Moral locus of control in hastened death when faced with irremediable health conditions

ABSTRACT

Following APA’s call to present research in reader-friendly styles, the objective of this study is to identify characteristics of a unique set of 101 people who chose to hasten their death when faced with irremediable health conditions without support from any state/medical-aid-in-dying programs. The methodology used was to collect information regarding education, spiritual orientation, beliefs in regard to their personal locus of control, their basis for moral decision-making, and belief in an afterlife from a group of people who had decided to hasten their deaths and compare those beliefs and personal traits to the general population and, where available, to people who chose to hasten their death using state supported medical aid in dying programs in the United States. The results showed statistically significant very high levels of education, less traditional religious beliefs, lack of belief in a conscious afterlife, a high feeling of internal locus of control, and a high sense of internal moral authority. This led to the conclusion that these personal and belief factors combine to create the concept of a high internal moral locus of control in this group of people who choose to hasten their death when faced with irremediable health conditions.

KEYWORDS:

• Moral locus of control
• hastened death
• locus of control
• medical aid in dying
• final exit
• end of life decisions

Introduction

In the face of irremediable health conditions that diminish one’s autonomy and ability to enjoy life, why is it that some people let Nature, God’s will, or doctors’ treatment plans determine the timing and experience of death and others take charge of that process and hasten their own deaths? Our study data suggest that the decision to exert some control over the path of death’s inevitable outcome is supported by some identifiable personal and belief factors that shape what is perhaps the highest individual moral decision humans can make, whether they decide to continue to live or die.

Most people have an intuitive moral comfort level about what circumstances are acceptable about the ending of one’s life when faced with irremediable health conditions. Ethical discussions and public legislation explore and declare under what circumstances a person may be supported in ending their own life. Ending one’s life under any circumstances triggers ethical discussion even though when a person decides on their own, and takes actions on their own to end their own life, it is not against the law to kill oneself in all of the United States and most of the countries of the world. Voiced most vigorously by some religious groups, some assert that individuals do not have the moral right to end their life, no matter the laws or lack thereof. They further argue that the moral base for that decision is not their own but rather lies outside of them, dictated by a god or the general overriding concept of the sanctity of (human) life. They assert that these factors should have more weight than an individual’s own wishes or level of suffering (Low, 2019).

In the majority of states within the United States that have laws in this regard, it is against the law to ‘assist’ someone in ending their own life. That is, it is illegal to help someone do something that is legal. That apparent legal illogic seems to reflect a moral concern that an individual should not be influenced by others in their decision as well as making sure it is that individual’s actions alone that lead to their death.

It is not against the law for a person to be with another for emotional support and comfort when they intentionally end their life. In states that have laws with varying descriptions about ‘assisting suicide’, it would commonly be against the law to provide a person a gun for doing so, or helping them hold the gun, or to help them pull the trigger if they are having physical difficulty in doing so – even if the person wants to die and wants help in doing so (Illinois Statutes 2011) (Kentucky Revised Statutes). This carefulness about undue influence and prevention of physical assistance is incorporated into a small but growing number of medical aid in dying laws in the United States that currently require that doctor prescribed medication to hasten one’s death must be administered by the individual to themselves – thus excluding some with physical limitations. The more a person’s decision and actions in deciding to hasten their death in the face of unacceptable and irremediable life conditions is their own, the more comfortable society seems to be with the moral acceptability of their choice and action.

Previous studies have shown that psycho-social factors such as loss of autonomy and agency are more important to this group of people who chose to hasten their deaths than are physical limitations or pain (Blake & Blake, 2021; Ganzini et al., 2008; Rodriguez-Prat et al., 2017). But there has been little research exploration of the personal beliefs and moral processing of the people who make this decision. This article explores the personal characteristics of people who do not qualify for state-supported physician aid in dying and take control of managing their own death anyway when faced with irremediable health conditions.

Information collection and analysis

Final Exit Network (FEN) provides publicly available information to those with irremediable health conditions who peacefully wish to hasten their death. It is also a resource for those without short-term terminal diagnoses whom state laws in the United States so far excluded (people with Parkinsonism, ALS, MS, chronic pain, dementia, and others). As part of the application for acceptance as a FEN client a person must pass phone screening (where acute depressive and actively suicidal persons are directed to other appropriate resources for help), write a personal statement explaining their desire to hasten their death, submit medical records reflecting diagnosis and treatment for an irremediable condition that are reviewed by a medical evaluation committee, and demonstrate not only a desire for but also the physical and mental capabilities of doing everything themselves in hastening their death. It was from these interviews, personal statements, reviews, and subsequent conversations that FEN volunteers began to notice what seemed to be some prominent strongly held self-directed attitudes, feelings, and beliefs about both living and dying in the applicants. This led to devising a rating scale and a research form to try to measure and quantify some of those factors and see if this group of people had different personal, spiritual, and moral perspectives than the general population. As part of the application process, they are asked to fill out a Quality-of-Life Impact Study (rating both physical and psycho-social factors affecting their current quality of life) and a research questionnaire (Blake & Blake, 2021). It is the data collected from 101 people between 2020 and 2021 who filled out the research questionnaire that provides the data presented here on education level, belief in an afterlife, spiritual orientation, source of moral authority, and locus of control. Except for education level, a review of the literature suggests how prominent these other factors are in those who choose to hasten their death has not been previously studied. The objective of this study is to help fill in that gap and further expand our understanding of how this group of people who choose to hasten their death in the face of irremediable health circumstances may be different. A chi-square test was applied to determine any significant differences between the FEN group and comparison groups.

It is important to point out that the population of people being studied here are generally older (median age in their 70s) and have irremediable health conditions. They are not the population of people who are depressed and suicidal; nor do they represent young people. The personal development, beliefs, family, and social dynamics are quite different, and so is the locus of control of older and younger people around the issue of ending one’s life. Unlike this current study group, adolescents who are suicidal are usually identified as having a sense of high external locus of control (Pearce & Martin, 1993). These young people feel out of control of their lives and cannot manage their external circumstances. People who generally have lived a long life and choose to hasten their deaths in the face of irremediable health conditions do not feel overwhelmed by external circumstances or stressors, are not depressed, are emotionally fully in control of themselves, and are making rational decisions based on their health circumstances (Blake & Blake, 2021; Ganzini, 2014).

Ethnic and cultural factors also impact end-of-life care and decision-making (Searight & Gafford, 2005), but that was not a part of the scope of this current study. In our research group who chose to hasten their death, 95% identified themselves as White, 2% Black American, 2% Hispanic, and 1% Asian Indian. Cultural and ethnic issues certainly affect attitudes and beliefs about afterlife, spiritual and religious beliefs, and source of authority in moral decision-making as well as one’s sense of autonomy and locus of control. Not surprisingly, given their social history, Black Americans in the U.S. feel more external locus of control than whites (Berry et al., 1992). Our study group is highly self-selected and by that process helps identify some significant common factors among people who choose to hasten their death when faced with irremediable health conditions.

Education and choosing to hasten one’s death in the face of irremediable health conditions

Data on the level of education of people choosing to hasten their death in states supporting medical aid in dying programs (MAiD) have been collected for a number of years and show that they tend to be more highly educated than the general US population (Table 1). The FEN group of applicants seeking support in hastening their deaths tended not only to be highly educated but also significantly more highly educated even than those who applied for support in hastening their death through state sponsored medical aid in dying programs.

Table 1. Educational levels in those with irremediable health conditions who hasten their deaths.

Level of Education	US Population n = 223,058^†	Oregon MAiD n = 245	Colorado MAiD n = 156	Final Exit Network n = 101
No high school diploma	9^a	5	7	2
High diploma or GED	28^a	23^b	21^c	3
Some college or associate’s degree	26	29^b	23	19
College degree	23^a	21	29	28
Graduate/Professional degree	14^a	21^b	19^c	38
Unknown	7	0	1	9

Numbers are rounded to the nearest percent.

Chi-squared tests significance indicated at p < 0.05.

^†Population in thousands.

^aSignificant difference between US and FEN.

^bSignificant difference between Oregon MAiD (Medical Aid-in-Dying clients) and FEN.

^cSignificant difference between Colorado MAiD (Medical Aid-in-Dying clients) and FEN.

US Census Bureau (2021), Oregon.Gov (2021), and Colorado Department of Public Health and Environment (2021).

85% of FEN applicants had at least some college, with 28% having completed a four-year degree, and a surprising 38% having advanced degrees. Highly educated people are known to place a strong emphasis on autonomy and are more likely to favour increased control over end-of-life decision-making (Verbakel & Jaspers, 2010). The application process for FEN, like Switzerland-based Dignitas and Pegasos and other state programs in the United States that support people in hastening their death, is rigorous, even somewhat difficult. The difficulty in applying and being accepted as a client requires some traits of organization, sustained effort, and self-directedness to access these options at the end of life. These behavioural assets are also those needed to complete higher education degrees, are reflected by higher levels of internal locus of control in people who obtain graduate degrees, and were likely used to direct their lives as well now in directing their own deaths (V. L. Smith, 2003). The fact that FEN is not a state sponsored program means both that it is available to individuals in states without any medical aid in dying programs and also that interested people have to search harder on their own to find the resource.

Spiritual identity and choosing hastened death

Multiple surveys have shown that non-religious people support options for hastening one’s death in the face of irremediable health conditions at a higher rate than religious people, but the majority of religious people, even those from religious perspectives seen as conservative except ‘Evangelicals’, support the choice of medical aid in dying (LifeWay Research, 2016; Schott, 2015). The majority of all Americans, across all educational, political, and ethnic groups, including some of the most religious, support this option (Brenan, 2018; Compassion and Choices, 2022; White, 2016). Previous studies have used various means and definitions of what constitutes being a religious person, so drawing conclusions sometimes has produced varying results. In the United States it does seem that generally higher levels of education, such as those identified in our study group, have correlated with people who are less traditional and supernatural in their religious beliefs, even though they may still attend church. This seeming irony is hypothesised to be due to educated people highly valuing the social connections they get through church attendance, but at ‘less fervent’ churches (Pew Research Center, 2017; Sacerdote & Glaeser, 2001).

In our study we did not focus on spiritual or religious practices or church attendance. We used self-identifying spiritual and religious categories similar to those in other studies (G. A. Smith, 2021). Based on the high education levels of FEN applicants, it was not surprising that they identified as less traditionally religious than the general public (Table 2).

Table 2. Religious affiliation differences by group.

Religious Identification	US Pew Research n = 2505	Census of American Religion n = 50334	FEN n = 101
Protestant	43^a	46^b	13
Catholic	19^a	22^b	2
Atheist, agnostic, none	28^a	23^b	47
Jewish	2^a	1^b	9
Muslim	1	1	1
Buddhist or Hindu	2^a	1^b	6
Other	4	3	2
No response	2	3	20

Numbers are rounded to the nearest percent.

Chi-squared tests significance indicated at p < 0.05.

^aSignificant difference between US Pew Research and FEN.

^bSignificant difference between Census of American Religion by PRRI and FEN.

Pew Research Center (2021b) and Public Religion Research Institute Staff (2021).

Besides the statistically significantly higher 47% of FEN clients who hastened their death identifying themselves as agnostic, atheist, having no religious identification, or generically spiritual, there were an additional very large 20% who did not respond to the question at all. Speculatively, this could reflect the traditional responses of non-believers to simply leave blank any questions asking what religious or spiritual group they belong to; so there may be even more ‘nones’ or other ‘non-believers’ in the study group than identified.

Table 2 shows that among the people who asked for support from Final Exit Network only about 15% who hastened their death identified themselves as Protestant or Catholic Christians. This suggests that traditionally religious people in the United States tend to support legislative options for people who want to hasten their death in the face of irremediable health conditions more than they are likely to seek out the option for themselves. Beyond being highly educated and tending to be more agnostic or non-theist, other factors in our study help identify additional characteristics and beliefs that are important in understanding those who choose to hasten their death.

Belief in an afterlife

Compared to 17% of all Americans, a statistically different 50% of FEN clients said they did not believe in any conscious afterlife (Table 3).

Table 3. Differences in belief in an afterlife by group.

Do You Believe in a Conscious Afterlife?	US Population	Final Exit Network
	n = 7252	n = 101
Yes	82^a	26
No	17^a	50
Missing	1	24

Numbers are rounded to the nearest hundredth.

Chi-squared tests significance indicated at p < 0.05.

^aSignificant difference between US and FEN.

Pew Research Center (2021a).

About 80% of American Christians, from mainline to evangelical, believe in Heaven (Pew Research Center, 2021a). In our study those who chose to hasten their death mostly seem to believe that this life is final or are not certain enough to answer whether they believe in an afterlife. It appears that the decisions and actions of this group who chose to hasten their deaths are guided by things other than how their life’s decisions and actions might affect any possible future existence or rewards after death. Nearly half of this group, or perhaps more with the large number of people who did not respond, believe neither in a deity nor an afterlife. Giving up the idea of a deity and an afterlife that perhaps gives some guidance on how to live a good life and make moral decisions would seem to push more moral responsibility onto an individual to decide. Additionally, abandoning a belief in an afterlife, that there is no ‘soul’ that either precedes or survives our human bodies, seems to raise the stakes further on trying to establish any moral ground for decision-making or to claim purpose or worth at all to human existence. For such individuals, the only meaning and purpose to life is what they create. So to hasten one’s death in the face of irremediable health conditions that make it impossible to continue to create a purpose or meaningful life is simply another step in a life-process of creating meaning by personal purposeful decision-making and actions. This is why having no acceptable medical treatments to produce an on-going acceptable quality of life, the prospect of having to move into a nursing home, and an inability to continue to create a meaningful life, previously reported by FEN, were the leading factors in this group’s wanting to hasten their deaths (Blake & Blake, 2021). This is also consistent with the more globally described ‘loss of autonomy’ as a reason for wanting to hasten death cited by applicants to state supported medical aid in dying programs (Wiebe et al., 2018).

Source of moral authority

Our study identified a high level of education, lack of traditional religious beliefs, and lack of belief in an afterlife in those who decide to hasten their death in the face of irremediable health conditions, but other important factors are also present. We asked FEN applicants about their source of moral authority in decision-making through a forced-choice question:

Check which of the following is closer to what you believe:

___I believe there are some pre-determined standards about what is right and wrong and how we should live

___I believe that we each have to decide for ourselves what is right and wrong and how to live

In our study group a significantly higher number of people than the general population said that they used their own judgement in deciding moral right and wrong more than they used predetermined standards that may come from some outside higher non-worldly consciousness or authority, perhaps reflected in ancient or more recent texts and spokespersons, that set out standards for human behaviour (Table 4). The identification that Americans in general tend to decide for themselves about what is right and wrong (64%) may reflect more moral relativism than is widely recognized, even among those who are religious. Our study found that of the people who chose to hasten their death in the face of irremediable health conditions, a statistically significant even larger 74% asserted being their own ultimate source of authority for moral decision-making. The United States is the only relatively wealthy country, and the only North American or European country where the majority of people profess that belief in God is a prerequisite to being good and moral (Pew Research Center, 2014b). Almost all other relatively wealthy countries do not make this connection, and this false assumption has been addressed in other writings (Epstein, 2009). But the residue of traditional teachings that predominated in historical American forbearers seems to have left a tendency to believe in a god or purposeful creator of the universe as a basis for moral guidelines even as church attendance in the United States continues to decline (Jones, 2021; C. Smith & Patricia, 2009). In this general American public religious ethos, and especially for practicing Christians, God has been the judge of whether one lived a good or bad life, and at least originally was the determiner of whether people went to Heaven or Hell. In this basic framework a belief in an external moral authority, whether a god, religious spokesperson, religious writings, or a believed social consensus remains strong, even if it is nearly always individually interpreted and applied.

Table 4. Differences in source for moral decision-making by groups.

Beliefs	US Population	Final Exit Network
Predetermined Moral Guidelines	n = 35,071	n = 101
Yes—there are predetermined standards	33%^a	15%
No—people decide for themselves	64%^a	74%
Missing responses	3%	11%

Numbers are rounded to the nearest percent.

Chi-squared tests significance indicated at p < 0.05.

^aSignificant difference between US and FEN.

Pew Research Center (2015) and Barna Group (2002).

In our study group, this lack of a strong or absolute external authority or guideline for moral decision-making seems to go hand in hand with the relative absence of traditionally religiously identified people among those who chose to hasten their death in the face of irremediable conditions. Whether it is a desire not to go to Hell, a belief in not interfering with God’s actions or will, or simply adopting predominant social views and deferring to outside influences for moral decision making regarding hastening one’s death, traditionally religious Americans represent a very surprisingly small minority of people who chose to hasten their deaths in our study group (Table 2).

Belief in a loving and directing divine power and living by prescribed virtues can bolster a sense of personal security and confidence for some when facing death (Megari, 2016). The assignment of moral questions and solutions to an external authority of how to live and deal with death can circumvent a personal struggle over whether humans have the moral right to decide whether to end their life in the face of irremediable and intolerable health circumstances. In some sense, questions about the meaning and purpose of human existence and decisions about life and death have been settled by ‘faith’ for many religious people. There is nothing to ponder or decide. It is the atheists, agnostics, and ‘nones’ with a high sense of inner moral decision-making authority who have to decide for themselves what makes life and death meaningful. They have to do so without a pre-ordained purpose, guidelines, or a god to affirm their choices as either good or correct. In our study, those who seek to hasten their deaths in the face of irremediable health conditions are more likely to rely on themselves for moral authority in their decision-making than does the general public. Eliminating the belief in a higher conscious power both facilitates and necessitates removing any external authority or reference to a higher power for making moral judgements and removes a higher consciousness that might provide emotional comfort and peace in tough decision-making. That does not mean that nontheists and people who rely on themselves for moral decision-making do not also ponder their suffering and death or do not long for equivalent meaning and emotional support (Brennan, 2018). Deep breathing, mindful meditation, biofeedback, communing with nature, having loving relationships, working for a cause, having a mission, or even having a pet, all also facilitate feelings of inner peace, connectedness, security, purpose, and contentment that can be accessed without religious belief in a higher power or authority guiding one to deal with both life and death.

Locus of control

There have been multitudinous rating scales and studies regarding locus of control following Rotter’s summary of his research on the concept in 1966 (Rotter, 1966; Twenge et al., 2004). For our research purposes, we boiled down a locus of control measure to one forced choice question:

Check which of the following is more true about what you believe:

___Most of the outcomes in our lives are a result of our own decisions and actions

___Most of the outcomes in our lives are determined by events, people, and forces over

which we have little control

People in the United States generally have a higher internal sense of locus of control compared to other countries and cultures and think that success in their life depends more on their own efforts than on forces outside their control (Berry et al., 1992; Gao, 2015; Shiraev & Levy, 2021). While FEN applicants did not identify themselves with an internal locus of control significantly statistically higher than the already high US general population, they did reject endorsement of the alternative high external locus of control at a significantly statistically different rate from the general population.

The results in our study were that 61% of the applicants who had decided to hasten their death endorsed a high internal locus of control and only 17% endorsed a high external locus of control (Table 5). Meta-analysis of studies of locus of control and religious perspective have generally led to the conclusion that less traditionally religious people, such as those in our study group, have a higher sense of internal locus of control (LOC) and people who are more highly religious have a higher sense of external LOC (Coursey et al., 2013). Studies with other conclusions seem to result from using differing methodologies and measurements. One study argued that individuals with high internal LOC were more likely to believe in an external divine power. This group of ‘believers’ said they ‘would appeal to God if they were in trouble’ and felt ‘that a divine power had helped them’. The conclusion was that people who scored high on their measure of internal LOC were also highly religious (Iles-Coven et al., 2020). However, appealing to God and having gotten help from a divine power seems to be a clear endorsement of an external locus of control. One resolution to this kind of conflict in the literature, of believing that divine powers intervene in one’s life and still claiming that the same people have a high sense of internal locus of control, is to suggest that some people who believe in a higher power may feel that a higher power has helped them have an inner personal sense of empowerment or control (Holt et al., 2003; Schieman, 2008). A belief in a power higher than oneself, especially a power that can intervene in daily life outcomes and change the natural worldly order, hopefully to influence things in our preferred direction through things such as rituals or prayer or church attendance, may increase an internal sense of faith, personal courage and hope; but it takes a significant redefinition of the traditional concept of internal locus of control when the source of that inner sense of personal confidence and empowerment is attributed to an outside entity or divine power.

Table 5. Locus of control differences between groups.

Locus of Control Beliefs	US Population	Final Exit Network Applicants
	n = 1,002	n = 101
Belief in high internal LOC	57%	61%
Belief in high external LOC	40%^a	17%
Missing	3%	22%

Numbers are rounded to the nearest percent.

Chi-squared tests significance indicated at p < 0.05.

^aSignificant difference between US and FEN.

Pew Research Center (2014a).

The accumulated body of research has sometimes led to some mixed or confusing nuances and conclusions, often due to variable ways of measuring both LOC and religiosity. In our study, we found high internal locus of control, low belief in a traditional higher power, lack of belief in an afterlife, and a high sense of internal moral authority for decision-making in our highly educated group who chose to hasten their death in the face of irremediable health conditions. In this group, having no way to remain fully in control of their lives and increasingly having to depend on others just to stay alive apparently becomes unacceptable. They are quite prepared spiritually, intellectually, and emotionally to step in and take charge of end-of-life decision-making when the medical system can do nothing to improve their autonomy and quality of life.

Moral locus of control in deciding to hasten death at the end of life

Previous studies have shown that people with a high inner locus of control support right to die legislation (Kaplan & Schneiderman, 1996). The experience of Final Exit Network in being invited onto the journey with people who have actually decided to hasten their death in the face of irremediable health circumstances is that people who make this decision to hasten their death generally have lived full and vigorous lives. They seem to bring a very high sense of self-directedness both in their actions in life and subsequently in their decision-making at the end of life. It appears that along with a high internal sense of locus of control, the factors of being highly educated, being agnostic, atheist, or not particularly identified spiritually, not believing in a conscious afterlife, and believing that they are responsible for making their own moral choices/decisions rather than following predetermined or externally promulgated standards, comprise an identifiable group of factors that contribute to a strong sense of internal moral locus. This new concept of moral locus of control in end-of-life decision-making reflects the degree to which an individual believes they are the final authority for making moral choices and decisions for how they live as well as how they die and the degree to which their intellectual and spiritual perspectives support their taking control of their dying process by hastening their death without fear of any external judgement. People with a high sense of internal moral locus of control are not immune to or unaffected by social norms, the impact of their actions on others, or the feelings of loved ones. Individuals with a high internal moral locus of control consider and are inevitably influenced by the cultural and religious framework, guidelines, and the feelings from the society and loved ones within which they are raised. They balance this with critical thinking, personal experience, and their own internal moral sense in ultimately determining what is right and wrong in decision-making and actions (Quilty, 2012). But when it comes to hastening their death in the face of irremediable health conditions, people with high inner moral control seem more likely to take the lead rather than follow along a passive or prescribed journey.

We found this high moral locus of control present in applicants to Final Exit Network seeking support in their decision to hasten their deaths. We suspect that this factor is likely significant in the population of those who make use of state-supported medical aid in dying programs to hasten their deaths, but that remains for a future study. These individuals not only feel they have the moral right but embrace the opportunity to control their ultimate final decision when life and health circumstances produce an unacceptable and irremediable quality of life. Because of this high internal moral locus of control, they are willing to hasten their deaths in a way not widely used in American society, is currently responded to by American society with mixed approval, and is actively condemned by significant religious groups and various political interests (Low, 2019).

The common existential and spiritual issues for people with either high external or high internal moral locus of control is how to achieve a sense of personal peace over the question of the meaning of our lives, especially when facing our end. Religious belief and a high external moral locus of control provide one way to combat the prospect that our lives may be an accidental result of and a meaningless consequence of creation, as are our deaths. Those with belief in a higher power and an external solution to the moral questions and meaning of both life and death can draw comfort from believing that a higher power verifies our importance and worth and is in control of and should direct our creation, our living, and our dying. This faith solution is often accompanied by the hope and comfort of some form of afterlife, reincarnation, or by a Consciousness that cares about our individual existence. But that is not the only solution to dealing with death anxiety and existential despair. Religious disbelievers without reassuring external explanations of their life’s worth or purpose and without promises and comforts about their deaths can also feel at peace. Our study suggests that this may be explained by a high sense of internal moral locus of control. People on both ends of the moral locus of control continuum, both the deeply felt external faithful believers and the total non-believers, have been shown to have less fear and anxiety about death (Jong et al., 2018). A personal sense of peace and sometimes empowerment from a belief in a higher power leaves some feeling more prepared to deal with the anxieties and moral challenges of life, including death. This belief system also leaves control and the ultimate moral decision about death up to God or the natural universe. In our study, these individuals are less likely to make a decision to hasten their own death in the face of irremediable health conditions and let God or Nature determine how they die.

The prominent presence of identified characteristics and beliefs in our sample group do not prove that they are causative in their decision to hasten their deaths. Their differences from the general population do, however, allow a hypothesis that these factors may be significantly contributory. A stronger future study design would compare the personal characteristics and beliefs of this group to other people with significant health problems who did not choose to hasten their death. Asking the study questions in exactly the same format and language in comparison groups would also strengthen any conclusions. The limitations of this study did not provide access to such comparison groups. Data from state-supported medical aid in dying programs have not included the questions studied here except for the level of education, so wider comparisons to people who use state-supported programs to hasten their deaths were also not available. Americans in general, while having high confidence in their internal locus of control, are not as religiously based as people in some countries nor as secular in their spiritual views as others. Further research could help identify whether the traits identified in this study are also significant in different ethnic and social settings around the world where people with irremediable health conditions choose or choose not to hasten their death.

Conclusion

People with a combination of a high level of education, a high sense of internal locus of control, a non-theist or no spiritual identification, a high inner sense of authority in moral decision-making, and lack of belief in an afterlife are inevitably influenced by these factors in their personal and moral choices throughout their lives on earth. In the face of unacceptable and irremediable health conditions, this same high internal moral locus of control may be a useful concept for medical providers, family, friends, and spiritual leaders in understanding, supporting, and honoring them when they decide to hasten their deaths.

Authors contributions

For statistical support, the author gratefully thanks Callie Zaborenko, Sociology Graduate Student at Purdue University.

Ethical approval

Ethical approval and an ‘exemption determination’ for all data collection and publication issued by Pearl IRB on 12/20/2019.

Disclosure statement

Final Exit Network collected the data and provided modest financial support for statistical analysis and publication costs. The author has no financial incentives in connection with the organisation.

Data availability statement

On request due to privacy/ethical restrictions.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The work was supported by the Final Exit Network.

Notes on contributors

Robert R. Blake

Robert R. Blake (b. 1942) was ordained as a Methodist minister after graduating from DePauw University and Garrett Theological Seminary. He subsequently completed a Ph.D. at Northwestern University in combined studies of psychology, religion, and pastoral counseling while evolving into a humanist/atheist. He continues practicing for more than fifty years as a clinical psychologist, the last thirty years of which he has also volunteered with death with dignity organizations.