Abstract:

Introduction:

Euthanasia means that someone other than the patient commits an action with the intent

to end the patient's life, for example injecting a patient with a lethal dose of medication. Patients

may consent to euthanasia, refuse euthanasia, or be unable to consent to euthanasia.

The American Nurses Association prohibits nurses' participation in euthanasia because

these acts are in direct violation of Code of Ethics for Nurses with Interpretive Statements, the

ethical traditions and goals of the profession, and its covenant with society. Nurses must provide

humane, comprehensive, and compassionate care that respects the rights of patients but

upholds the standards of the profession in the presence of chronic, debilitating illness and at end-

of-life.

Legalization of Euthanasia:

Historically, nurses have played a key role in caring for patients at end-of-life across

healthcare settings. Nurses provide expert care throughout life's continuum and at end-of-life in

managing the biopsychosocial and spiritual needs of patients and families both independently

and in collaboration with other members of the interprofessional healthcare team.

According to literature, euthanasia will shorten the period of pre-mortem suffering and

eliminate fear about how and when death will occur. The patient will have a measure of control
over the process of dying (Singer and Siegler, 1990). Also, the legalization of euthanasia has the

potential to save society considerable amounts of money, presently spent on the care of patients

with terminal cancer, AIDS, and other incurable diseases. This study did not include the

considerable costs paid by the patients and their families (Emanuel and Emanuel, 1994).

The legalization of euthanasia also implies the microethical concerns of one individual's

autonomy (to request and receive euthanasia or physician-assisted suicide) take priority over the

macroethical concern for the autonomy of others in society (the elderly, the sick and those who

feel a burden), a change which has implications far beyond medical practice.

With that in mind, regardless of any religion or belief, it is justifiable to assert that life has

value and meaning which will be reduced by the widespread practice of euthanasia (Singer and

Siegler, 1990; Association for Palliative Medicine, 1993; Dickens 1994).

The number of requests for euthanasia and the nurse's subsequent illegal action was

initially startling to some, especially in the Asch study, where 17% of the critical care nurses

received requests and 16% engaged in assisted suicide or euthanasia.

Situational Indications of Euthanasia:

Severe, unrelieved pain, or fear of unrelieved pain at some time in the future, is an

important reason why patients may seek assisted dying (Sullivan, 1997). The management of

other physical symptoms is continually improving, making them unlikely candidates for

euthanasia (Woodruff, 1999). Patients' attitudes to euthanasia change when a positive attitude

and effective relief are introduced. Eleven of 870 patients (1.3%) referred to a specialist palliative
care service in Sydney wanted their deaths accelerated, but this number fell to five (0.6%) after

the institution of comprehensive palliative care (Glare, 1995).

Uncontrolled suffering in a dying patient is a medical emergency, not an indication for

euthanasia (Wanzer et al., 1989). Terminal sedation for intractable distress in dying patients will

control symptoms in most cases, and this process does not constitute euthanasia (Chater, 1998;

Lynn, 1998).

Requests for euthanasia may relate to severe anxiety or depression. A review of the

literature concluded that 'psychiatric morbidity among patients requesting physician-hastened

death is considerable' (Chochinov and Wilson, 1995). An American study found that cancer

patients who seriously considered euthanasia were significantly more likely to be depressed

(Emanuel et al., 1996). Patients' attitudes change when depression is treated (Ganzini and Lee,

1997; Massie et al., 1994). Severely depressed patients, particularly those with more

hopelessness, showed a significant increase in desire for life-sustaining measures after treatment

of depression (Ganzini et al., 1994).

Also, patients may request euthanasia for a variety of other reasons including loss of

dignity, unworthy dying, dependency and tiredness of life-best grouped as existential distress

(Association for Palliative Medicine, 1993; Cherny et al., 1994). Cognitive techniques can help

patients modify the appraisal of their lives, diminish distress and enhance a sense of positivity.

Insight-directed therapy can help patients acknowledge that there are meaningful tasks to be

done, joys to be shared, things to be said or completed, relationships to be savored and

differences to be settled (Association for Palliative Medicine, 1993; Cherny et al., 1994; Kelly et
al., 1996). Attention to the psychosocial and spiritual aspects of care can influence patients not

to act on their previous requests for euthanasia (Severson, 1997). At the Hospice Rozenheuvel

in Holland (established in 1993), approximately 25% of patients asked for euthanasia at the

time of admission. "When they hear what can be done for them, and how many possibilities of

care and creative solutions to their problems are available, they hardly ever mention

euthanasia further." (Zylicz, 1995)

It is reported that 50% of patients with AIDS consider euthanasia (Breitbart et al., 1996;

Onwuteaka-Philipsen and van der Wal, 1998; Starace and Sherr, 1998). Requests of euthanasia

from patients with AIDS often relate to fears - fear of death, fear of pain, fear of dependence or

fear of being a burden - and it requires careful and considerate communication to elicit the

underlying cause (Cole, 1993; Voigt, 1995).

Ethical arguments about euthanasia-related to principles

It seems too simple to state (Snelling, 2004) that the justification for euthanasia is built on the
principles of beneficence and respect for autonomy, while its opponents rely on the principle of
non-maleficence.
Respect for autonomy
In the nursing ethics literature, euthanasia as an ethically good practice is often justified on the
respect for an individual’s autonomy. According to Farsides (2006), doctors and nurses must
respect a request for euthanasia as an expression of the patient’s autonomy, even if they do
not consider themselves capable of or want to carry out this request. Similarly, Willard
indicated that caring for a patient is best achieved by respecting the patient’s autonomy, even if
he or she requests euthanasia. According to Kuhse, 29 a good death is an autonomous death.
Thus, the independent choice to die must not be thwarted by the maternal attitude of
unprincipled, feminine nursing ethics of care.
However, the nursing ethics literature also offers four criticisms against the characterization of
euthanasia as a morally right practice with respect for a patient’s autonomy. Appeals to the
principle of autonomy in order to justify euthanasia seem problematic. The first criticism is that
euthanasia itself, at least in part, carries the connotation of having minimal regard for the
autonomy of others. Schaart and Boer30 stated that euthanasia
not only deals with a patient’s autonomy regarding life in general or his or her life in particular
but also, and above all, deals with a patient’s autonomy over and against other people.
Blondeau31 argued that respect for a patient’s autonomy could not directly erase the
importance of the social community. Just as life is a social practice, dying is also a social
practice: it does not happen outside of a social network. McCabe32 stated that the biased
choice to support a patient’s autonomy undermines the autonomy of the nurses involved in
caring for that patient. They are not obliged to honor every preference that a patient may
express. Nurses do not have to advocate anything and everything a patient may want. Beech33,
therefore, argues that, for full respect of autonomy to occur, nurses, as well as patients, must
be allowed an equal opportunity to exercise their autonomy. Similarly, Goodman34 also has
problems with the notion that the act of euthanasia violates nurses' autonomy in the process of
respecting the patient’s autonomy.
The second criticism is grounded in the idea that euthanasia does not administer justice to the
autonomy of the patient. Low and Pang35 consider respect for a patient’s autonomy as
necessary, but not absolute. They found it strange that advocates of euthanasia support patient
autonomy by making this same autonomy senseless, because after euthanasia is completed the
patient no longer enjoys his or her autonomy.
Low and Pang thus consider euthanasia to be an escape, in which pain is alleviated by
eliminating the patient. Euthanasia, therefore, illustrates an inability to deal with death.
Blondeau31 also questions the quality of autonomy for a patient who flees from uncertainty
and anxiety by choosing to die. According to Rumbold, 36 basing on the principle of a patient’s
autonomy, euthanasia only confirms a defeatist perspective, in which there is no room for an
affirmative answer to personal suffering. According to McCabe, 32 respect for a patient’s
autonomy as justification for the act of euthanasia considers only those who can make, or have
made, their wishes clear. The ‘non-autonomous’ patient, who can no longer communicate with
his or her environment, is made to suffer. One who uses the principle of respect for autonomy
as justification for euthanasia, therefore, runs the risk of denying a person dignity once he or
she is incapable of expressing himself or herself as an autonomous individual.
The third criticism lies in the argument that, if one considers euthanasia at least as a socially
justified possibility of choice, a patient’s autonomy is in danger because of growing social
pressure on some specific patient populations.
37,38 This type of social climate hinders a patient from making a well-considered and free
decision. The possible occurrence of discrimination against vulnerable groups makes euthanasia
dangerous. 39
Begley40 fears that because of the growing focus on the ‘procedure of care,’ a patient may be
afraid to withdraw his or her euthanasia request once the procedure has started.
Pollard and Winton, 41 as well as Low and Pang, 35 point out that the so-called free request for
euthanasia does not always happen freely.
The last criticism is based on the misuse of autonomy to justify euthanasia. Indeed, McCabe32
criticizes how the nursing ethics literature currently uses the concept of autonomy or self-
determination to explain a link between nursing care and euthanasia. This type of autonomy
concerns an asocial, individualistic construct of autonomy based on desires rather than on
reason or understanding. According to McCabe, 32 the application of the principle of autonomy
in this way leads to predominant preference-utilitarianism or forced ethic of consequences in
which ‘morally good’ corresponds with ‘autonomously chosen.’
Non-maleficence
In the nursing ethics literature, a rejection of euthanasia mostly occurs on the grounds of the
non-maleficence principle. Owing to irreversible damage to patients’ lives, McInerney and
Seibold42 ardently plead against euthanasia. According to this perspective, euthanasia is too
drastic an intervention to be used in end-of-life care. It makes dealing correctly with death
almost impossible; it is also irreversible. 37
The principle of non-maleficence is applied in two ways. First, the sanctity and inviolability of
life and the human person do not allow euthanasia to be considered as good ethical nursing
practice.
22,36 According to nurses, human life deserves respect,
especially now when society encounters the problems of an aging population where health care
costs that are increasing. 43
Second, using this argument the gift character of life is often translated into a religious stance.
The religiously interpreted resistance to euthanasia starts from the presupposition that life lies
in God’s hands and that our life is not our own. 44 Religion helps us to see ourselves and others
as persons. 45 Fitzpatrick46 emphasizes that the problem with such reasoning is that it works
only for those who share the same religious presupposition.
The principle of non-maleficence also has its opponents. Schaart and Boer30 and Zimbelman44
suggest that the fundamental norm, ‘respectforlife,’ is not absolute. Kuhse and Singer47 reject
the sanctity-of-life principle, which states that each human life is of equal dignity and inviolable.
According to these authors, one must have good reasons for preferring the condition of
allowing one to die over the situation of helping one to die. Moody48 also sweeps aside the
sanctity-of-life principle and views it as an illusion.
Beneficence
Nurses are primarily portrayed as patient advocates who must do good. The principle of
beneficence generates an obligation to promulgate the individual and legitimate interests of
others. In the ethical debate on euthanasia, the ethical principle of beneficence also functions
as a two-edged sword that can be used for support or opposition. If nurses want to do good for
patients, then, according to some authors, quality-of-life arguments have to be employed,
whereby the quality of one’s life and its dignity is worth more than the length of life.
47,49 In line with respect for the beneficence principle as an argument for euthanasia,
Simpson26 refers to the concept of ‘wrongful life,’ which implies that a certain state of life is
bad, intrinsically wrong, and harmful in comparison to death. Death is then precisely considered
as good and right. According to Zimbelman, 44 the quality-of-life argument ensures that health
care workers do not become subject to biological idolatry – the error of vitalism – or
therapeutic obstinacy. In this respect, Davis et al. 50 discuss ‘the overall good of an individual
patient’ and state that what is medically suitable for a patient is not always what the patient
wants.
Nevertheless, there are sharp remarks in the nursing ethics literature concerning this argument
in favor of euthanasia. These remarks question the direct link between doing good for a patient
and euthanasia. The concept of beneficence carries with it an indistinctness: how is one to
consider the ‘patient’s best interests,’ and which necessary actions does one have to fulfill to
meet them?28 In interpreting the significance of doing good for a patient, the patient’s desire
to die may not simply be identified with a desire to be killed.
37 Van der Arend51 states that patients’ interests are never served by causing their death, even
if they believe so and if they desire to die. Goodman34 calls compassion an insufficiently strong
motive for justifying euthanasia.
The nursing ethics literature on euthanasia poses many more questions. Can one rationally
judge the worthlessness of someone’s life?39,46 Is there something like a life not worth being
lived?35,36 Is it not a contradiction to terminate life by seeking a better quality of that life? 36
McCabe32 warns about the ethics of desire that outstrip the ethics of reason. When the
feelings and wishes of patients or other persons involved attain the upper hand, there is a
threat of moral relativism whereby the sentiments of the majority promulgating the patient’s
interests determine what good ethical nursing practice is.
Justice
In promoting or protecting patients’ interests, Kuhse29 defends the notion that euthanasia can
be necessary for the expression of real justice. Here the principle of justice appears as an
expression of excellent care for the patient.
Allmark21 states that one does not have to resort to a utilitarian way of thinking wherein
euthanasia is considered to be an ethically justified form of good dying; for example, in cases in
which it would be unjust and cruel to refuse a request for euthanasia. Justice here means that
everyone receives according to his or her need and gives
according to their possibilities.

The literature offers two warnings about using the principle of justice in the argument for
euthanasia. First, the danger of being self-righteous (or the threat of calling something ‘just’ to
fit in its domain) is genuine. Self-gratification and self-serving behavior are the characteristics of
a new social movement, of which euthanasia is but a part off. 43 Second, the right to die does
not morally obligate nurses actually to carry out patients’ requests for euthanasia. 44
Ethical arguments about euthanasia-related to the profession
According to some authors, the violation of the non-maleficence principle is not only
detrimental to the gift of the character of life, but it can also cause serious harm to the integrity
of the nursing profession.35,38.
Several ethical arguments for and against euthanasia emerge from the literature, and they
prompt the nursing profession to reflect deeply on its attitude towards this problem.
Nursing practice based on trust Simpson26 and Kowalski 52 both plead in favor of the argument
that patients should always be able to trust that a nurse will not kill them. Euthanasia as such
can create a dimension of suspicion that changes the very character of a nurse’s role as healer
and advocate. In this context, Zimbelman44 also warns of the distrust that can arise in
institutions that co-opt into their policy the possibility of euthanasia. Confidence in the
relationship between patient and nurse suffers from this type of system. McCabe53 states that
nurses’ involvement in the execution of euthanasia truly harms society’s trust in the nursing
profession.
Patients have the right to exercise their decisional authority relative to health care decisions,
including preceding life-sustaining treatments. The provision of medications with the intent to
promote comfort and relieve suffering is not to be confused with the administration of
medication with the intent to end the patient's life. In palliative sedation, medications are used
to create varying degrees of unconsciousness for the relief of severe, refractory symptoms at
end-of-life, when all other palliative interventions have failed. Some clinicians and ethicists
consider this an alternative to assisted suicide, as the intention of the physician is not to cause
death, but to relieve suffering (Quill, Lee, & Nunn, 2000). Some have argued that patients have
a right to the independent choice of assisted suicide and that quickly ending suffering is an act
of beneficence (Ersek, 2004, 2005).
2.7 Exercise of autonomy
The principles of individual autonomy and self-determination lead some to believe that there is
a fundamental right to request and receive euthanasia or physician-assisted suicide; others
argue that such a right does not exist (Singer and Siegler, 1990; Saunders, 1992; Roy, 1993;
House of Lords, 1994).
The concept of absolute individual autonomy is at odds with modern society. Innumerable laws
and regulations exist, accepted by society as a whole, which limits individual autonomy to
protect the rights of others.
. Total individual independence was termed by Shaw as "Middle-class blasphemy. We are all
dependent on one another, every soul of us on earth" (Shaw GB, Pygmalion).
. Comprehensive and multidisciplinary palliative care, focused on the needs and wishes of the
patients and their families, can do more to enhance individuals' autonomy and self-respect.

Legislative and community initiatives:

Nurses will likely be increasingly exposed to requests from patients or families and encounter
ethical dilemmas surrounding the legal option of assisted suicide. Nurses need to be aware of
their sense of suffering, discomfort, confusion, and inadequacy that could be caused by aid-in-
dying. Nurses should seek the expertise and resources of others including nurse colleagues,
other interprofessional healthcare team members, pastoral services, hospice specialists, and
ethics consultants/committees when confronting the complexity of these issues.
Acknowledgment of the struggle of those loved ones caring for the patient and the patient’s
vulnerability can connect nurses deeply with the experience of the patient and family.
Despite changes in a few states regarding the legalization of assisted suicide, the public, as well
as professional nursing, remains uneasy. Seventy percent of the Ferrell et al. (2002) sample of
oncology nurses opposed legalization of assisted suicide. Carroll (2007) found a public divided,
but an increasing acceptance toward support of both assisted suicide and euthanasia. Nursing
needs to be prepared for political and public moral discourse on these issues and to understand
how The Code responds to these questions. Nurses must examine assisted suicide and
euthanasia not only from the perspective of the individual patient but also from the societal
and professional community perspectives as well. Involvement in community dialogue and
deliberation on these issues will allow nurses to recommend, uphold initiatives, and provide
leadership in promoting optimal symptom management and end-of-life care.
The Oregon Nurses Association (ONA) has developed resources to guide nurses in their practice
around patient or family requests for assistance in dying (ONA, 1997). Nurses can choose to be
involved in providing care to a patient who has made a choice to end his/her life or may decline
to participate based on personal moral values and beliefs. In this latter case, the nurse can
“conscientiously object to being involved in delivering care. ONA states that the nurse is obliged
to provide for the patient’s safety, to avoid abandonment, and withdraw only when assured
that alternative sources of care are available to the patient” (Task Force, 2008, p. 2). If the
nurse chooses to stay involved with the patient, the nurse may do all of the following:
• Explain the law as it currently exists.
• Discuss and explore patient options concerning end-of-life decisions and provide resource
information or link the patient and family to access the services or resources they are
requesting.
• Explore reasons for the patient’s request to end his or her life and make a determination as to
whether the patient is depressed and, if so, whether the depression is influencing his or her
decision, or whether the patient has made a rational decision based on personal values and
beliefs (ONA, 1997, p. 2).

The nurse as an independent moral actor

In the same profession-orientated perspective, Aroskar54 refers to the integrity of nurses, who
should never be used merely as a means to achieving patients’ goals, here meaning patients’
wish for death. According to McCabe, 32,53 when euthanasia is justified through the practical
use of the principle of respect for autonomy, this runs counter to nursing’s moral practice.
Nurses are more than simple executors of patients’ wishes. When nurses become involved in
carrying out euthanasia, many issues are at stake: the true nature of nursing, the professional
dignity of nurses and, above all, the autonomous character of nursing concerning doctors and
patients.
Professional integrity in the function of euthanasia
Nevertheless, the professional integrity argument is also used to support euthanasia to the
extent that professional integrity can be thought of as a form of responsibility for a fellow
human being and as respect for a patient’s autonomy. In this context, White55 clearly states
that assisted suicide, which in her article is understood to be euthanasia, is compatible with the
professional integrity of nursing. This integrity underlies explicitly nurses’ motivation for
respecting patient autonomy, promoting patient well-being and providing compassionate care.
Here, euthanasia is in line with the proper character of the nursing profession, which focuses on
protecting human dignity, promoting patients’ interests and caring for patients.

Ethical arguments about euthanasia-related to the concept of care

Framing euthanasia as a moral problem from a care-orientated perspective has a different
starting point from that of a principle- and profession-orientated perspective.
The central question from this viewpoint is how to define good care.
Euthanasia as the pinnacle of care
In the nursing ethics literature, some authors plead for the case that euthanasia is an
expression of care for patients in distress. Ellis49 is in favor of permitting euthanasia so that
dignified care can be delivered during dying in the same way that nurses strive to deliver
patient care in life. Farsides27, therefore, stresses that requests for euthanasia should not be
considered a sign of care failure. Willard28 endorses the notion that euthanasia is indeed not
incompatible with care and is an amoral possibility, even though other treatment options, such
as palliative care, now exist. Particularly during the terminal phase of life, it is critical that
nurses acknowledge that patients are fellow human beings who are worthy of dignity and
respect, and this is crucial for all caring. For Kuhse,29 who sees no separating line between
palliative care and euthanasia, euthanasia is best understood as a form of specialized care.
However, this view challenges some long-accepted principles, rules, and laws that are unjust
and stand in the way of excellent patient care.
For Begley,40 who considers euthanasia to be part of terminal care, euthanasia is not opposed
to caring for patients. In line with Kuhse, she even calls euthanasia a challenge for healthcare
workers: ‘The challenge of euthanasia ... is clear: are those who claim to be the advocates of
the dying person ready to accept this challenge?’ (p. 305).40 According to Begley,
comprehensive care has to imply the possibility of euthanasia. Woods56 defends the idea that
euthanasia should be an integral part of palliative care. For him, euthanasia is consistent with
palliative care ethics because he regards it as being on a continuum with the use of palliative
sedation.
Care as a challenge for euthanasia?
There are also those who challenge Begley’s position. It is not euthanasia that poses a challenge
but the development of care for the patient in need. According to several nursing ethicists,
euthanasia is in direct opposition to care. For them, it is unthinkable that euthanasia would
comprise a part of nursing caring practice.
The idea that care for a dying person should be improved is an argument often heard in the
literature against linking euthanasia and excellent care. Coyle37 states that conditional
legalization of euthanasia does not advance the goal of improving care for dying people. She
offers some tools for nursing management. The primary condition for proper care is the
empathic attitude a nurse shows towards a patient. Suffering is not denied, and patients and
their families feel that they are not left alone or abandoned. Nurses do not let their patients
down; feelings of abandonment or despair have to be heard. Consistent with the principle of
beneficence against euthanasia but from the care perspective, Coyle37 asserts that the
expression wishing to die is not the same as the desire to be killed. There is a difference
between ‘I wish I were dead’ and ‘kill me.’ According to Beech33, it can be contended that
euthanasia is not conducive to care for dying people; it even undermines this kind of care. In
carrying out euthanasia, health care professionals may become weary of death in general,
which could lead to a less compassionate attitude towards caring for dying patients.
Similarly, Pollard and Winton41 accuse many of unjustly considering euthanasia as a rational
alternative, a possibility in the care of elderly, dying and severely disabled people. According to
both authors, a better care alternative is possible. Remmers57 interprets the longing for death
as a cry for more attention and support in the dying process. Goodman34, therefore, sees that
the most critical role of nurses is to offer the fittest, most respectful, supportive, skilled and
compassionate care. She refuses to consider euthanasia as care and to justify it as a way of pain
control. In this context, Gauthier58 asks himself, ‘whose pain does euthanasia aim to relieve:
that of the patient or that of the healthcare worker and the relatives?’ Volkenandt59 also does
not consider the choice between supportive care and euthanasia to be an ethical dilemma.
Euthanasia does not meet his vision of reasonable care, which acknowledges pain without
eliminating the patient.
Low and Pang35 reject the idea that euthanasia is an option or possibility of choice in palliative
care. They state that euthanasia radically counteracts the fundamental principles of medicine
and nursing in general, and of palliative care in particular. For them, genuine care is the
cornerstone of palliative care – defined as care that does not unnecessarily postpone or hasten
the end of life60 – and is incompatible with the possibility of euthanasia. These nurse ethicists
consider euthanasia to be the opposite of palliative care. Killing opposes the most fundamental
principles of palliative care, such as ‘doing good’ and ‘not harming.’ From their perspective,
euthanasia cannot be considered to be a confirmation of life; it degrades life and deprives a
patient of his or her final growth in humanity. Karkheck 61 also supports this plea among nurse
ethicists for adequate care that does not point to the termination of life. To her, the issue of
euthanasia illustrates the shortcomings in our care of terminally ill patients. As such, ethically
justified end-of-life decisions do not include assisting with euthanasia, which denies patients
their final stage of life. Bandman and Bandman45 are more explicit and believe that, in general,
not intervening in the dying process is ethically preferable to killing. They consider euthanasia
to be an intervention that is too aggressive and prefers the hospice concept of Cicely Saunders.
These views also inspired Oduncu, 62 who rejects killing as due care.
Euthanasia relieves pain by eliminating the patient. According to Oduncu, it is not possible for
euthanasia to be part of the duty of caregiving. He pleads for skilled and compassionate care in
accompanying dying people and prefers optimal instead of ‘maximal’ (euthanasia included) but
incomplete care. Along these lines, Arndt22 pleads for the development of ‘individualisierende
Pflege’ (individualizing care), which makes euthanasia superfluous. McCabe53 also believes that
the ultimate concern of nursing care, that is, healing of patients, excludes euthanasia. For her,
euthanasia is antithetical to nursing activity and cannot be considered to be a ‘nursing-as-
healing praxis.’
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