method, populations, studied, survey questions, and timing. To account for quality, studies were grouped into those employing random (38) versus nonrandom (26) sampling. Across both categories, White respondents consistently demonstrated higher support for PAD than racial and ethnic minority groups, particularly Black Americans, in both unadjusted and adjusted analyses. Although some studies show adding religion variables eliminates this association, the largest and most methodologically rigorous studies still show that race and ethnicity retain an independent association with PAD attitudes. Notably, there was a paucity of studies examining trust in the health care system as a potential factor.

Conclusions:

Overall, the evidence suggests lower support for PAD among racial and ethnic minority groups that may reflect, in part, distinct sociocultural factors extending beyond religion or socioeconomic status. This review highlights the need for more research on trust in health care and nuanced understanding to guide discussions on PAD policy and practice in diverse populations.

Keywords

ethnicity medical aid in dying physician-assisted death physician-assisted suicide race

Introduction

Since 1997, physician-assisted death (PAD)—also referred to as physician-assisted suicide (PAS) or medical aid in dying—has become legal in 11 jurisdictions in the United States. These laws allow physicians to prescribe lethal medications in response to requests by competent, terminally ill patients (life expectancy of 6 months or less). The practice remains controversial. One notable feature of PAD is its relation to race and ethnicity: it is almost exclusively a policy among wealthy, European countries,¹ and the U.S. states that have legalized PAD generally have a lower percentage of Black residents than the national average (Oregon, Washington, Colorado, etc.). Even in a diverse state like California, the practice disproportionately occurs among the White population.²

Although most Americans support legalizing PAD, previous studies have shown that Black and other racial and ethnic minority groups are less supportive than White individuals.^3–8 Differences also exist in attitudes toward other end-of-life issues such as the use of life-sustaining treatment and advance directives.^9,10 The interplay between race, ethnicity, and attitudes toward and participation in PAD is undoubtedly complex, and yet, significant gaps remain in the literature that hinder a comprehensive understanding of this issue. While previous studies suggest racial and ethnic differences in PAD attitudes, they often do not explore the reasons behind these differences.

To our knowledge, this is the first comprehensive review of the literature to date that systematically examines the relationship between race, ethnicity, and attitudes toward PAD. By synthesizing and analyzing existing research, this study addresses critical gaps in understanding the nuanced dynamics that may influence PAD attitudes and participation. With more states considering PAD laws, it seems crucial to understand the values, beliefs, and perspectives of historically disadvantaged groups in this debate.^11,12

We therefore conducted a comprehensive literature review and narrative analysis examining two key questions: (1) What is the association between race and/or ethnicity and attitudes toward PAD? (2) What are the potential explanations for such associations?

Methods

Given the extreme heterogeneity in the literature relevant to our study goals, we adopted a narrative review framework with a comprehensive literature search. This approach allowed us to better capture and synthesize diverse study populations, designs, and outcome measures, enabling a broader understanding of the range of evidence available. While a systematic review and meta-analysis were initially considered, substantial variation across studies rendered quantitative synthesis unfeasible.

To be included in the review, articles had to focus on assisted dying [PAD, medical aid in dying, PAS, and euthanasia and/or assisted suicide (EAS)] and report new primary data and/or analysis on the relationship between racial and ethnic groups in the United States and their opinions or attitudes toward PAD. Articles were excluded if they: did not report new primary data or analysis of existing data, did not focus on U.S. populations, were review or opinion articles, or focused on withholding or withdrawing of life-sustaining treatments or on suicide without third-party involvement (i.e., not assisted dying).

To identify potentially relevant studies, PubMed, Web of Science Core Collection, and PsycINFO databases were searched from their inception to December 2024 using strings related to PAD, behavior and culture, and race and ethnicity. The search strategies were drafted by an experienced librarian and further refined through team discussion. Complete details of the search can be found in Supplementary Data S1. The database search was supplemented by a manual search and scanning reference lists of included articles; this was particularly important since even articles whose primary focus was not on race and ethnicity and PAD (and therefore difficult to capture) could still contain “new primary data and/or analysis on the relationship between racial and ethnic groups.” C.S. and M.N. served as independent screeners for the selection of articles; any disagreement was resolved by discussion or, when needed, further discussion with S.Y.H.K.

A data charting form was jointly developed by C.S., M.N., and S.Y.H.K. to determine which variables to extract. C.S. and M.N. independently charted the data, discussed the results, and updated the data-charting form in an iterative process. Data on sample frame characteristics, sampling method, sample size, number of participants by race/ethnicity, the specific question asked, the effect of race/ethnicity (both unadjusted and adjusted), and the covariates included in the adjusted analysis were abstracted. Given the highly heterogeneous nature of the studies, we used only a single quality metric to classify them into two main groups—random (i.e., census or probability-based sampling scheme that sought representativeness to a target population) and nonrandom sample studies.

Results

The comprehensive search of databases yielded 587 unique results, providing 33 eligible articles, and an additional 31 articles were found from manual searches and screening citations in the articles, for a total of 64 articles included in the review. A PRISMA flowchart (Fig. 1) documenting the results of the search and screening process is provided.¹³

FIG. 1.

PRISMA flow diagram. Flow of study selection for narrative review on race/ethnicity and attitudes toward physician-assisted death (PAD). A total of 1,177 records were identified through database searches and 133 through citation screening and manual search. After removal of duplicates, 587 and 128 records, respectively, were screened by title/abstract. Following exclusions, 61 reports from databases and 57 from citation screening and manual search were sought for retrieval and assessed for eligibility. After excluding studies that were non-U.S. populations, lacked primary data, did not report data by race/ethnicity, or focused on end-of-life practices outside of PAD, 64 studies were included in the final review (33 from databases and 31 from other methods).

The set of articles was quite heterogeneous regarding PAD questions asked, populations studied (general public, patients, older individuals, physicians, clergy, students, etc.), time of study, racial/ethnic categorizations and terms used, sampling methods, and analytic strategies. Table 1 provides a brief description of how we handled this heterogeneity in synthesizing our findings.

Table 1.

Navigating the Heterogeneity Among Studies

Variation in studies	Our approach
Questions used to assess PAD attitudes	The questions asked about: moral permissibility of PAD, legalization of PAD, willingness to perform or refer for PAD, and PAD preferences for self. When we refer to responses to multiple questions simultaneously, we use the general qualifiers “supportive” and “not supportive” to indicate valence.
Terminology for assisted dying practice	The literature on assisted dying covers both direct termination of life (usually by injection) and death by self-ingestion of prescribed drugs (1). The terms “euthanasia” and “physician-assisted suicide”, respectively, are the terms most commonly used across the studies [we use “euthanasia and/or assisted suicide” as a broader term that covers both when referring to groups of studies that report data on both practices]. We follow the authors’ use when describing their results as much as possible. However, when referring to the general topic in the introduction or discussion sections, we use “physician-assisted death.”
Terminology for race and ethnicity	This review uses the concept of race and ethnicity not as an inherent biological construct, but as a proxy for the shared sociocultural beliefs, values, and experiences that influence a group’s collective identity. However, given the wide time period covered, there is no uniform use of the terms in the articles. Thus, in the Results, we follow the authors’ use, e.g., some used a single combined category which, for example, use White to mean non-Hispanic White. Also, some articles lumped different groups into a single “other” category in their analysis. Because of space constraints, we sometimes use “other” when referring to various groups in multiple studies to make a point in our own discussion. In our own uses in the Discussion, we use “Black” and “White” to refer to racial and ethnic categories encompassing “Black or African American” and “Caucasian or non-Hispanic White.”

PAD, physician-assisted death.

Table 2 (random sample studies) and Table 3 (nonrandom sample studies) provide concise summaries of significant associations of race/ethnicity and attitudes toward PAD. Detailed p-values or other measures of statistical significance can be found in Supplementary Data S3.

Table 2.

Studies with Random Samples or Samples of Entire Populations of Interest

Reference	Sample frame	Type of question asked^a	N	N by race/ethnicity	Race/ethnicity effect (unadjusted)^b	Race/ethnicity effect after adjusted analysis^b	Covariates^c
Attell (2020)¹⁴	General public (1977–2016 GSS)	EAS legalization	30,319	White 81%, Black 14%, Other race 5%	N/A	Black<White; Other race<White	Age, period, cohort, gender, party affiliation, education, religious affiliation
Balboni et al. (2018)¹⁵	Practicing clergy	Morality and legality of PAD	1005	Asian 1.3% (12), Black or African American 10.9% (104), American Indian or Alaskan Native 0.5% (5), White or Caucasian 85% (809), Other 3.6% (34), Hispanic or Latino 3.9% (Thirty-seven)	N/A	No	Gender, age, years in ministry, higher congregational income, U.S. region, educational level, denominational identity, higher EOL medical knowledge, distrust in the health care system, and agreement with religious beliefs including the value of life apart from quality of life, spiritual purpose in suffering, and that only God numbers our days
Bulmer et al. (2017)¹⁶	General public (2007 Baylor Religion Survey)	Morality of PAS	1427	White 86.9% (1432), Black 6.4% (106), Other race 11% (182)	N/A	Black<White	Age, education, sex, Protestant, Catholic, other religion, religiosity, political liberalism, authoritarianism, extraversion, agreeableness, conscientiousness, neuroticism, openness
Burdette et al. (2005)¹⁷	General public (1998 GSS)	Morality of PAS	1111	White 80%, Black 14%, Other race 6%	Black<White; Non-White<White	Non-White<White	Vignette female, vignette 35 years old, vignette 18 months to live, female, age, education, rural residence, native southerner, political orientation, contact with illness, Conservative Protestant, Moderate Protestant, Liberal Protestant, Catholic, other faith, church attendance, strength of affiliation
Curlin et al. (2008)¹⁸	Physicians from the American Medical Association Physician Masterfile	Morality of PAS	1144	White 78% (869), Asian 12% (158), Hispanic 5% (57), Black 2% (26), Other 3% (31)	No	Asian<White	Age, gender, region, care of dying, intrinsic religiosity, religion influences medicine
Curry et al. (2000)¹⁹	Physicians in Connecticut from specialities “most likely” to have experience with request for PAS	Morality of EAS	2805	Caucasian 85% (2352), Asian 10% (273), Other 5% (148) [Hispanic (68), African American (44), Native American (25), unspecified physicians (11)]	Writing lethal prescriptions: Native American<Hispanic=Asian<African American<Caucasian<Other Administering lethal prescriptions: Asian<Other<Hispanic<African American=Caucasian<Native American	N/A	N/A
Emanuel et al. (1996)²⁰	Oncology patients from hospitals in Massachusetts; oncologists from Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, and other states; and members of the general public in eastern Massachusetts	Morality of EAS	703	White (614), Other (61), Black (18)	N/A	No	Sex, age, marital status, religious affiliation, importance of religion, strength of religious beliefs, income, education, employment status, self-perceived health status, possession of an advance care directive, participation in making end of life decisions for a family member or friend, depression, pain, and physican functioning, participation in a support group, self-perceived chance of cure of cancer, perceived disease status, having a hospital admission within the past year
Emanuel et al. (2000)⁵	Terminally ill patients and their caregivers	Patient: EAS legalization, EAS for self Caregiver: Morality of EAS, whether patients discussed EAS with a physician or “hoard[ed] drugs”	988	Patients: White 78.9%, African American 13.7%, Other 7.4%. Caregivers: White, Hispanic, Other (192), African American (25)	EAS legalization: African American<White EAS for self: No Caregiver support for EAS: No Patients who discussed EAS with physician or “hoard[ed] drugs”: No	EAS legalization: African American<White EAS for self: African American<White Caregiver support for EAS: No	Patients: Religiosity, age, education, income, length of illness, pain, depressive symptoms, physical activity, feeling of appreciation, care needs. Caregivers: Religiosity, age, education, income, patient interference in caregiver’s life, caregiver perception of patient pain, caregiver level of support
Finlay (1985)²¹	General public (1977–1978 GSS)	EAS legalization	2719	White, Black	Black<White	Black<White	Age, region, education, religiousness, conservativeness, opposition to premarital sex, homosexual relations between consenting adults, extramarital sex, free speech, support for suicide and abortion
Ganzini et al. (1996)²²	Psychiatrists in Oregon	Morality of PAS	296	Caucasian (278), others not categorized	No	N/A	N/A
Givens & Mitchell (2009)²³	General public (1998 GSS)	EAS legalization	786	White 79.9% (628), Other 21.1% (158)	Other<White	N/A	N/A
Hamer et al. (2024)²⁴	Physicians in Colorado caring for patients likely to qualify for MAiD	Provision of MAiD	300	Non-Hispanic White 78.8% (234), Asian/Pacific Islander 12.1% (36), Other 9.1% (27)	No	Non-White<non-Hispanic White	Gender, time in practice, specialty, and practice setting
Hamil-Luker & Smith (1998)²⁵	General public (1996 GSS)	EAS legalization	1231	Black, non-Black	N/A	Black<non-Black	Age, education, income, sex, south, size of community, health, beliefs and practices variables, religious identity variables, religious affiliation variables
Howard et al. (1997)²⁶	Oncologists from Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, and other states	Morality of EAS, EAS for self	336	White (296), Other (40)	EAS for self: No	Morality of EAS: No EAS for self: No	Demographics, religious beliefs, attitudes, health factors, characteristics of oncology practice including years of practice
Jorgenson & Neubecker (1981)²⁷	General public (1977 GSS)	EAS legalization	1461	White (1281), Black and others (180)	Black and others<White	Black and others<White	Number of children, age, size of place (age 16), political view, church attendance, religiosity, general happiness, health satisfaction, suicide, sex
Lachenmeier et al. (1999)²⁸	Adults in Michigan	Morality of PAS for terminally-ill patients, PAS for self, PAS for self in 8 scenarios	603	White, Other (including African-American, Hispanic, or Asian)	PAS for self when experiencing chronic pain: Other<White Morality of PAS for terminally-ill patients, PAS for self, and PAS for self in the other 7 scenarios: No	N/A	N/A
Leinbach (1993)²⁹	General public (1977–1978, 1982–1983, 1985–1986, 1988–1991 GSS) organized into 3-year groupings from 1977 (ages 45, 46, and 47) through 1991 (ages 59, 60, and 61)	EAS legalization	3980	White, Black	N/A	Race third most important covariate after religious attendance and religious conviction reported but comparisons not provided	Religious attendance, religious conviction, region, family income, number in household, socializing with friends, work status, financial changes, number of adults in household, age, marital status, education, satisfaction with finances, community size, family income at 16, happiness, party identification, socializing with relatives, social class, gender, number of siblings, number of children, relative finances, family type at 16, political views, mother’s education, religious preference
Lichtenstein et al. (1997)⁶	Detroit residents	PAS legalization, euthanasia legalization, PAS for self	257	Black 62%, 38% White	PAS legalization, euthanasia legalization, PAS for self: Black<White	PAS legalization: No	Sex, age, education, religiosity
MacDonald (1998)³⁰	General public [1988 GSS, 1994 Ohio Death and Dying Survey (DANDS)]	EAS legalization	GSS: 949 DANDS: 460	GSS: White (824), Black (125). DANDS: White (426), Black (34) .	N/A	GSS: Black<White DANDS: No	GSS: Sex, age, education, household income, political conservativism, biblical ethicalism. DANDS: Sex, age, education, household income, political conservativism, life belongs to God, fear of giving others the power to end one’s life
Marsala (2019)³¹	General public (1985 to 2014 GSS)	EAS legalization	6638	White (5176), Black (925), Other (537)	N/A	Black<White; Other<White	Cohort, age, sex, marital status, years of education, political ideology, religious affiliation, religiosity
Mebane et al. (1999)³²	Internal medicine and family practice physicians from AMA database	Morality of PAS for terminally ill patients, PAS for self in persistent vegetative state scenario, PAS for self in irreversible brain damage scenario	437	White 64.1% (280), Black 35.9% (157)	N/A	Black<White	Gender, age
Monte (1991)³³	General public (1985 GSS)	EAS legalization	1201	White, Black	N/A	Black<White	Age, sex, place of residence, religious affiliation, attendance at religious services, religious commitment, education, income, political identification, freedom of expression, suicide approval
Moulton et al. (2006)³⁴	General public (1977–2004 GSS)	EAS legalization	19,398	White 83.2% (16,141), Black 13.8% (2674)	N/A	Black<White; Other race<White	Survey year, age, sex, education, southerner, rural residence
Seidlitz et al. (1995)⁷	Adults aged 60 or older	PAS legalization	802	White 90.4% (715), Black 7.2% (57), Other 2.4% (19), Refused 1.4% (11)	Black<Other<White	Black<Other<White	Age, gender, marital status, religiousness, self-rated health, satisfaction with family relationships, income
Sharp (2017)³⁵	General public (1985, 1988, 1989, 1990, 1991, 1993, 1994, 1996, 1998, and 2008 GSS)	EAS legalization	8905	White 84%, Black 11%, Other 5%	Race/ethnicity effect reported but percent comparison not provided	Black<White	God characteristics, religious affiliation, religious attendance, views about Bible, gender, education, age, marital status, political party identification, region, year of survey
Sharp (2017)³⁵	General public (1991, 1998, and 2008 GSS)	EAS legalization	1799	White 83%, Black 11%, Other 6%	Black<White	Black<White	Belief in miracles, religious affiliation, religious attendance, views about Bible, education, age, marital status, parent, political party identification, region, year of survey
Sharp (2018)³⁶	General public (1988, 1991, 1993, 1994, 1998, 2000, 2006, 2008, 2010, 2012, and 2014 GSS)	EAS legalization	10,437	N/A	N/A	Black<White	Belief in God, characteristics of God, experiences of God, religious affiliation, religious attendance, views about Bible, gender, education, age, marital status, being a parent, political party identification, region
Sharp (2018)³⁶	General public (2007 Baylor Religion Survey)	Morality of PAS	1356	White 84.4%, Other 10.8%, Black 4.8%	Black<White<Other	White<Other	Belief in heaven, belief in hell, religious affiliation, frequency of religious attendance, views about Bible, belief in God, belief in “Higher Power,” gender, education, age, marital status, having children, political party, region
Sharp (2019)³⁷	General public (1988, 1989, 1990, 1991, 1993, 1994, 1996, 1998, 2000, 2002, 2004, 2006, 2008, 2010, 2012, and 2014 GSS)	EAS legalization	19,967	White 79%, Black 13%, Other 8%	Black<Other<White	Black<White; Other<White	Belief in life after death, religious affiliation, religious attendance, views about Bible, gender, education, age, marital status, being a parent, political party identification, region
Sharp (2019)³⁷	General public (2007 Baylor Religion Survey)	Morality of PAS	1598	White 83.6%, Other 9.1%, Black 7.4%	N/A	No	Witnessing and or experiencing miraculous healing, religious affiliation, frequency of religious attendance, views about Bible, belief in God, gender, education, age, marital status, being a parent, political party identification, region, authoritarianism, neuroticism, extraversion, conscientiousness, agreeableness, openness to new experiences
Sharp (2019)³⁷	General public (1988 GSS)	EAS legalization	885	White 84%, Black 13%, Other 4%	Black<White	No	Views about Bible, importance of Bible in making decisions, frequency of reading Bible at home, religious affiliation, religious attendance, gender, education, age, marital status, having children, political party identification, region
Singh (1979)³⁸	General public (1977 GSS)	EAS legalization	1398	White (1238), Black (160)	Black<White	Black<White	Age, sex, place of residence, religious affiliation, attendance at religious services, religious commitment, education, income, political identification, freedom of expression, suicide approval
Sulmasy et al. (1998)³⁹	General internists in New York City, Philadelphia, Chicago, Los Angeles, Atlanta, and Washington	Provision of PAS	206	White 83% (171), Non-White minority 17% (35)	N/A	Non-White minority<White	Resource conservation index, sex, response format, years in practice
Thomas et al. (2014)⁴⁰	Physicians and residents in Connecticut	Provision of euthanasia	424	Attendings: White 89%, Asian 9%, Other race 2%, African American 1%, More than one race 1%. Residents: White 46%, Asian 39%, Other race 7%, African American 6%, More than one race 2%.	No	No	Residents (ie., not an attending), religion not important, Catholic
Tolle et al. (2004)⁴¹	Decedents by natural causes in Oregon	Morality of PAS and PAS for self	1384	White 82% (1132), American Indian 5% (67), Black 5% (62), Asian-Pacific Islander 5% (63) Hispanic 4% (60)	Morality of PAS: Black<White PAS for self: No	No	Gender, age, education, income, religion, religiosity, cause of death, hospice enrollment, symptom distress
Ward (1980)⁴²	General public (1977 GSS)	EAS legalization	1453	White 87.5%, Non-White 12.5%	Non-White<White	Non-White<White	Age, sex, education, religious intensity, attitudes toward suicide
Whitney et al. (2001)⁴³	Physicians from the American Medical Association Physician Masterfile	PAS legalization	541	White 76% (482), Asian or Pacific Islander 13% (83), Hispanic 5% (29), African American 3% (20), Other ethnicity 3% (20), Native American or Alaskan 0.3% (2)	No	White<Hispanic	Age, gender, specialty, training status, provide direct care, care for terminally-ill patients, region, political self-identification, religious affiliation, importance of religion
Ziegler et al. (2005)⁴⁴	Michigan voters	PAS legalization	1230	White (1038), Black (192)	No	No	Age, sex, income, ideology, party identification

Some studies explicitly assessed attitudes toward the legalization of these practices. Others focused more broadly on perceptions of their acceptability or ethicality—we use the term “morality” to describe these questions.

We use the race/ethnicity terms as reported in each individual study.

If race or ethnicity was not statistically significant in the adjusted analysis, we bolded the covariates that were significant.

EAS, euthanasia and assisted suicide; MAiD, medical aid in dying; PAD, physician-assisted death; PAS, physician-assisted suicide.

Table 3.

Studies with Nonrandom Samples

Reference	Sample frame	Type of question asked^a	N	N by race/ethnicity	Race/ethnicity effect (unadjusted)^b	Race/ethnicity effect after adjusted analysis^b	Covariates^c
Berens et al. (2022)⁴⁵	General public	PAD legalization for nonterminal illnesses	2139	White 72.8% (1557), Black 13.8% (295), Asian 5.3% (113), American Indian or Alaska Native 1.5% (33), Mixed Race 3.1% (67), Other 3.5% (74); Hispanic 16.8% (360), Non-Hispanic 83.2% (1779)	Black<White	No	Religious service attendance, religion, political views, own QOL, marital status, are you close to someone with a mental illness?, age group, have you ever had a mental illness?, age, case QOL, respondent gender, scenario, scenario condition, scenario loss, household income, finances, scenario gender, education, have you had a physical disability?, has anyone close to you had a physical disability?
Blank et al. (2001)⁴⁶	Nonterminally ill elderly hospitalized patients	EAS for self	158	White 95.6% (151), Non-White 4.4% (7)	Non-White<White	No	Depressed, social support, religious coping, organizational religion, age, married
Braun^d (1998)⁴⁷	Seniors and their adult children in Hawaii	Morality of PAD	245	Caucasian (48), Chinese (48), Filipino (50), Native Hawaiian (50), Japanese (49)	Filipino<Hawaiian<Caucasian<Chinese<Japanese	N/A	N/A
Braun et al.^d (2001)⁴⁸	Adults aged 60 or older and their adult children in Hawaii	Morality of PAS	202	Native Hawaiian (45), Chinese (40), Filipino (40), Japanese (39), Caucasian (38)	Filipino<Hawaiian<Caucasian<Chinese<Japanese	Filipino<White; Hawaiian<White	Advocacy for discussing/documenting wishes, trust in others, wanting to control one’s death, fears and anxieties about life’s end, reliance on religious guidance, and fatalism about death’s timing, senior, immigrant, Catholic, education, experience with life-threatening illness and family caregiving
Breitbart et al. (1996)⁴⁹	Ambulatory HIV-infected patients in New York City	PAS legalization, PAS for self	373	Caucasian 38%, African American Thirty-seven%, Hispanic 23%, other 2%	Non-Caucasian<Caucasian	PAS for self: Non-Caucasian<Caucasian	Experience with the death of a friend or family member, suicidal ideation, quality of social supports, frequency of attending religious services
Butt et al. (2003)⁴	College students at a private Midwestern university	Morality of PAS	Initial 136, follow-up 119	European-American 75%, Asian American 13.2%, some other ethnicity 8.1%, African American 2.2%, Latin American 1.5%	Minority American<European-American	Minority American<European-American	Age, gender, marital status, family history of mental illness or suicide scale, attitudes towards seeking professional psychological help scale, Beck Depression Inventory, Beck Hopelessness Scale
Caralis et al. (1993)⁵⁰	Patients from University of Miami School of Medicine’s general medicine continuity clinics	Morality of PAD, PAD for self	139	African American (51), Non-Hispanic White (49), Hispanic (39)	African American<Hispanic<Non-Hispanic White	African American<Hispanic<Non-Hispanic White	Socioeconomic status
Cicirelli^d (1997)⁵¹	Adults aged 60 or older in Indiana	EAS for self	388	White 68.3%, Black 31.7%	Black<White	No	Gender, socioeconomic status, marital status, age, health, functional dependency, quality of life, religiosity, life events, social support, variables related to fear of death, well-being, locus of control
Cicirelli^d (1998)⁵²	Adults aged 60 or older in Indiana	EAS for self	447	White 65.3%, Black 34.7%	Black<White	N/A	N/A
Espino et al. (2010)⁵³	Older adults from outpatient care sites in San Antonio	PAS legalization	208	Non-Hispanic White (108), Mexican (100)	Non-Hispanic White<Mexican American	No	Religiosity, male sex, and age
Gill & Voss (2005)⁵⁴	Adults with disabilities in Chicago	PAS legalization for terminal illness, PAS legalization for disabilities	29	White (13), African American (11), Latino (2), Multiracial (2), not stated (1)	PAS legalization for terminal illness: Latino<African American and multiracial<White PAS legalization for disabilities: Latino<African American and multiracial<White	N/A	N/A
Hare et al. (2000)⁵⁵	Small rural community residents and outpatients at an internal medicine clinic in Wisconsin	PAS legalization	1,218	Caucasian 94% (1148), Asian American/Pacific Islander 1.6% (19), African American 1.5% (18), Hispanic 1.4% (17), Native American 1.0% (12), Biracial 0.3% (4)	No	No	Age, education, access to health care, burden, dignity, experience with death, pain, individual rights, all of life’s transitions have value, vulnerable people might be exploited, religious beliefs
Himchak (1997)⁵⁶	Older persons in New Jersey, New York, and Pennsylvania	Morality and legality of euthanasia	329	White (157), Black (56), Hispanic (59), Asian (57)	Black<White	Yes but comparisons not provided	Life satisfaction, total religiosity, religion, gender/age
Horsfall et al. (2001)⁵⁷	Students at Texas university	Morality of PAS	282	White 74.5% (210), African American 19.2% (54), Hispanic 5% (14), other 1.4% (4)	African American<Other<Hispanic<Caucasian	N/A	N/A
Koch et al.^d (1999)⁵⁸	Older adults and their adult children in Hawaii	Morality of PAD	245	Filipino (50), Hawaiian (50), Japanese (49), Caucasian (48), Chinese (48)	Filipino<Hawaiian<Caucasian<Chinese<Japanese	N/A	N/A
Koenig et al. (1996)⁵⁹	Patients in the Duke University Medical Center Geriatric Evaluation and Treatment Clinic	Morality of PAS	168	White 87%, Black 13%	Black<White	Black<White	Sex, college education, cognitive status, income, Conservative Protestant, dementia, quality of life index
Littlejohn & Burrows-Johnson (1996)⁶⁰	General public in Hawaii	Morality and legality of EAS	185	Caucasian 44.9%, Polynesian 24.1%, Asian 20.4%	No	N/A	N/A
Mangino et al. (2021)⁶¹	General public	EAS legalization for people with dementia	1708	White 75.1% (1285), Black 11.3% (193), Asian 6.4% (109), two or more races 4.0% (69), other race 2.5% (42), American Indian or Alaska Native 0.8% (13)	No	N/A	N/A
Martinez et al. (2017)⁶²	Non-Hispanic White and Latino adults aged 60 or older from outpatient clinics in San Antonio	PAS for self in scenario of slight chance of managing pain, PAS for self in scenario of chance of managing pain through treatment	204	Non-Hispanic White (106), Latino (94)	Non-Hispanic White<Latino	No	Religiosity, depression, survey form, education, gender, Latino acculturation level
Mouton et al. (2000)⁶³	Adults aged 60 or older at primary care clinics in San Antonio	Morality and legality of PAS	194	Mexican American 51% (99), Non-Hispanic White 28.4% (55), Other 20.6% (40)	Other<Mexican American<Non-Hispanic White	No	Age, gender, marital status, education, depressive symptoms, annual income, global health status, acculturation (MA only), religiosity, spirituality
Periyakoil et al. (2016)⁶⁴	Residents of California and Hawaii	Morality of PAD	California (1095), Hawaii (819)	California: White 38.5% (422), Hispanic/Latino 31.9% (349), Asian 19.5% (214), Black/African American 10% (109), Hawaiian/Pacific Islander 0.1% (1) Hawaii: Asian 47.1% (386), White Thirty-seven.5% (307), Hawaiian/Pacific Islander 9.4% (77), Hispanic/Latino 4.0% (33), Black/African American 2.0% (16)	California: Black<Filipino<Hispanic<Japanese<White<Chinese Hawaii: Black<Hispanic<Filipino<Hawaiian<Japanese<White<Chinese	No	Age, gender, level of importance ascribed to faith, religion, spirituality
Roberts et al. (1997)⁶⁵	Psychiatrists at the Academy of Psychosomatic Medicine Annual Meeting	Provision of PAD	184	Anglo-American 83%, Hispanic American 7%, Asian American 4%, African American 2%, Native American 2%	N/A	No	Vignettes, agents, gender, personal philosophy, practice characteristics, religious influence, influence of medical training
Singer et al. (2022)⁶⁶	Oncology advanced practice professionals in New Mexico hospital	Provision of PAD	77	White 88.3% (68)	No	N/A	N/A
Wade & Anglin (1987)⁶⁷	Students at UCLA	Morality of euthanasia for self and for parents	98	White (52), Asian (24), Black (11), Mexican American (9), Native American (1), Middle Eastern (1)	Support for euthanasia for parents for reasons of “mental alertness and parent’s wish”: Asian and Other<White Support for euthanasia for self and for parents for other reasons: No	N/A	N/A
Warner et al. (2001)⁶⁸	Medical students at University of New Mexico	PAD provision and decision-making	166	Anglo American 67%, Hispanic American 20%, Asian American 5%, Native American 4%, other ethnic group 4%	N/A	No	Patient vignette, agent participating in assisted dying
Wasserman et al. (2005)³	Students at large, urban state university in the southeastern United States	Morality of euthanasia	176	White (81), African American (95)	African American<White	No	Gender, spiritual meaning, access to health care, age, individual experience with physicians, perceived capacity for discrimination

Others focused more broadly on perceptions of their acceptability or ethicality—we use the term “morality” to describe these questions.

We use the race/ethnicity terms as reported in each individual study.

If race or ethnicity was not statistically significant in the adjusted analysis, we bolded the covariates that were significant.

Braun (1998), Braun et al. (2001), and Koch et al. (1999) likely have largely overlapping samples, but all three studies were included for completeness. Similarly, Cicirelli (1997) and Cicirelli (1998) appear to have substantial sample overlap, but both were included for completeness.

Group 1: Studies with Random Samples or Samples of Entire Populations of Interest

38 studies used random sampling or a census of local groups.^19,22 Of these, 24 surveyed the general public;^{6,14,16,17,21,23,25,27–31,33–38,42,44,69–72} 4 surveyed terminally ill patients and caregivers,⁵ relatives of decedents,⁴¹ oncology patients, oncologists, and the public,²⁰ or older individuals;⁷ 9 surveyed physicians;^{18,19,22,24,26,32,39,40,43} and one surveyed clergy.¹⁵

In total, 34 reported adjusted and/or multivariable analyses (but only 20 also reported unadjusted analyses). The publication dates ranged from 1979 to 2024. The survey questions ranged from attitudes toward the morality and/or legality of euthanasia and/or PAS,^{5–7,14–23,25–38,41–44,69–72} willingness to perform it (in physician surveys),^24,26,39,40 and personally considering it.^{5,6,26,28,32,41}

Eighteen of these studies analyzed data from the General Social Survey (GSS), a nationally representative survey regularly collected since 1972 by the National Opinion Research Center.^{14,17,21,23,25,27,29–31,33–38,42,70,72} Ten of the GSS studies represent analyses of various overlapping years of surveys, from 1977 to 2016 (see Supplementary Data S2for details).^{14,21,29,31,33–37,72} Three report analyses from the 1977 GSS,^27,38,42 2 report analyses from the 1998 GSS,^17,23 2 report analyses from the 1988 GSS,^30,70 and 1 reports analysis from the 1996 GSS.²⁵ Three studies analyzed data from the 2007 wave of the Baylor Religion Survey, a nationally representative survey administered by the Gallup Organization.^16,69,71

General public

Twenty of 24 general public studies found Black respondents and other racial and ethnic minority group respondents were less likely than White respondents to be supportive of EAS.^{6,14,16,17,21,23,25,27,29–31,33–38,40,42,69,72} Five studies provided unadjusted point estimates, with racial and ethnic minority support of EAS legalization ranging from 39% to 56%, and support among White participants ranging from 65% to 76%.^{6,23,27,38,42}

Seventeen of the 22 general public studies that reported multivariable analyses found an independent race and/or ethnicity association, where non-White and/or Black respondents were less likely to be supportive of EAS even after adjusting for several covariates.^{14,16,17,21,25,27,29–31,33–38,42,72} For example, the largest study in this group (N = 30,319) found Black and ‘other race’ individuals were less likely than White individuals to support legalized euthanasia, after controlling for gender, education, political affiliation, religious affiliation, and after adjusting for age, period, and cohort effects.¹⁴ In 3 studies, adding religion variables such as religiosity, religious beliefs, and/or religious affiliation to the model eliminated the association with race.^6,69,70

Patients and caregivers, relatives of decedents, and older individuals

African American terminally-ill patients and caregivers were less likely than White, Hispanic, or other race respondents to support or have personally considered euthanasia or PAS, even after controlling for religion/religiosity (support among patients: 38% versus 64%; support among caregivers: 12% versus 31%; personally considered: 6% versus 11%).⁵ Older White respondents were more likely than Black or other race respondents to support PAS legalization, even after controlling for religiosity (51% vs. 15%).⁷ Family members of White Oregon decedents were more likely than those of Black decedents to report that decedents were in favor of PAS as a policy and had personally considered PAS (policy: 35% versus 15%; for self: 18% versus 0%). However, in the logistic regression for personally considering PAS, religiosity, age, and symptom distress were the only significant associations.⁴¹ In a study of oncology patients, oncologists, and the general public, race/ethnicity was not a predictor of EAS attitudes.²⁰

Physicians and other professionals

In the 9 physician surveys, 5 found White physicians were more likely than physicians from racial and ethnic minority groups to support PAS;^{18,19,24,32,39} the effect remained in 4 of the 5 studies even after adjusting for various covariates.^18,24,32,39 Racial and ethnic minority physician support for PAD ranged from 21% (Asian) to 70% (Other), while support among White physicians ranged from 33% to 76% in the 4 studies reporting unadjusted results.^18,19,24,32 One study reported that Hispanic physicians were less likely than White physicians to oppose legalized PAS (AMA master file sample plus delegates N = 1000, but containing only 22 African American and 33 Hispanic respondents).⁴³ Finally, 3 physician studies^22,26,40 (with very few respondents from racial and ethnic minority groups) and 1 study surveying U.S. clergy¹⁵ reported no association with race.

Group 2: Studies with Nonrandom Samples

26 studies nonrandomly selected respondents from various groups (8 general public;^{45,47,48,55,58,60,61,64} 3 older individuals;^51,52,56 1 inpatient;⁴⁶ 6 outpatients;^{49,50,53,59,62,63} 5 undergraduate or medical students;^3,4,57,67,68 1 each of persons with disabilities,⁵⁴ psychiatrists,⁶⁵ and oncology advanced practice professionals);⁶⁶ of these, 17 reported adjusted analyses. The publication dates ranged from 1987 to 2022. The questions ranged from attitudes toward the morality and/or legality of EAS,^{3,4,45,47–50,53–61,63–65,68} personally considering it,^{46,49–52,62,63,67} and a provider’s willingness to perform or refer a patient for it.^65,66 Only 4 studies had more than 1000 respondents.^45,55,61,64

General public

Of the 8 studies that surveyed the general public on a variety of questions regarding attitudes toward EAS,^{45,47,48,55,58,60,61,64} 3 reported Black respondents were less supportive (60% Black/African American versus 76% White⁶⁴; Black or African American OR= 0.75, compared to White respondents⁴⁵; Black or African American OR = 0.51, White OR = 0.75, with ‘other race’ as reference)⁶¹ while 3 Hawaiian studies^47,48,58 reported that Filipino respondents were less supportive (26–33% Filipino versus 58–74% Caucasian versus 71–90% Japanese). In 3 of these studies, the race and ethnicity effect were nonsignificant when controlling for variables such as age and religiosity.^45,61,64 Two studies did not report any difference in attitudes toward EAS between racial and ethnic groups.^55,60

Older individuals

All 3 studies of older individuals (≥60 years old) reported that White respondents had more positive attitudes toward EAS than Black respondents,^51,52,56 of which 1 study provided point estimates (21% White versus 15% Black individuals “endorsed” voluntary euthanasia for themselves; 16% White versus 6% Black individuals “endorsed” assisted suicide for themselves).⁵¹ In all 3 studies, the association with race remained even after adjusting for a variety of variables, including religion.

Patients

One study surveyed older inpatients,⁴⁶ while six studies surveyed outpatients (older,^53,59,62,63 HIV-positive,⁴⁹ and general outpatients).⁵⁰ Five of these seven studies reported that White patients were more likely to support EAS.^{46,49,50,59,63} In the two studies that reported unadjusted percentages,^49,50 Non-Hispanic White support for EAS legalization ranged from 61% to 76%, while non-White (non-Caucasian, African American) support ranged from 36% to 57%. Non-Hispanic White support for EAS for oneself ranged from 46% to 50%, while non-White support ranged from 20% to 28%. In 3 of these 5 studies, White race was associated with positive attitudes toward EAS even in multivariable models.^49,50,59 In 1 study that compared Mexican-American individuals and non-Hispanic White individuals, the association was present only for the assisted suicide for oneself question, but not the policy question, when controlling for gender, income, and religiosity.⁶³ There was no race association when controlling for depression, age, and religiosity in the last study.⁴⁶

In two studies that asked about PAS when experiencing extreme chronic pain, Latino and/or Mexican American older outpatients reported greater support than non-Hispanic White patients (N ≤ 208), although there was no effect when controlling for covariates such as age, gender, and religiosity.^53,62

Other surveys

Five studies surveyed undergraduate^3,4,57,67 or medical⁶⁸ students; 4 reported that White students were more likely to have positive attitudes toward EAS than various non-White groups.^3,4,57,67 However, a path analysis model in one study indicated that spiritual meaning was the primary mediating variable in explaining race and ethnicity differences in attitudes toward euthanasia.³

In 1 small study (N = 29) of individuals with disabilities, White participants were more likely to support assisted suicide.⁵⁴ Two small surveys of health professionals [psychiatrists (N = 184; 83% Anglo-American)⁶⁵ and oncology advanced practice professionals (N = 77; 88% White)]⁶⁶ reported no difference in attitudes between racial and ethnic groups.

Discussion

This narrative review of the literature brings together heterogeneous data examined over nearly 45 years, confirming the robust relationship between race and ethnicity and attitudes toward PAD. The studies with large, randomly selected samples consistently report this association,^14,34,35,37 showing significantly lower rates of support for PAD among racial and ethnic minority groups, particularly among Black respondents. Negative studies tended to have very few Black and/or racial and ethnic minority respondents.^{20,22,26,40,60,65,66,68} It is important to note here that race and ethnicity serve as proxies for the broader sociocultural factors that reflect the shared history, experiences, and values within communities. Even so, race and cultural influences are many and complex, and cultural values and experiences are one of many factors that may influence attitudes toward PAD, with the understanding that these may vary significantly across individuals and subgroups within a broader community.

Although one cannot draw causal inferences, the results provide evidence regarding potential explanations for the finding. For instance, socioeconomic status did not appear to explain racial differences in attitudes toward PAD.³⁰ In surveys of physicians (i.e., persons with similar socioeconomic status), studies, including the one study we found with a substantial representation of Black physicians,³² showed differences, even after adjusting for various covariates.^18,19,24,39 Several other studies show that the association between race and PAD attitudes is largely independent of socioeconomic factors.^{25,29,30,33,38,50,59}

The most frequently examined explanatory factor in the association between race/ethnicity and PAD attitudes is religion. Among the 24 studies that did not find a significant association with race and ethnicity in adjusted analyses, 21 contained at least one statistically significant religion-related variable (see Supplementary Data S3 for a summary). These religion-related variables ranged from: religiosity or self-reported strength of religious beliefs; religious affiliation/denominational identity; frequency of religious service attendance; and specific religious beliefs (e.g., life belongs to God, belief in miraculous healing, etc.).

Previous research has shown that Black Americans are more religious and participate more often in both organized and individual religious practices than White Americans.⁷³ Some speculate this may arise from religion providing meaning and refuge in overcoming a long history of oppression. Some Black Americans may regard illness and death as another struggle to overcome, and treatment decisions may be guided by a spiritual framework that emphasizes survival in the face of adversity.⁷³ This may also explain the greater preference of Black Americans for life-sustaining treatment at the end of life.^74,75

However, differences in religious commitment between Black and White Americans may not entirely explain the difference in attitudes toward PAD. Although some studies do show that adding religion variables eliminates the association between race/ethnicity and PAD attitudes, the largest, highest-quality studies still show an independent race association, particularly significant for Black and “other” race respondents.^{14,21,29,31,35–37} Notably, in 21 of the 43 studies that included religion-related variables, race and ethnicity remained significant, suggesting that cultural, historical, or structural factors beyond religion may also influence these attitudes.

One possible factor explored by scholars is distrust in the medical system that may be rooted in both individual experiences with racial discrimination and the shared historical experiences of Black Americans, including systemic barriers to health care access and instances of medical exploitation (e.g., the Tuskegee syphilis study, Henrietta Lacks).^30,76 Black Americans may be less likely to believe that physicians or the medical establishment will follow their best interests when it comes to end-of-life care.⁶ There is perennial concern in PAD discussions that PAD may be offered as an alternative to quality end-of-life care, especially for those who receive poorer quality end-of-life care, pain management, hospice use, and provider communication.^11,77–79 However, only 1 small study (of undergraduates) looked at the role of trust in medicine and PAD attitudes and found that while Black American students do exhibit higher levels of distrust of medicine, it was not associated with PAD attitudes.³

These findings suggest there may be some other unmeasured factor related to the shared sociohistorical experiences and religio-cultural values of Black Americans. Some scholars have proposed given the history of oppression Black Americans have experienced, “suffering may be an expected part of life rather than a reason to terminate life.”^32,80 Others have further noted that familiarity with struggle and extreme hardship and other factors may also explain racial differences in attitudes toward PAD.^6,42 Another factor may be differences in attitudes toward community and relationships, as PAD seems to fit better with a White, Western, individualist view of life that prioritizes individual control.^11,81–83

The findings of our review highlight the potential reasons why PAD is used predominantly by White patients even in racially diverse states like California where Whites make up less than 40% of the population but account for nearly 90% of PAD cases,¹¹ with much lower relative use of PAD among Black and Latino individuals. This trend appears to be present in all jurisdictions that report race and ethnicity data for individuals who request or receive PAD—including Oregon, Washington, Colorado, Hawaii, New Jersey, Maine, and Washington DC.^84,85 Although some have suggested access to health care as a factor affecting access to PAD,⁴¹ these trends are also likely due to the social and cultural influences of race and ethnicity, enumerated above, that affect preferences for PAD.

Policymakers should be sensitive to the diversity of views on PAD associated with race and ethnicity. Washington DC, for example, reportedly passed its Death with Dignity Act in 2016 following advocacy efforts primarily led by White individuals, despite reservations within the Black community.⁸⁶ Members of historically privileged groups, who may have greater access to care, may feel empowered to seek a right to PAD (and trust a health care system to safely provide it), but they may not fully appreciate the implications for others who, because of structural or other reasons, lack such privilege. While distinct from racial and ethnic minority perspectives, the concerns voiced by Canadian disability advocates similarly highlight issues of structural vulnerability and potential coercion in the implementation of PAD. Despite opposition from these groups and expressions of concern from the UN Human Rights Council,⁸⁷ the Canadian government enacted legislation that critics argue effectively makes PAD more accessible than the standard interventions and resources that many people with disabilities would rather have.^88–92 Thus, when debating not just whether but also how to implement PAD policy, policymakers should carefully consider the views of marginalized groups.

Further, our findings suggest that in jurisdictions where PAD is legal, it is important for health care providers to understand the cultural values of the populations they serve and how these values might influence health behaviors, including requests for PAD. While it is essential to avoid stereotyping, knowing that differences in views exist supports the practice of taking a cultural and spiritual ‘history.’ Asking open-ended questions about beliefs and attitudes—which may indeed be influenced by an individual’s race or ethnic membership—can help providers gain a more comprehensive understanding of patients’ preferences and ensure that care decisions align with their values.⁷⁵

Our study has limitations. Many studies included small samples and/or very small numbers of non-White participants (limiting usefulness of models in them), recruited participants from a single center, and used nonprobabilistic sampling. There were multiple GSS studies included in our review that reported analyses from various overlapping years of surveys; we included them all as they used different analyses to test their hypotheses. Findings were also difficult to compare across studies because of the large heterogeneity in populations surveyed, in classifications of race and ethnicity, sampling methods, questions asked, analyses used, and the wide time frame of the studies. Definitions of euthanasia and PAS also varied across studies and over time. In several studies, euthanasia and PAS were not treated separately and racial and ethnic minority groups were often lumped together as “other” or non-White. Because our inclusion criteria were broad, if race and ethnicity appeared in a study’s analysis model, we included the article even if race/ethnicity relationship to PAD was not its primary focus. This likely explains why our database search yielded 33 eligible articles, supplemented by 31 additional articles from manual searches and reference lists, reflecting the secondary nature of race/ethnicity data in many studies.

Despite these limitations, our main findings confirm that there are significant differences between racial and ethnic groups regarding their attitudes toward PAD. These differences are likely due to a complex array of variables, the most prominent of those examined being factors related to religion. While the impact of distrust in the health system has not been sufficiently studied, socioeconomic factors appear to play only a minor role. There seems to remain an independent association with race and ethnicity, particularly among Black Americans, which deserves further study. Such studies might include not only empirical questions, such as the role of trust in the health care system which has been relatively unexplored in relation to PAD, but also ethical questions about how such findings ought to inform policy debates on PAD.

Authors’ Contributions

All authors have read and approved the final version of the article. M.N.: Methodology, formal analysis, investigation, data curation, writing—original draft, writing—review and editing. C.S.: Methodology, formal analysis, investigation, data curation, writing—review and editing. K.S.J.: Writing—review and editing. S.Y.H.K.: Conceptualization, methodology, formal analysis, investigation, writing—review and editing, supervision.

Footnotes

Acknowledgments

The authors thank Talia Bernhard and EJ Jardas for early-stage assistance with preliminary title and abstract screening, and Alicia Livinski for support with database searches.

Author Disclosure Statement

The authors of the study have no potential conflicts of interest to declare with the research, authorship and publication of this article. The opinions expressed are the authors’ own and do not represent the views of the NIH, DHHS, or the U.S. government.

Funding Information

This work was funded by NIH Clinical Center Department of Bioethics. The funding body played no role in the design of the study and collection, analysis, interpretation of data, and in writing the article.

Supplemental Material

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