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The mediated discourse and voice of euthanasia: the Israeli media as a case study
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  1. Baruch Shomron
  1. Communication Studies, Ben-Gurion University of the Negev, Beer-Sheva, Israel
  1. Correspondence to Baruch Shomron, Communication Studies, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; baruchshomron{at}gmail.com

Abstract

Euthanasia is an important social and quality of life issue. However, it is highly controversial and thus continuously debated especially given its legitimacy and legality differ between countries. Little is known about the role media plays concerning this topic. To fill this gap, this study applies a mixed methods approach to a case study of Israeli media, including a quantitative content analysis of news articles (to measure the discourse of ‘civil participation’), a thematic analysis of news articles (to examine the ‘voice’) and a quantitative content analysis of Facebook comments (to measure ‘being heard’). Results indicate that while the media highly enables the media capability of ‘voice’ (both ‘voicing’ and ‘being heard’), it limits the media capability of ‘civil participation’ to a narrow array of discourse, hindering the social debate. These results reveal the role the media plays regarding euthanasia, integral to individuals’ quality of life through the realisation of their media capabilities, and in relation to the act of euthanasia itself.

  • social science
  • internet
  • journalism
  • end of life care
  • cultural studies

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Introduction

Euthanasia is a highly controversial act pertaining to individuals’ quality of life. The act of euthanasia refers to the intentional ending of a person’s life with the intent of alleviating great pain or suffering. This act is habitually assisted or administered by medical practitioners (Gaignard and Hurst 2019, 1–2; Huxtable 2009, 328–29; Shondell and Gonzalez 2013, 297). Yet the legitimacy of the act and its legalities often differ between countries, resulting in continuous and active debates in different societies (Boston, Bruce, and Schreiber 2011, 615–16; Ladki et al. 2016). However, while the media plays a central role in other social issues due to the vital media capabilities (Shomron and Schejter 2020, 2-3; Shomron and Tirosh 2020, 2-5), little is known about the media’s role in society concerning euthanasia. Indeed, the paucity of literature is primarily limited to opinions expressed for and against the procedure (Booth and Blake 2020, 4-10; Jaye et al. 2019, 4–7; Johnstone 2014, 32; Rietjens et al. 2013, 6–7; Wright et al. 2015, 137–38; Yu, Wen, and Yang 2020, 4–5). Thus, many of the characteristics of the mediated debate remain unknown. Furthermore, the mediated ‘voice’ of the affected people and the question whether they are ‘being heard’ have not been studied to date. Yet these aspects are vital to understanding the media’s role regarding euthanasia. Therefore, through a case study of Israeli mainstream media and a mixed methods approach, this study sets out to measure the mediated euthanasia discourse (‘civil participation’) and examine the euthanasia voice (‘to voice and to be heard’). This is achieved through a quantitative content analysis of news articles (to measure the discourse of ‘civil participation’), a thematic analysis of news articles (to examine the ‘voice’) and a quantitative content analysis of Facebook comments (to measure ‘being heard’). Thus, this study contributes to a more wholesome understanding of the media’s role in society regarding euthanasia. This role’s importance derives from two different aspects. First, the topic of euthanasia itself is one that pertains to quality of life. Second, the analysis of the media’s role through the capabilities approach—capabilities refer to what a person can be or do and represent quality of life (Sen 2005, 151-63)—asserts that people’s ability to use the media for their own needs represents in itself quality of life (Shomron and Schejter 2019, Shomron and Schejter 2020). Thus, this study sets out to fill the aforementioned gaps and reveal the media’s role regarding euthanasia.

Literature review

The act of euthanasia

The question whether an individual has the right to end his or her life is highly controversial in societies around the world based on or influenced by religious beliefs, moral convictions and human rights principles (Yu, Wen, and Yang 2020, 4–5). These reasonings have manifested into legislations and regulations, which differ between countries, occasionally modified in accordance with changing public sentiment (Huxtable 2009, 327–335). For example, some opponents cite religious dogma addressing the intrinsic value and sanctity of life that humans do not have the right to end their own lives, a decision which they believe rests in the hands of God alone (Ladki et al. 2016, 2-13; Yu, Wen, and Yang 2020, 5), while advocates have ‘asserted that human beings have the right to die and to die with dignity’ (Yu, Wen, and Yang 2020, 6). The latter emphasises the quality of a person’s life, implying that the legitimacy of intentional death is conditional on the existence of human suffering (Shondell and Gonzalez 2013, 297). Yet the term ‘suffering’ is ambiguous and encompasses a wide range of understandings, from acute physical pain accompanying terminal illness (routinely defined as having less than 6 months to live) to individuals suffering mental illness such as depression or existential sufferings (Boston, Bruce, and Schreiber 2011, 615; Jansen, Wall, and Miller 2019, 190–92; Yu, Wen, and Yang 2020, 5-6). Indeed, each one of the aforementioned characteristics encompasses a large variety of differentiating understandings by different groups and individuals (Boston, Bruce, and Schreiber 2011, 615). For instance, Gaignard and Hurst 2019, 3–6 pointed to eight motives for euthanasia deriving from existential sufferings: ‘physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden, and loss of pleasurable activities’ (Gaignard and Hurst 2019, 3).

The complexity of euthanasia is not limited to its motivations and extends to a variety of procedural types included in the act itself. These range from the more active acts of euthanasia, such as the medical personnel either injecting a patient with a lethal drug or prescribing a lethal drug for the individual to self-inject, to the more passive acts of euthanasia, such as treatment withdrawal and the removal of a patient from life support (Brassington 2020, 3-5; Kiliclar et al. 2017, 90–91; Moshe and Avital 2020, 2–3). This variation in types of procedures is value-laden and not merely a technical one. Indeed, the more active the procedure, the more it is frowned on by opponents (Brassington 2020, 11–12). Similarly, the ‘healthier’ the patient is subjectively perceived by society, the more opposition to their euthanasia. Thus, some circumstances are considered more socially ‘qualifying’ than others, with a preference to physical illnesses over mental illnesses, and older people over younger (Moshe and Avital 2020, 7–9).

Accordingly, even among the countries which have enabled euthanasia, the types of procedures available and the qualifications for each of the procedures vary greatly (Hurst and Alex 2017, 206–207). This then leads some individuals who do not qualify in their home countries, or who live in countries in which any form of euthanasia is illegal, to travel to other countries which are more enabling (Higginbotham 2011, 178; Luley 2015, 618–19; Shondell and Gonzalez 2013, 297–98; Yu, Wen, and Yang 2020, 6). For example, Switzerland (through the organisation of ‘Dignitas’) has been a prominent destination country to euthanise due to its relative ease of regulations in both the procedure itself and its accessibility to foreign citizens (Luley 2015, 618–19). Other countries that grant euthanasia include Belgium, Canada, Colombia, Mexico, the Netherlands and a handful of states in the USA (Kiliclar et al. 2017, 93; Shondell and Gonzalez 2013, 297). Public support has risen for the act over the past two decades (Ladki et al. 2016, 2-13), with New Zealand becoming the latest country to legalise the act of euthanasia following a 2020 referendum in which two-thirds of the voters supported the act (Jha 2020).

Scholars have recognised a form of travel and tourism to other countries for the purpose of euthanasia by referring to it as ‘death tourism’, ‘suicide tourism’ and ‘assisted-suicide tourism’ (ie, Higginbotham 2011, 178; Huxtable 2009, 330–33; Luley 2015, 618–19). This practice has come to include not only the aspect of travelling, but also components of organised tourism similar to other forms of tourism, such as the engagement of ‘agencies that specialize in choreographing everything from travel, hotel stays, and doctor visits to the actual specifications of the place of death’ (Shondell and Gonzalez 2013, 296). Indeed, the past two decades have seen the rise in popularity of euthanasia and euthanasia tourism, turning the phenomenon into a ‘life style choice’ for many individuals around the world, even when illegal in their country of origin (Ladki et al. 2016, 2-13).

Euthanasia in Israel

The question of euthanasia is highly controversial in Israel as in other countries. Indeed, the debate mirrors the discourse in other countries concerning moral, legal, religious, ethical and philosophical notions (Grinberg, Amzaleg, and Gamarov-Berman 2018, 3–5; Inthorn et al. 2015, 330–331; Moshe and Avital 2020, 2; Neubauer-Shani 2011, 210-21210–21; Schicktanz, Raz, and Shalev 2010, 363–68; Velan et al. 2019, 8–11). An overall central part of the debate in Israel concerning euthanasia reflects secular-religious discord. Jewish Orthodox religious dogma asserts the sanctity of life (Inthorn et al. 2015, 330–331; Neubauer-Shani 2011, 208–221; Schicktanz, Raz, and Shalev 2010, 363–68) regardless of quality of life (Cohen-Almagor and Merav 2000, 121–122). This has manifested in the prohibition of active euthanasia, although Jewish religious law does permit passive euthanasia in some limited circumstances, such as withholding treatment from terminally ill patients in unique circumstances (Kinzbrunner 2004, 566). Concurringly, studies have consistently found that Jewish-Israelis differ in their opinions regarding euthanasia as a result of religiosity, with secular Jews mainly supporting the act and religious Jews mainly opposing it (Grinberg, Amzaleg, and Gamarov-Berman 2018, 3–5; Inthorn et al. 2015, 330–331).

A limited form of euthanasia was legalised in Israel through the 'Bill of Rights for the Terminally Ill' (2005). This law authorised medical personnel to conduct passive euthanasia (treatment withdrawal) on terminally ill patients (with less than 6 months to live) who had the capacity to express their unequivocally desire for it. Yet, despite this narrow scope, it has been suggested that authorities largely negated the law’s implementation (Neubauer-Shani 2011, 209). However, there have also been rare instances in which the Israeli judicial courts have authorised individual petitions for euthanasia even outside the narrow scope of the law (Cohen-Friedman 2014). Clearly, the debate on euthanasia is ongoing in Israel. For example, a physician-assisted suicide law in the Israeli parliament failed to pass by a narrow margin in 2016 (Gal 2016), after successfully passing the government’s committee for legislation (Velan et al. 2019, 2). Moreover, a recent study conducted among Israeli physicians found that ‘the support for DAD [doctor-assisted death] in Israel is on the higher side of the support scale in countries where assisted death is not legalized’ (Velan et al. 2019, 8). Even so, by international comparison Israel is on the more restrictive side of Western countries concerning legalised euthanasia (Schicktanz, Raz, and Shalev 2010, 367–68).

Media capabilities and euthanasia

Media, both traditional and contemporary, can play an important role in society regarding euthanasia. This stems from the important capabilities that the media can enable (Shomron and Schejter 2020, 2-3; Shomron and Schejter 2020, 1728). Capabilities represent what a person can do or be, reflecting the opportunities available to each individual in society (Sen 2005, 151–63). The capabilities approach was developed by Sen 1993, 30–50; Sen 2005, 151–63) and Nussbaum 1997, 279–285; Nussbaum 2011, 17–21) as a framework for the fair distribution of resources in society. This approach critiques Rawls (1971) theory of distributive justice by asserting that fairness in society can be achieved through the distribution of opportunities rather than primary goods, as the latter does not translate well into actual opportunities (Nussbaum 1997, 279–285; Nussbaum 2011, 17–21; Sen 1993, 30–50; 2005, 151–63). The capabilities approach is a rights-based approach which strives for quality of life, well-being and freedom (Sen 2005, 151–63) and thus offers a more wholesome understanding of the media’s role in society (Shomron and Schejter 2020, 2-3; Shomron and Schejter 2020, 1728).

Indeed, media in all its forms is one of the most important resources in society as it enables vital capabilities (Couldry 2010, 102–104; Couldry 2019, 43–44; Garnham 1997, 26–34; Hesmondhalgh (2017, 212–214); Hesmondhalgh 2018, 151–56; Jacobson 2016, 789–807; Kaushik and Lopez-Calva 2011, 154–156; Schejter and Tirosh 2017; Shomron and Schejter 2020; Shomron and Tirosh 2020). In this study, I use the model of seven media capabilities (Shomron and Schejter 2020, 2-3) to understand the media’s role concerning euthanasia. The seven media capabilities include ‘Civil participation’, which refers to the active debate and discourse in society regarding any and all topics. This capability emphasises free speech and pluralism and is inherent to the democratic society (Bardoel and d’Haenens 2008, 343; Hesmondhalgh 2017, 212–214; Jacobson 2016, 799; Nussbaum 2011, 33–34; Sen 1999, 8; Shomron and Schejter 2020, 2-3; Shomron and Schejter 2020, 1728). ‘Voicing’ refers to a person’s ability to relate their life story and conditions and to be heard when doing so (Couldry 2010, 6). This capability stresses the importance of ‘the hearing that people get’ when expressing themselves (Sen 1999, 10). ‘To be secure’ refers to the mediated advocation for people’s rights and safety (Jacobson 2016, 799; Nussbaum 2011, 33–34; Sen 1983, 36). ‘To be informed’ refers to people’s accessibility to vital information and news (Bardoel and d’Haenens 2008, 343; Hesmondhalgh 2018, 151-156; Sen 1999, 8–9; Shomron and Schejter 2019, 4-5). ‘Identity and belonging’ refers to the mediated depictions of culture and diversity influencing how people perceive themselves and others (Bardoel and d’Haenens 2008, 343; Gerbner and Gross 1976, 172–94; Schejter 2009, 24-26; Sen 1993, 30–50; 2005, 151–63; Tuchman 1979, 528–42). This capability relates to social-cultural freedoms and affects an individual’s integration and social standing (Sen 1993, 30–50; Sen 2005, 151–63). ‘Identification and imitation’ refers to mediated social learning and accessibility to desired mediated role models (Hesmondhalgh 2018, 151–156; Sen 2005, 151–63). ‘Pleasurable entertainment’ refers to the mediated enjoyable cultural experiences in areas such as music, literature and art (Nussbaum 2011, 33–34; Sen 2005, 151–63).

In this study I focus solely on two media capabilities regarding euthanasia: civil participation and voicing. While other capabilities could be relevant to this phenomenon, the two chosen capabilities represent the core of the mediated activity regarding euthanasia. Civil participation represents the ongoing social debate, and voicing represents the patient’s and their families participation in the discourse.

However, very little is known regarding euthanasia and the media. While ample studies point to a considerable amount of media attention to the topic of euthanasia, they are rarely data-driven and routinely do so in the narrow context of (assisted-suicide) tourism (Huxtable 2009, 327; Luley 2015, 618-19; Pratt, Tolkach, and 2019; Ladki et al. 2016, 2-13; Shondell and Gonzalez 2013, 301; Yu, Wen, and Yang 2020, 5–6). Indeed, scholars have suggested media could be playing a central role in the social discourse surrounding euthanasia in society (Gaignard and Hurst 2019, 6; Pratt, Tolkach, and 2019, 3–4; Stone 2012, 1575). The media’s centrality regarding euthanasia plausibly derives from the potential of media capabilities as these regularly play a central role in society regarding all topics of life (Shomron and Schejter 2020, 2-3; Shomron and Schejter 2020, 1728; Shomron and Tirosh (2020)) as well as from the more specific media role as a mediator of mortality and death (Stone 2012, 1575–76; Walter 2009, 2–4). Yet to date only a small array of empirical studies have been conducted on the media’s role regarding euthanasia.

While some studies have pointed to a more balanced and indepth debate on euthanasia occurring in the news media (Rietjens et al. 2013, 6–7; Wright et al. 2015, 137–38), it has also been suggested that the media tends to portray the debate in a simplistic and binary form (Booth and Blake 2020, 11; Johnstone 2014, 32). Additionally, studies have shown the euthanasia debate is ongoing on social media. For example, an exploratory study of YouTube comments on suicide tourism revealed that individuals were sharing opinions and attitudes for and against the act on the platform (Yu, Wen, and Yang 2020, 5–6). This was also the case in a study conducted on social media content in New Zealand, which pointed to value-laden comments often challenging the state’s role (Jaye et al. 2019, 4–7).

Despite the aforementioned studies, little is known regarding the media’s role in euthanasia in general and in particular the mediated ‘civil participation’ and ‘voicing’ of those affected by it. Moreover, no such studies have been conducted on the Israeli media, whether traditional or contemporary. Therefore, to fill the lacuna, this study sets out by asking the following research questions (RQ):

RQ1: What are the characteristics of the mediated ‘civil participation’ regarding euthanasia discourse in Israeli news media?

RQ2: What are the ‘voiced’ motivations of those directly affected by euthanasia to share their stories in the news media?

RQ3: What are the characteristics of ‘being heard’ when ‘voiced’ as seen through Facebook interactions?

Methods

This study employs a mixed methods approach of both quantitative and qualitative analyses using three distinct samples.

Sample 1

The first sample included 130 articles, which represented all of the articles discussing euthanasia in the past decade (from 1 January 2011 to 30 September 2020) published on two central Israeli news venues: Ynet and Israel Hayom. This lengthy duration was advantageous as it allowed the aggregation of a substantial corpus of articles, as well as reduce the risk of any incident dominating the results. The articles were collected through the insertion of relevant search words into the search engines on each media site (ie, euthanasia, mercy killing, assisted suicide, Dignitas), as well as through article tags, which connect articles by topic on the news websites. A quantitative content analysis was then conducted to measure the capability of ‘civil participation’ regarding the discourse of euthanasia on these news venues.

The two news venues were chosen for their high levels of audience exposure, which indicates their centrality as a media resource. Thus, Ynet is the most popular digital Israeli news website (Dover 2016), and Israel Hayom is the most popular Israeli print newspaper (Surname et al 2020). Moreover, these news venues stem from two distinguishable ideological and political factions. While Ynet belongs to the centre-left liberal faction on the Israeli political map, Israel Hayom belongs to the right-wing conservative faction (Dahan 2017, 99-105). Thus, both news venues used in this study contribute to a more wholesome understanding of the Israeli media.

Intercoder reliability tests were performed on sample 1 and sample 3. Such tests are required to cancel out any subjective judgements (Macnamara 2005, 10-11). Intercoder reliability was measured with Cohen’s kappa coefficient for each variable (Wang 2011, 15-16) for a 95% probability level of K >0.85 (Lacy and Riffe 1996). Although the author was the primary coder in this study, an experienced second coder coded 10% of the articles and Facebook comments.

Variables included media venue (Ynet, Israel Hayom), article type (news article, opinion column), article’s publication date (2011–2020), time of publication (before the euthanasia was conducted, after the euthanasia was conducted), gender (male, female, both, unknown), age group (children and teenagers, adults, elderly, unknown), context (actual death, general discussion), cause of euthanasia (physical, mental, unknown), physical causes of euthanasia (cancer, neuromuscular disease, general disability, Alzheimer, genetic disorders, persistent vegetative state, Parkinson, undefined), mental causes of euthanasia (depression, loneliness, adjustment difficulties, undefined), sentiment towards euthanasia (support, oppose, neutral), the nationality of the person committing euthanasia (Israeli, non-Israeli), the place where the euthanasia took place or was to take place (Israel, abroad), who was to assist in the act of euthanasia (medical staff, independently), profession of the deceased (journalists, authors, scientists, teachers, athletes, clerks, engineers, medical practitioners, restaurateur, unknown), who is the main voice in the article (the person who chose to be euthanised, their family members and friends, the general public), group identity (majority, minority), did the article include a picture of the person who chose to be euthanised (yes, no), was the picture taken when that person was still healthy (yes, no), was the picture taken during sickness of that person (yes, no), and did the article include a picture of the person during the euthanasia procedure (yes, no).

Sample 2

The second sample included all of the articles from the first sample which contained the personal stories of euthanasia which were recounted by the individuals themselves or their family members and friends. In total, 36 such articles were identified. Articles with personal stories were chosen as they could be seen as the realisation of the capability of ‘voice’ (Couldry 2010, 6;Shomron and Schejter 2020, 2-3; Shomron and Schejter 2020, 1728). A qualitative thematic analysis (Ritchie et al. 2013) was then conducted on these articles with the intent of revealing the motivations of directly affected individuals to share their stories in the media.

Sample 3

The third sample included all of the Facebook posts and comments to those posts which appeared on the formal Facebook accounts of the two media venues and which discussed articles from the second sample. In total, 18 such Facebook posts were identified. These posts received 4463 comments, of which 2733 comments were available for analysis and therefore analysed. The posts were collected through the insertion of relevant keywords from each of the 36 articles’ headlines and content into each of the news venues’ Facebook search engines. A quantitative content analysis was then conducted to measure the capability of ‘voice’ and the aspect of ‘being heard’. Intercoder reliability tests were performed on this sample as mentioned earlier.

Variables included the social interaction on each post: number of likes, shares and comments. Furthermore, the comments’ sentiment was measured (expressing sympathy and emotional support, expressing apathy and hostility towards the victims and their families, expressing support for the act of euthanasia, expressing opposition to the act of euthanasia, non-identifiable or other).

Results

This chapter includes three sections regarding euthanasia in the Israeli media: a quantitative measurement of ‘civil participation’, a qualitative analysis of the mediated ‘voice’ of those directly affected, and a quantitative measurement of that voice ‘being heard’ as seen through Facebook interactions.

Civil participation

The capability of ‘civil participation’ refers to the active debate and discourse in society on any and all topics. This capability emphasises free speech and pluralism and is inherent to the democratic society (Bardoel and d’Haenens 2008, 343; Hesmondhalgh 2017, 212–14; Jacobson 2016, 799; Nussbaum 2011, 33–34; Sen 1999, 8–9; Shomron and Schejter 2020, 2-3; Shomron and Schejter 2020, 1728).

Frequency of discourse

The frequency of articles appearing on this subject in the past decade was initially used to measure this capability. During the course of this study, a combined total of 130 articles concerning euthanasia were published on both media outlets. These comprised 95 articles on Ynet (73.1%) and 35 articles on Israel Hayom (26.9%), suggesting that this capability was being realised to a larger degree on Ynet. On average, 13 articles were published a year, fluctuating between an annual minimum of 3 articles and an annual maximum of 25 articles. Yet the overall trend suggests a decline in euthanasia articles over time (figure 1). An χ2 test found no significant difference between Ynet and Israel Hayom throughout the years of publication (χ2(df=9)=9.160, p<0.423), signalling that the realisation of this capability might be diminishing over time.

Figure 1

Euthanasia publications by year.

Identity of the speaker and sentiment

The capability of civil participation, that is, who was taking part in the context of euthanasia, was measured next. The individuals appearing in the articles were mostly from the general public (71.5%), followed by the person who chose to be euthanised (14.6%) and their family members and friends (13.8%). No significant differences were found between Ynet and Israel Hayom, respectively (χ2(df=2)=1.414, p<0.493). The articles on Ynet comprised 69.5% of the general public, 16.8% of persons who chose to be euthanised and 13.7% of their family members and friends, relative to Israel Hayom at 77.1% of the general public, 8.6% of persons who chose to be euthanised and 14.3% of their family members and friends. Furthermore, most articles appeared as news items (79.2%) compared with opinion columns (20.8%). No significant difference was found between Ynet and Israel Hayom in this context (80% and 20% vs 77.1% and 22.9%, χ2(df=1)=0.127, p<0.722). Additionally, the discussions in the articles were almost evenly divided between actual stories of euthanasia (51.5%) and sharing of general opinions regarding the topic (48.5%). No significant differences were found between Ynet and Israel Hayom in this regard (52.6% and 47.4% vs 48.6% and 51.4%, χ2(df=1)=0.169, p<0.681).

When analysing the sentiment of the articles, most articles expressed neutrality (73.1%), relative to supporting euthanasia (20.8%) or opposing euthanasia (6.2%). No significant differences were found between Ynet and Israel Hayom in this context (χ2(df=2)=5.911, p<0.052), with 70.5% neutral, 25.3% supporting and 4.2% opposing on Ynet, and 80% neutral, 8.6% supporting and 11.4% opposing on Israel Hayom. In 50.8% of the stories the actual time of the euthanasia was mentioned relative to 49.2%. Of the articles that mentioned the time, 85% of the articles were published after the euthanasia was conducted and 15% of the articles were published prior to the euthanasia. No significant differences were found between Ynet and Israel Hayom in this regard (χ2(df=2)=1.705, p<0.426). The time of the euthanasia was mentioned in 52.6% of the articles on Ynet and 45.7% on Israel Hayom. Of those mentioned, most were after the euthanasia event (82% on Ynet vs 94% on Israel Hayom) relative to before the act (18% on Ynet vs 6% on Israel Hayom).

Euthanasia: who chose it?

The identity of those in the articles who chose to be euthanised was the study’s final measurement. Of those who identified their gender, males made up the lion share (59.5%) relative to females (39.2%) and 0.8% included both genders. No significant differences were found between Ynet and Israel Hayom (60% and 37.9% vs 57.1% and 42.9%, χ2(df=3)=0.492, p<0.921). Most articles identified the gender of the person going through euthanasia (60.8% males vs 39.2% females). Likewise, most articles identified the age group of the person going through euthanasia (63.8% vs 36.2%). The largest age group consisted of adults (54.2%), followed by the elderly (26.5%) and children (19.3%). Some differences were found between Ynet and Israel Hayom, with Ynet comprising 50% adults, 31.6% elderly and 18.3% children, and Israel Hayom comprising 65.2% adults, 21.7% children and 13% elderly; however, they were not significant (χ2(df=3)=3.112, p<0.375). Most articles did not reference the profession of the individual who was planning to or had already gone through euthanasia (79.2% vs 20.8%). Of the professions mentioned, 52% were journalists, 11.1% were authors, 11.1% were scientists, 7.4% were teachers, 3.7% were athletes, 3.7% were clerks, 3.7% were engineers, 3.7% were medical practitioners and 3.7% were restaurateurs. No significant differences were found between Ynet and Israel Hayom in this context (χ2(df=9)=9.776, p<0.369), with 25.3% of articles referencing the profession on Ynet relative to 8.6% on Israel Hayom. In 40% of the articles, the group identity of the person who chose to go through euthanasia could be identified. Of these, 98% were identified as belonging to the majority group and 2% as belonging to a minority group. No significant differences were found between Ynet and Israel Hayom in this regard (χ2(df=2)=0.928, p<0.629). The nationality of the person going through euthanasia was usually Israeli relative to non-Israeli (56.9% vs 43.1%). No significant difference was found between Ynet and Israel Hayom in this regard (χ2(df=1)=0.590, p<0.443), with Ynet comprising 58.9% Israeli relative to 51.4% on Israel Hayom, and concurringly 41.1% non-Israelis relative to 48.6%.

Furthermore, only 33.8% of the articles included a picture of the person who chose to go through euthanasia. Of these, 77.3% included a picture of that person when they were still healthy, 22.7% included a picture of that person during their sickness (ie, in the hospital) and 9.1% included a picture during the procedure of euthanasia (the total of picture types can exceed 100%, as some articles had more than one picture). No significant difference was found between Ynet and Israel Hayom in this regard (χ2(df=1)=0.595, p<0.440).

The discussed reasons for euthanasia

Most Ynet and Israel Hayom articles identified the reason for going through euthanasia (53.8% vs 46.2%). Of the reasons identified, an overwhelming majority (90%) cited physical ailments, while the remaining (10%) were for mental ailments. No significant difference was found between Ynet and Israel Hayom in this regard (χ2(df=2)=0.609, p<0.738), with Ynet identifying a reason for committing euthanasia in 58.8% relative to 48.6% on Israel Hayom. Of the reasons identified in the news venues, most were physical (90.5% on Ynet vs 88.2% on Israel Hayom), and only a minority were for mental ailments (9.5% on Ynet vs 11.8% on Israel Hayom). The main physical ailments comprised cancer and neuromuscular disease (table 1). No significant difference was found between Ynet and Israel Hayom in this context (χ2(df=8)=4.828, p<0.776).

Table 1

Physical reasons for committing euthanasia by news venue

The mental ailments mostly included depression and loneliness (table 2). Yet, as the number of cases was too low, no significance tests could be performed on this variable.

Table 2

Mental reasons for committing euthanasia by news venue

The discussed characteristics of the act itself

The characteristics of the act of euthanasia as they appeared in the news media revealed that the location where the euthanasia took place or was to take place was usually abroad relative to in Israel (60.8% vs 39.2%). No significant difference was found between Ynet and Israel Hayom in this regard (χ2(df=1)=0.264, p<0.607), with Ynet comprising 37.9% taking place in Israel relative to 42.9% on Israel Hayom, and concurringly 62.1% taking place abroad relative to 57.1%. Additionally, in 90% of the articles, the euthanasia was conducted or to be conducted by formal medical staff in a medical facility, relative to 10% of the articles in which individuals committed euthanasia independently. Formal medical euthanasia accounted for 93.7% of the stories on Ynet, relative to 80% of the stories on Israel Hayom. This was significant (χ2(df=1)=5.322, p<0.021).

Voicing

The capability of ‘voicing’ refers to a person’s ability to relate their life story and conditions and to be heard when doing so (Couldry 2010, 6; Sen 1999, 10).

The mediated voice of euthanasia

Of the 130 articles published in both media venues regarding euthanasia, 36 articles (27.7%) represented the realisation of ‘voice’, as they contained the personal stories of individuals regarding euthanasia, recounted by the individuals themselves (18) or their family members and friends (18). Ynet published 29 of these stories and Israel Hayom published 7 of them, thus the latter can be seen as enabling less of this capability. A qualitative thematic analysis of the motivations to share their stories in the media was conducted in order to understand the mediated voice.

To help others and make a difference

The process of euthanasia was described by individuals in the articles as tiresome, full of bureaucratic hurdles and legal obstacles. Prominent among them is the inability to go through euthanasia in their home countries. Thus, many individuals and family members viewed the sharing of their stories in the media as social-political activism, with the expressed intent of bringing about change and easing the process for others. For instance, an elderly scientist from Australia shared his story in the media prior to his death for the purpose of criticising the illegality of the procedure in his home country: “I’m not happy. I want to die. That’s not very sad. What’s sad is that they prevent this procedure,” he said. “My feeling is that an older person like me should have full civil rights including the right to help me end my life” (Ynet, 30 April 2018). Similarly, after a young woman in her early 30s who was suffering a terminal illness committed suicide illegally with the help of a medical practitioner, a family member relayed that: “after they announced her death, many relatives and friends came to the house, where one of the main issues that came up was euthanasia. ‘The issue of euthanasia in Israel needs to be legalized’, said one of the relatives” (Ynet, 30 November 2012). A husband who accompanied his wife to Switzerland for the procedure said: “he mainly hoped that his words will move something here [in Israel] for other people, and maybe save other patients the difficult trip abroad, and their family the mental anguish of returning the body to Israel” (Israel Hayom, 12 September 2014).

There was no choice

In the articles, both the individuals who went through the procedure and their family members and friends routinely justified the choice in the media by explaining that there was no other way and they therefore should not be judged by society. The explanations focused mainly on the insufferable pain which they were experiencing. For instance, a woman in her early 70s suffering from Parkinson explained:

“I can no longer live with these pains. I cannot anymore. That’s why I’m quitting… It’s important to me not to be judged. I’m not committing suicide, just putting an end to my pain. I do not want to die, really,” she told us then, “but I cannot live with the pain. It is impossible, it is impossible to live in this way. I have no other choice. (Ynet, 8 May 2017)

Similarly, a woman in her late 50s suffering from amyotrophic lateral sclerosis (ALS) explained:

you shouldn’t judge a person until you are in their shoes, sorry everyone, but it’s my decision to make! As well as the execution! I cannot anymore!!! … All this in an attempt to explain the thing that cannot be explained. Because how can one explain such great pain that attacks the body, that it makes a woman who loves life to lose interest in her life and want to stop it immediately. (Israel Hayom, 12 Cohen-Friedman 2014)

Another example can be seen with twin brothers in their mid-40s who completed the procedure together after being born deaf and slowly turning blind:

their older brother Derrick explained: “many people will wonder why they chose euthanasia when they did not suffer from a terminal illness. But their lives moved from one illness to another. They were really exhausted. The fear that they would no longer be able to see or hear each other was unbearable for them.” (Ynet, 15 January 2013)

I am now in a better place

Many of the articles shared the last living moments of the individuals, emphasising their happiness and contentment at finally achieving their desired goal of euthanasia. For example: “In her last four days, she was peaceful and content, and died with her daughter and her granddaughter by her side. ‘The day before she died she smiled at everyone. She got what she wanted’” (Ynet, 19 October 2014). Similarly, a woman in her mid-30s who flew to Switzerland for the procedure explained:

I’m like someone whose legs were amputated in an accident, I’m lying amputated in a field with excruciating pain and no helicopter comes to save me, the only helicopter that will stop the pain is death. On January 16 my helicopter arrives. It’s a good day, Gali [the reporter]. Remember that, think about it like that, it’s a good day for me and therefore for everyone. (Ynet, 17 January 2017)

An elderly man explained: “I’m glad I have a chance to end it,” he said the day before the procedure. When asked if he has any last-minute remorse he replied: “By no means” (Ynet, 10 May 2018). Indeed, this theme also represents the motivation to clarify through the media that these individuals were feeling no remorse even in their last moments.

Remembrance and tribute

Family members and friends expressed their motivation to share these stories in the media with the intent of commemorating and paying tribute to those that had passed away. This theme was manifested in different ways. In some cases, the family members and friends wished to emphasise the tragic circumstances which led to their beloved’s death. For instance:

I promise we’ll tell her story… We’ll make sure her story stays here, stays here the way she wanted, for all its complexity, a story of honor. Everyone will make my story what they want it to be - a story about childhood sexual abuse, a story about motherly love, a story about choosing to die with dignity, a story about eating disorders, a story about the instinct of life, the story is all these things together and inseparable. (Ynet, 17 January 2017)

In other cases the family members and friends wished to commemorate their loved ones in a larger-than-life style. For example, after a journalist in his late 50s who was diagnosed with cancer went through the procedure, his friend recounted: “He was a terribly colorful man, crazy, hot, wild, professional, sociable and lonely and above all mysterious. It was impossible not to love him despite the contradictions” (Israel Hayom, 9 August 2011). Likewise, a woman’s friend recounted: “The story of her life and death is a story about a beloved and valued woman, strong and soft, who helped hundreds of families in her life and her character will continue to accompany many even after her death” (Ynet, 20 March 2017). Indeed, many of the articles included complimentary memories of the deceased, highlighting their personal qualities and contributions throughout life.

The supporting family

Many of the articles described the supportive role that family members served for the deceased during the latter’s sufferings as well as during the procedure. For instance: “They [the family] were all there for her in fire and water, they never left her alone for a moment in the hospital, they did shifts and there was always someone to sleep with her there” (Ynet, 1 December 2012). This theme might serve to disperse the possible notion that people choose euthanasia due to a lack of support and help from their surroundings, as well as possibly shedding an accusatory light on family members and friends insinuating their lack of support. Indeed, this theme corresponds with the previous themes of justification. Additionally, the articles routinely pointed to the presence of family members in the process in both general support and in accompanying beloved ones during the procedure. For example:

she traveled with her three sons - Nimrod, Eli and Ami, along with her Filipino nanny Norian to Zurich, Switzerland, the seat of the organization “Dignitas” - which helps people from all over the world die with dignity. There, after a cup of coffee overlooking the lake and surrounded by the people closest to her, she put an end to her life. (Ynet, 20 March 2017)

To say goodbye and thank you

In many of the articles, individuals expressed their last farewells and gratitude to all those who knew them. For instance: “I enjoyed almost every moment of my not-so-short life. I thank everyone who showered me with affection and love, and there were quite a few of those around me that I liked and loved very much. Thank you for everything” (Ynet, 8 August 2011). Likewise: “don’t mourn me too much, so that I can go on my way without sorrow. Thanks for everything” (Israel Hayom, 2 December 2012) and “Goodbye to all my dear friends and family that I love” (Ynet, 3 November 2014).

To be heard

Of the 36 articles relaying ‘voice’, 18 appeared on the formal Facebook accounts of the media venues (50%). In order to ascertain if the aforementioned voice was also ‘being heard’, the interactions associated with these articles were initially measured on Facebook. The 18 articles received a total of 48 468 likes, averaging 2693 likes per article. Furthermore, the articles received a total of 2966 shares, averaging 165 shares per article. Additionally, they received a total of 4463 comments, averaging 248 comments per article. These results point to an abundance of interactive activity, suggesting that the voice of euthanasia is being heard. It should be noted that no distinction was made between specific Facebook comments to specific articles due to ethical considerations, thus focusing on all the articles and all the comments as a whole.

The sentiment in the Facebook comments was then measured. Of the 4463 comments associated with the 18 articles, 2733 comments were available for analysis (61.2%). The comments were divided into three categories: expressing sympathy and emotional support or apathy and hostility towards the victims and their families (63%), debating the legitimacy of the act (20.1%), and non-identifiable or other (16.9%). These comments can be seen as corresponding with the aforementioned themes, representing the aspect of ‘being heard’ when voicing.

Indeed, the act of euthanasia is controversial and seen by some as morally wrong and religiously sinful (Ladki et al. 2016, 2-13; Yu, Wen, and Yang 2020, 5). It is therefore plausible to interpret many of the voiced themes as an attempt by the victims and their families to justify their actions and receive public acceptance (ie, There was no choice; I am now in a better place). Results show that 63% of the comments expressed sympathy and emotional support or apathy and hostility towards the victims and their families. Of these, most Facebook comments expressed emotional and moral support for the victim and their families relative to those that expressed apathy and hostility (99% vs 1%). Thus, this could hypothetically be interpreted as being on the spectrum of public acceptance (agreeing with the act) to public understanding (without agreeing with the act).

Moreover, corresponding with the aforementioned voiced theme of promoting change (To help others and make a difference), the substantial prevalence of debate on Facebook (20.1% of comments) regarding the legitimacy of the act of euthanasia can be seen as the instigation of social discourse, a form of activism. Furthermore, most Facebook comments in this category expressed support for the act of euthanasia relative to those who opposed it (63% vs 37%), hypothetically pointing to the successful persuasion of readers (although no causality can be determined here).

Discussion

This study set out to understand the media’s role regarding euthanasia discourse (‘civil participation’) and euthanasia voice (‘to voice and to be heard’). This was accomplished through a mixed methods approach, including a quantitative content analysis of news articles (to measure the discourse of ‘civil participation’), a thematic analysis of news articles (to examine the ‘voice’) and a quantitative content analysis of Facebook comments (to measure ‘being heard’). To date, relevant literature concerning media and euthanasia is rare and limited, with existing literature focusing mainly on opinions expressed for and against the procedure (Booth and Blake 2020, 4–10; Jaye et al. 2019, 4–7; Johnstone 2014, 32; Rietjens et al. 2013, 6–7; Wright et al. 2015, 137-38; Yu, Wen, and Yang 2020, 5–6). Indeed, the characteristics of the participants in the debate, the ‘voice’ of the affected and the question whether the affected are ‘being heard’ have not been studied to date. However, these aspects contribute to a more wholesome understanding of the media’s role in society regarding euthanasia.

Results indicate that the mediated social discourse (‘civil participation’) concerning euthanasia is limited to a small array of populations and circumstances, with an inclination to discuss adult men from the majority group who suffer from a physical ailment. This narrow mediated discourse mirrors the larger social debate of this topic in society (ie, Boston, Bruce, and Schreiber 2011, 615; Gaignard and Hurst 2019, 6–7; Jansen, Wall, and Miller 2019, 193–95; Shondell and Gonzalez 2013, 302; Yu, Wen, and Yang 2020, 5–6). For example, a central notion in the social debate relates that the legitimacy of euthanasia depends on limited ‘qualifying’ circumstances (Moshe and Avital 2020, 7–9). Concurringly the news media tends to focus primarily on limited qualifying incidents such as adults and not children, and physical ailments and not mental ailments. Moreover, as with other topics of media coverage, the news media tended to focus in the context of euthanasia mostly on high status populations such as men and the majority group, possibly due to economic perspectives and power relationship perspectives (Dixon and Linz 2000, 565–67; Kama 2015, 186–7).

Additionally, despite the differences in ideology and political leaning between both news venues chosen for this study, they were mostly identical in the characteristics of their coverage of euthanasia discourse. Indeed, the main difference between the venues concerned only the frequency of coverage, with Ynet leading Israel Hayom in a ratio of 3:1 articles in the topic. This could be explained by Israel Hayom’s right-wing conservative leaning, which possibly leads the paper to cover less of the topic relative to Ynet’s centre-left liberal leaning (Dahan 2017, 99–105). Moreover, while the ‘correct’ levels of coverage for this topic in the media cannot be determined, the decline in coverage in both venues suggests the mainstream media is not propagating activism, social change or even much of a debate regarding this topic in the public sphere. This then possibly points to a limited and modest role the media is actually playing in society regarding euthanasia. This finding defies scholars’ expectations regarding the media’s role and euthanasia (Gaignard and Hurst 2019, 6; Pratt, Tolkach, and 2019, 3–4; Stone 2012, 1575–76) and the media’s role as a mediator of mortality and death (Stone 2012, 1575–76; Walter 2009, 2–4), and represents the hindering of the media capability of ‘civil participation’ possibly impeding opportunities in society (Shomron and Schejter 2020, 2-3; Shomron and Schejter 2020, 1728).

Contrary to the narrow discourse, the mediated ‘voice’ of euthanasia manifested in a substantial per cent of articles and represented a large variety of voices (as seen through the six distinct motivations to voice euthanasia in the media). However, while findings relay that this capability was enabled in the Israeli media, as Ynet leads Israel Hayom with a ratio of 4:1 articles portraying voice, it can be assumed that the latter is less enabling of this capability. This finding concurs with the aforementioned results concerning the discourse differences between the two news venues, and plausibly derives from their differences in ideology and political leaning as previously discussed (Dahan 2017, 99–105).

The analysis of the Facebook results indicates that the mediated voice of euthanasia was indeed ‘being heard’. While the ‘correct’ levels of ‘being heard’ cannot be determined, the high prevalence of interactive activities on Facebook posts seen through the high number of likes, shares and comments can serve as an indication that those affected were reaching large audiences through their mediated voice. Furthermore, as the sentiment in most comments was supportive—and even though causality cannot be determined here—this could interpretively suggest a spectrum of ‘being heard’ from readers sympathising with the affected (without agreeing to the act itself) to the persuasion of the readers to agree to the act itself or agree with the justifications of the individual who went through with it. However, the reader should bear in mind the limitations of Facebook analysis. Although the analysis of social media comments is advantageous for understanding public sentiment (Yu, Wen, and Yang 2020, 5), this method suffers from limitations, such as not serving as a representative sample of the general public, easily manipulated by fake accounts and bots, and due to the lack of anonymity possibly influenced by social desirability bias (Kosinski et al. 2015, 15–19, 31–32). Future research could address this by correlating public reactions on social media with other research methods such as laboratory experiments and anonymous surveys.

In conclusion, this study contributes to a better understanding of the media’s role in society in general and the role it is actually serving in the context of euthanasia. While the article refrains from taking a position for or against euthanasia, it arguably demonstrates the important role the media should play regarding this topic through the media capabilities of ‘civil participation’ and ‘voice’ (both ‘voicing’ and ‘being heard’). Furthermore, as enabling capabilities is the responsibility of policymakers (Nussbaum 2011, 26–27), this article suggests they do more to allow a more inclusive mediated discourse, with all individuals and notions expressed. Yet, while the responsibility of improving the quality of life of individuals is ascribed to ‘government and public policy… as defined by their [people’s] capabilities’ (Nussbaum 2011, 19), the capabilities approach as a goals-based theory focuses on the ends rather than the means, thus reflecting neutrality of preference regarding economic approaches and practical solutions (Sen 1985, 17–19). Therefore, while policymakers are expected to solve injustice, they are not limited or directed to any one particular solution or approach. Thus, possible solutions for a more inclusive mediated discourse regarding euthanasia can include the strengthening of a more ‘free and independent press’ (Sen 2009, 335–336), possibly lowering regulatory barriers and political censorship. Likewise, the solution can include strengthening the public service orientation of media venues (Scannell 1990, 13–15), thus promoting public media which is characterised by a ‘serve-all’ approach and less of a dependency on market considerations (Karina and Gunilla 2011, 211), as well as promoting a more ‘public-service’-oriented commercial media through regulation charters (Schejter 2009, 82–84). Furthermore, the methods and approaches of capability enablement can manifest differently between countries as a result of cultural differences and institutional set-ups (Bruggemann et al 2014, 1055–1057). Seemingly, the common denominator of these diverse methods and approaches is the responsibility of policymakers to enable their people’s capabilities and quality of life. Indeed, while the general enablement of capabilities and their successful realisation represents quality of life and well-being, this is of increased importance regarding a topic solely concerned with an individual’s quality of life such as euthanasia.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Bibliography

Footnotes

  • Contributors BS is the sole author of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.