AN INVESTIGATION INTO THE ATTITUDE OF PROFESSIONAL NURSES TOWARDS EUTHANASIA

The purpose o f the study was to identify professional nurses attitudes towards euthanasia. A descriptive study of the attitudes of p ro fess iona l nurses towards euthanasia was undertaken. The data collecting instrument was a questionnaire , which was self-administered to 26 professional nurses working in different wards. The majority o f professional nurses were against euthanasia in hospitals. It was also evident that professional nurses need to be involved in decision making on euthanasia. Though professional nurses revealed negative a ttitudes towards euthanasia, there are situations in which they felt passive euthanasia was necessary.

A descriptive study of the attitudes of p r o fe s s io n a l nurses tow ards euthanasia was undertaken.The data collecting instrument was a q u e stio n n a ire , which was self-administered to 26 professional nurses working in different wards.
The majority o f professional nurses were against euthanasia in hospitals.It was also evident that professional nurses need to be involved in decision making on euthanasia.
Though professional nurses revealed n egative a ttitu d e s towards euthanasia, there are situations in which they felt passive euthanasia was necessary.

INTROD U CTIO N
Advancement o f medical technology has made it possible for medical doctors to extend the life span o f patients who are chronically ill and those who have been diagnosed as having brain damage.It is also common in general hospitals, w here those patients who are chronically ill, brain damaged, babies bom with gross abnormalities are assisted to die because the medical team feel that is worth more than life to those patients.This practice is called euthanasia and is defmed as good death (Kneigh and Ames, 1980).This practice has created great controversy in the nursing profession.Some nurses feel that it does not signify dignified death because it is not a natural death and the patient concerned does not undergo all the stages of the death process.Some nurses feel that it is done for the good of the patient.
A sig nificant experience m otivated the researcher to investigate nurses attitudes towards euthanasia.While he was allocated in Maternity unit, an anencephalic baby was bom.The doctor who saw the baby ordered that the baby m ust neither be fed nor resuscitated to shorten her life.The baby was not fed and died in two weeks.
The question arises : Was it a peaceful death or a painless death?What was the standpoint of the nurses in this incidence?What was their attitude in terms of ethical consideration of this case?

STATEM ENT O F TH E PROBLEM
Prevalence of diseases which progress to prolonged terminal illness and which are incurable have created a problem among professional nurses.It has caused much controversy and conflict on whether to assist those patients to die or leave them to die a natural death or prolong by life support systems and medical means.
Professional nurses are sometimes in an ethical dilemma when they have to stop the life support system to patients whose recovery has been proved impossible and patients who are in the terminal stage of their illness.Kuhse (1988) maintains that there is some justification in passive euthanasia because the nurse or doctor is not the direct cause of death.Despite, this be it passive or active euthanasia, the result is the end of the patient's precious life.Implied in the nurse's professional code of ethics is the fact that every person who is the consumer of nursing care should feel absolutely safe in her hand.Man, as implied by natural laws, has a right to life (Mellish, 1978).Nursing ethics endows certain rights to the patients, the right to care, the right to life and the right of the patient to have a say in his care and treatment.The question to be investigated is : "What are the attitudes of professional nurses towards euthanasia?
O BJECTIV ES Specifically the study addresses the following objectives:-1.To identify the views of professional nurses concerning euthanasia.

DEFINmON OF TERMS
To facilitate understanding of the report by the re a d e r, th e fo llo w in g te rm s m u st be understood to mean the following:- • Euthanasia refers to "well" "good" or "easy" death (Mellish, 1978:87) • Passive euthanasia as defined for this study, refers to allowing someone to die by passive means or by doing nothing that may prolong life of the critically ill person, such as omitting resuscitation, ceasing m ed icatio n or feed in g in p articu la r instances.
• Active euthanasia refers to actively causing death such as administration of an overdose of a drug or a lethal dose in the form of oral medication or injection.
• Voluntary euthanasia refers to the client's acquiescence to the decision, on when and how to end life.Systematic random sampling was done.The researcher consulted a duty roster.Using the duty roster the researcher took all names that were against even numbers until twenty six nam es were chosen.A pproxim ately 53 professional nurses were on the staff.
The sample consisted of twenty six (26) professional nurses selected by systematic random sampling from different wards.

INSTRUM ENT
The researcher compiled a questionnaire which was self-administered to twenty six professional nurses.
The questionnaire was divided into three sections.Section A consisted of personal d etails o f the respondents.S ection B consisted of closed-ended questions in which the respondents w ere to give yes or no responses.Section C consisted of statements that presented situations which might have occurred during patient care and where euthanasia might have been indicated.For each statem ent closed and open-ended questions in relation to the paragraph were asked.A copy of the questionnaire may be obtained on request to the researchers A p ilo t stu d y w as u n d e rta k e n to ten professional nurses.As a result of the pilot smdy, the improvement of the questionnaire was made.

E TH IC A L CONSIDERATION
Permission from the respondents was obtained and the purpose of the study explained.
Respondents were assured of confidentiality of information.Permission for conducting the study was obtained from the authorities in-charge of the hospital.
Numerical analysis of data was used.
All questionnaires which were sent to twenty six (26) professional nurses were returned.

FINDINGS
The study showed that 92% of respondents were females.This is probably due to the fact that the nursing profession is still female dominated.Therefore, the findings about the attitudes of professional nurses towards euthanasia in this study are predominantly those of female professional nurses.The study revealed that 73% of respondents had worked in situations where euthanasia was instituted, and therefore their responses were based on their personal experience.The respondents were requested to give their views about euthanasia.

TABLES: EXPOSURE TO EUTmNASIA
In seeking to find out whether respondents would like medical practitioners to involve them in taking decisions on euthanasia, 65% felt strongly that they should be involved.The response is supponed by Kuhse (1988), who states that in most instances doctors prescribe action designed for euthanasia and nurses carry it out without being involved in decision making.This is also supported by Black (1995) who strongly feels that nurses need to ask them selves this question ; "Are we allowing ourselves to be manipulated by the pro euthanasia lobbyist?" This suggests that nurses need to be involved in decision making on euthanasia issues in hospital.

AGE RELATED EUTHANASLV
The respondents were requested to state if the patients's age should be considered in decision making about euthanasia.It is interesting to note that the researcher's focus was on the elderly in this item.He wanted to establish whether the respondents felt that the elderly people when terminally ill, should be the victims of euthanasia.
The respondents were almost equally divided on this issue, 54% felt that the age of the patient should be a factor, whilst 46% felt that the age should not be a factor in making decisions related to euthanasia.
The feeling that the patient's age not be a factor when making decisions related to euthanasia, is supported by Thompson and Thompson (1981) who maintain that the ontological rule approach to ethics and euthanasia is that the aged are human beings whose lives are to be respected regardless of age productivity.
The respondents were requested to state whether the patient's next of kin be involved in decision making to stop or withhold medical care or life-support systems.Fifty four percent (54%) gave a "yes" response and 46% gave a "no" response.This shows that what is acceptable to some nurses is unacceptable to others.Therefore, acting against the wishes of the next of kin may be interpreted by some as right and by others as wrong.

A D M IN IS T R A T IO N O F A L E T H A L DOSE
The respondents were presented with a hypothetical case of a patient dying from cancer.The patient was alleged to be in great pain and was pleading to be given a lethal dose of a drug, which the doctor agreed to prescribe.
The respondents were requested to state if they would agree to administer the drug.The response was that 88% stated that they would not administer the lethal dose, but did not state the reasons.It was therefore not clear whether the "No" responses came from fear of breach o f the code of professional conduct or reflection of euthanasia on religious grounds.
Twelve percent (12%) stated that they would administer the lethal dose of a drug.When requested to give reasons for their response, 6% of the 12% stated that they would administer the lethal dose of a drug in order to relieve suffering whilst 6% did not give reasons.given by respondents was that the nature will take its course and must be allowed to do so without anyone hastening the death of the baby.Fifteen percent (15%) of respondents felt that the baby should be assisted to die.They stated that the life of a malformed baby is of no value to both the parent and to the baby itself.
The idea of assisting a malformed baby to die, is supported by Nursing Times (Editorial, 1992), which suggests that doctors should ease the baby's dying rather than prolonging it by insensitive means such as modem medical technology, but is further pointed out that doctors should start from a position which seeks to preserve and value life rather than to judge it as not worthwhile.
The respondents were further requested to state whether they felt the doctor was justified in prescribing the lethal dose of a drug for the patient.Eighty one percent (81%) felt that the doctor was not justified.When requested to state the reasons why they felt the doctor was not justified, they stated that administering a lethal dose of a drug to the patient is murder.
Nineteen percent (19%) who stated that the doctor was justified to prescribe a lethal dose of a drug, supported their response by saying that as long as there is no hope for recovery for the patient, death must be hastened in order to relieve suffering.
As reflected in Table 10, the findings suggest that most nurses are against the active form of euthanasia.It implies that as doctors prescribe euthanasia, nurses unwillingly carry out orders, and are then left in an ethical dilemma.
They are left to carry out orders that are sensitive according to their ethical code of conduct and religious beliefs.Though respondents had differing opinions on this item (Table 10), Mellish (1978), states that nurses need to clarify their own thoughts and philosophies and to be able to present to those committed to their care an image of a person who is worthy of such trust, one who will help and support those in need of such support in life and until death.
Also, according to South African laws, the deliberate taking of human life remains a crime, and the nurse is expected to be a law abiding citizen (Searle, 1986).This explains why som e n u rses w ould n ot ag re e to adm inister a prescribed drug themselves (Compare Table 4 with Table 10).

M A L FO R M E D BABY BEIN G A SSISTED T O DEE
The respondents were presented with a hypothetical case o f birth of a severely malformed infant.They were asked to state if such a baby should be assisted to die.Eighty five percent (85%) o f respondents were against assisting a baby to die.The reason In seeking to find out if life of a malformed baby should be prolonged by use of artificial means, the findings were as follows:-Eighty percent (80%) of respondents were negative about prolongation of life.They stated that surgical treatment or other means of correcting a m alform ation should be instimted if possible rather than prolonging Ufe.
Twenty percent (20%) of respondents felt that the life o f a m alform ed baby should be prolonged, but no clear reasons were stated.

NURSING A PA TIEN T W HEN TH ER E IS NO H O PE O F RECOVERY
In trying to establish as to whether respondents would like to nurse a patient for whom there is no hope of recovery, and whose life is m aintain^ by artificial means, 77% said they would not like to nurse a patient for whom there is no hope of recovery.They gave a reason that it is a waste of time and energy to nurse such a patient.This response supported the resp o n d en ts' view s about om itting, resuscitation where most nurses were in fav o u r o f o b e y in g o rd ers fo r passiv e euthanasia (see Table 9).This should be of great concern to the nursing profession which has a caring and not a curing aspect It appears that nurses are following a medical model and not a helping model.
Nurses are expected to care for the sick until he/she dies a peaceful death.

DISCUSSION
The findings of the study indicated that most professional nurses (73%) in the sample have been exposed to euthanasia situations in hospital.
It is also evident from the study that the resp o n d e n ts have had e x p e rien c e and exposure only to passive euthanasia, such as d elib erately om itting resuscitation to a critically ill patient with an aim of hastening death.This suggests that passive euthanasia is practised in hospital and that active euthanasia such as administering a lethal dose of a drug to a patient is not practised.Probably this is attributed to the fact that euthanasia is illegal in South Africa.
It is interesting to note that the study revealed contrasting attitudes that respondents showed about e u th a n a sia p rac tice .T h ere are situations in which the respondents were negative towards euthanasia practice and situations in which they were positive.
The respondents' negative attitudes were identified from the following items:- S ix ty tw o p e rc e n t (6 2 % ) o f the respondents felt that euthanasia was not necessary (Table 1).
Eighty eight percent (88%) of respondents felt that a lethal dose of a drug should not be administered to a critically ill patient in order to hasten death (Table 10).The respondents further felt that the doctor is not justified to prescribe a lethal dose of a drug for the patient.They viewed this action as murder.The respondents were against assisting a malformed baby to die (Table 11).They stated that the nature must be allowed to take its course without anyone hastening the death of the baby.
A lth o u g h th e stu d y rev e ale d th a t professional nurses are against euthanasia, there are situations in which respondents responded positively.
Positive responses were identified from the following items It was evident from the snidy that most respondents (77%) felt that a critically ill patient with no hope of recovery must not be resuscitated (Table 9 and Table 13).
The respondents stated that this action would be a waste of time and energy. b The study revealed that respondents were not in favour of prolonging life of a malformed baby by use of artificial means (T a b le 12).T hey fe lt th a t the malformation, if possible, be corrected surgically or by any other means.
It is therefore evident from the study that respondents felt that passive euthanasia is necessary in some situations and not in others.
It was evident from the study that professional nurses are of the opinion that euthanasia should be decided according to age.The respondents maintained that the elderly when terminally ill, be considered for euthanasia, but the type of euthanasia was not indicated (Table 6).This is of great concern since the aged are human beings whose lives are to be respected regardless of age productivity (Thompson & Thompson, 1981).T helivesof the elderly should be regarded as important by nurses, since the nursing profession has a geriatric training course, aimed at preparing interested nurses in caring for the aged.
The study revealed that 54% of respondents felt that the next of kin of the patient must be involved in euthanasia decision.This suggests that professional nurses are in line with the scientific approach of nursing.
The sftidy showed that 65% of respondents felt that they should be involved in taking decisions on euthanasia.Nurses would like to be involved in decision making on euthanasia issues in hospital and the involvement of the nursing team in decision making about e u th a n a sia is v ita l, w ith th e m edical practitioner taking the lead.
It was also evident from the study that respondents had negative attitudes towards active euthanasia.TOs was revealed by the item on administration of a lethal dose of a drug to the patient who is critically ill or has terminal illness.Most respondents (88%) stated that it must not be administered, and 81% felt that the doctor was not justified to prescribe a lethal dose of a drug.They regarded this action as murder.

CONCLUSION
On the whole, the findings of the study suggest that, though respondents showed negative attitudes towards euthanasia in general, there are situations in which they felt that passive euthanasia would be justified, and other situations in which they felt that it would not be justified.
Active euthanasia such as administration of a lethal dose of a drug was regarded as murder by most respondents.F in in g s reveal that probably nurses find themselves in a dilemma in situations where they are instructed to implement euthanasia decisions, when they have not been inv o lv ed in the debate.Therefore, the feeling was that, professional nurses must be involved.This is a challenging issue for nurses who need to be more assertive in their work situation when decisions about patient care are debated.
It is interesting to note from the responses that some nurses are still keeping their promise which they made when they pledged that they will not take or knowingly administer any harmfiil drug to any patient under their care.
It is equally disturbing to note that a high n u m b er o f n u rses w o u ld su p p o rt and participate in euthanasia.
It is striking to note that many nurses would not like to care for patients whose lives are maintained by artificial means, but regarded nursing these patients as a waste of time and energy.This suggests that such nurses be made aware that nursing is a caring/helping profession.Therefore, such nurses need to be m otivated to revive their philosophical landmarks, as stated in a South African Credo of Professor Searle, (1980).

LIM ITATIONS O F TH E STUDY
The findings cannot be generalised to all professional nurses, but are just specifically for professional nurses employed in one of the hospitals in KwaZulu-Natal.
Professional nurses' attitudes were mostly measured by questions with a "yes" or "no" responses, which makes it difficult for the researcher to generalise findings as the real attitudes o f professional nurses.The questions were also not directed to simations encountered by each professional nurse in practice, but were hypothetical situations formulated by the researcher.
c) A SSIST IN G A M A LFO RM ED BABY T O D IE