THE DILEMMA “ FOR ” AND “ AGAINST ” EUTHANASIA AND LEGAL AWARENESS OF THE DISABLED

Aim: to study the legal awareness of the disabled and to solve the “for” or “against” euthanasia issue Material and methods: The study includes 305 polymorbid disabled people and is certificated by the General territorial Expert Medical Commission (LEDC) at University Hospital “St. Marina” Varna for the period OctoberDecember 2011. The study uses sociological method direct and group inquiry and statistical methods: analysis (χ2), analysis of variance, correlation analysis (r), regression analysis (β). The processing of the results was performed by SPSS v.17.0 for Windows. Results: The study of the legal awareness of euthanasia revealed a need for more information among polymorbid disabled people. There is a discrepancy between their more positive, supportive attitude (acceptance of euthanasia) and lack of willingness to actually conduct. The reasons for this can be found in the sporadic public discussions on the debate on euthanasia and in the increased distrust of the health care system. Respondents believe that euthanasia at this stage cannot be imputed as an obligation for the Bulgarian medics. Conclusion: The legal public awareness issue is essential to protect the rights of the citizens, for the realization of those activities that require strict compliance with the Constitution, laws and regulations. The legal awareness study of the disabled for solution of the “for” or “against” euthanasia issue presents an opportunity to discuss a way out of a hopeless situation for patients in terminal condition.

Legal awareness (LA) determines the behavior together with the rules, along with them, and sometimes in spite of them [1].Its specific feature is that it reflects the legal reality and the contained in it legal rights and obligations.Norms themselves are a "bearer" on certain legal awareness of both the regulators and the source of power.Good knowledge of legal regulations is a prerequisite for compliance, which is at the base of the provision of legal order.
The legal awareness issue of the polymorbid disa-bled people as a vulnerable group in society is essential for the legal policy implementation.The cognitive component of their legal awareness plays a significant role in the realization of those activities that require strict compliance with the Constitution, laws and regulations.The most common problem of legal competence is to establish the general level of knowledge of the law, mechanisms of transmission of legal information and its accumulation in individual and group consciousness in the form of legal knowledge [2,3,4].The implementation of legislative changes concerning major social and legal issues such as euthanasia requires study of the legal consciousness of Bulgarian citizens -their awareness, attitudes and readiness to behave in legally significant situations.The studies of a number of authors, including D. Boonin (2000) and O. Kapinus (2006), prove that the reliability of the expressed opinion on the "for" or "against" euthanasia issue is greatest among the vulnerable groups of society, including the disabled people with multiple diseases [5,6].
The aim of this article is to examine the legal awareness of the disabled people and to solve the dilemma "for" or "against" euthanasia.

MATERIAL AND METHODS
The presented study is part of a PhD-research project on "Legal consciousness for legalization of euthanasia and QoL of polymorbid patients with permanently diminished working capacity" (main investigator: P. Mancheva MD, PhD; Protocol/permission from 13. 10. 2011 by Ethical Commission Medical University -Varna).
The study's sample was prepared on the basis of the register of General TEMP in the Hospital "St.Marina" -Varna.The determination of the population includes preinspection of the register of General TEMP at University Hospital "St.Marina" -Varna and the Regional Card-index of Medical Expertise (RCME), Varna and covers 2058 polymorbid patients with disability (PPD).Representative sample was formed on the basis of selection criteria and includes 305 PPD subject to certification and re-certification of Common TEMP at University Hospital "St.Marina" -Varna for the period October-December 2011, which represents 15% of the population (confidence interval ensures the representativeness of the sample is 14.83%, the repre-sentative error is 3.98%).
The study's inclusion criteria: disabled with three or more chronic diseases; a certain degree of disability; living in Varna; appearing in the register of General TEMP at University Hospital "St.Marina" -Varna and RCME -Varna.
The study's exclusion criteria: patients who are not a certain degree of disability; patients with less than three chronic diseases; patients which case for certification is an inquiry to TEMP by the employer regarding his/her working capacity; children; The questionnaire for assessing the Legal Conscience of euthanasia includes 28 questions divided into three areas corresponding to the three elements of its structurecognitive element (I -information), concerning awareness of the problem-a psychological element (A -Attitude), expressing the attitudes towards euthanasia -a behavioral element (C -Conduct) on preparedness in legally significant situations.Questions from 1 to 5 inclusive refer to age, sex, education, profession and religion.The questions that evaluate LC are from I.1 to I.10 refer to the level of awareness of the polymorbid disabled people.The control questions I.10, ².11 and I.12 aimed to examine the self-esteem of the patients regarding their knowledge of/on the essence of the concept of euthanasia, its forms, the countries where it is legalized and the legal framework of the problem here.
Questions A.13, A.14 and A.15, included in the assessment of the psychological element of LC, included possible listed answers in order to ensure the adequate choice of the patient.The other questions on the psychological element A.16, A.17, A.18 and the questions concerning the behavioral element C.19, C.24, S.25, C.26, S.27 were judged by a three-level scale -"I agree" (A.19, S.28 -"yes") 'disagree' (A.19, S.28 -"no") and "do not know" (A.19, S.28 -"I do not know").In order to be given greater choice, which could affect the accuracy of the answers in questions R.20, S.21, C.22 and C.23, was used the three-step scale of Likert.
The reliability of the questionnaire is 80.70%.

RESULTS AND DISCUSSION
The study included 305 PPD people represented by different age groups, gender, employment, education and religion.From those patients who accepted to participate in the study one did not submit the questionnaire due to exitus letalis two days after receiving it, and three othersfor unknown reasons (response-rate -98.71%).The average age of the respondents was 60 years old +10 years of which 52.80% men and 47.20% women.12.80% of the patients are with primary education, 47.50% are with secondary education, 16.10% with college/secondary special education and 23.60% have university degrees.In terms of employment -the majority is with 50.80% and they are unemployed, 26.30% have retired, and 22.90% are still working.The religious affiliation of the respondents, despite the heterogeneous composition is mainly of representatives of the Christian religion -73.80%, profess the Orthodox faith , 5.20% are, 7.20% are Methodists, 1.3% are Protestants.Only 9.80% are Muslims and atheists are just 2.60%.
The study of this vulnerable social group determined the awareness towards euthanasia and the knowledge of the regulations in our country and around the world.The awareness of the polymorbid disabled people is not influenced by age, but is directly related to sex.The results show a better awareness towards the nature of the euthanasia in women (p <0.05).The role of the women in the traditional Bulgarian society -taking care of sick family membersforces them to search for more information on issues related to euthanasia which leads to a better understanding of the problem.Low awareness of the respondents with primary education is understandable, expected and logical, as much as the very good knowledge of the problem in patients with university and college education.
The analysis of the impact of employment on the awareness regarding legislation found the lowest rate of awareness among pensioners compared to unemployed and working people, possibly due to the limited access to relevant sources of information for this age group.The survey results show the growing importance of the religious affiliation of the respondents.The most well-informed patients were those who profess the Christian religion-with predominantly high percentage of Adventists.This can be explained by the position of the SDA, which is not completely against euthanasia.The SDA does not accept the active euthanasia, but in exceptional cases allows the usage of passive euthanasia in order to be shortened the inhuman suffering.This fact opens space for debate among Adventists and creates prerequisites for their greater awareness of the problem.The least level of knowledge of the nature of euthanasia was found in Muslims.This result is not unexpected, considering the fact that Islam strictly prohibits suicide and euthanasia.That does not predispose to search for more information on these issues.
It was established a statistical significant difference in the obtained results regarding the knowledge of the problem (p <0.01), and its legal regulation (p <0.01).The lowest level of awareness about the nature of euthanasia is shown by the respondents with primary education (58.90%) .The better informed patients are those with university and college education -85%.
The majority of the respondents are familiar with the concept of "euthanasia" (78%), but only 51.50 percent think that they are informed about the legislation in Bulgaria (p <0.001).The patients, who are aware of euthanasia's nature, are divided between the two extreme answers -agree and disagree of the application of euthanasia on terminally ill patients who experience severe pain and suffering (p <0.001).The patients, informed about legislation on euthanasia in Bulgaria, are on the opinion that terminally ill in our country should have the right to refuse treatment (p <0.001).
The comparison of these results with the responses to the control questions shows a significant discrepancy between the views of the patients and their actual level of awareness.Respondents in 68.20% of the cases do not identify countries where euthanasia is permitted and in 51.10% of the cases the people acknowledge that they need more information about it.
A significant relation was established between the awareness of the patients on euthanasia and the right of the terminally ill people to deny further treatment (p <0.001).The patients, who are not familiar with the nature of euthanasia in the highest percentage, are not aware of the right to refuse treatment (57.60%).The respondents who say that they know what euthanasia is (38.40%)believe that in our country the patients should not be denied their right of treatment (Fig. 1): The study of the cognitive component of the LC of the PPD showed that this vulnerable social group is not sufficiently informed, particularly in terms of the legal regulations of the problem here in Bulgaria.There is a divergence in the respondents' views of the actual situation, even in those who consider themselves informed about the nature of euthanasia and are familiar with the regulations.
The data from the survey of the awareness concerning euthanasia shows the need for further information on this important social and legal problem among the group of patients that was studied.The results reveal the necessity to develop methods and programs in order to be ensured the access to adequate and reliable information concerning the condition of the problem "euthanasia" at home and abroad.The legal awareness is an element of legal consciousness, in which dominates the cognitive content of law.In this sense, the accumulation of legal knowledge is the initial stage in the complex process of the psychological impact of the law on individual and group legal awareness regarding euthanasia, i.e. forming a second elementthe psychological.The study of legal awareness of dilemma "for" or "against" euthanasia in Bulgaria is an opportunity to discuss output for patients with incurable disease patients.
A significant statistical connection was found in terms of the awareness of the patients regarding the issues/questions related to euthanasia and the right to refuse treatment (p<0.001) (Figure 3

CONCLUSIONS:
The problem of legal awareness of the society is essential to protect the rights of citizens and for the realization of those activities that require strict compliance with the Constitution, laws and regulations.The research of the legal consciousness of euthanasia in our study showed a need for more information among polymorbid disabled people and discrepancy between their more positive, supportive attitude (acceptance of euthanasia) and lack of willing-ness to actually conduct.The reasons for this can be found in the sporadic public discussions on the debate on euthanasia and in the increased distrust of the health care system.Another reason is also the opinion of the disabled that euthanasia at this stage ca not be imputed as an obligation for the Bulgarian medics.The research of the legal awareness for the disabled and the dilemma "for" or "against" euthanasia on our country presents an opportunity to discuss a way out of an impossible situation when patients suffer from an incurable disease.