Nurses’ attitudes towards euthanasia in conflict with professional ethical guidelines

Abstract

Background:

Despite the significant role of nurses in end-of-life care, their attitudes towards euthanasia are under-represented both in the current literature and the controversial debate that is ongoing in several countries.

Research questions:

What are the attitudes towards euthanasia among Finnish nurses? Which characteristics are associated with those attitudes?

Research design:

Cross-sectional web-based survey.

Participants and research context:

A total of 1003 nurses recruited via the members’ bulletin of the Finnish Nurses Association and social media.

Ethical considerations:

Ethical approval was obtained from the Committee on Research Ethics of the university to which the authors were affiliated.

Findings:

The majority (74.3%) of the participants would accept euthanasia as part of Finnish healthcare, and 61.8% considered that Finland would benefit from a law permitting euthanasia. Most of the nurses (89.9%) thought that a person must have the right to decide on his or her own death; 77.4% of them considered it likely that they would themselves make a request for euthanasia in certain situations.

Discussion:

The value of self-determination and the ability to choose the moment and manner of one’s death are emphasized in the nurses’ attitudes towards euthanasia.

Conclusion:

A continuous dialogue about euthanasia and nurses’ shared values is crucial due to the conflict between nurses’ attitudes and current ethical guidelines on nursing.

Keywords

Attitude ethics euthanasia Finland registered nurse social media web-based survey

Introduction

In keeping with the definitions used in the euthanasia legislation in Belgium and the Netherlands, euthanasia refers to a deliberate act which is intended to terminate a person’s life at his or her own explicit request.^1

–5 In contrast to physician-assisted suicide, euthanasia is always performed by someone other than the person requesting it. In the 21st century, it has been a topic of much controversy in several countries, including Finland, Greece, Spain and Great Britain.^6
–8 In 2012, the National Advisory Board on Social Welfare and Health Care Ethics acknowledged the existence of possible situations where euthanasia could be ethically justified,⁶ an announcement which led to more intensified debate in Finland. As of 2015, euthanasia is legal in Belgium, Holland and Luxembourg, whereas it is an illegal act in Finland, a position which is in keeping with most other countries.⁶

The unique role of nurses in the euthanasia process

Nurses have a unique and important role in the euthanasia process in countries where it is legalized. Compared to physicians, nurses are considered to be more involved with the end-of-life care of patients, due to their greater bedside attendance and frequent confrontation of patients’ suffering.^7,9
–11 According to the Belgian euthanasia law, a consultation with the nursing team which is directly involved in the care of the patient is required before a physician can perform the act of euthanasia. In many cases, a nurse is also the first person to whom a patient expresses the euthanasia request, and he or she subsequently reports the request more widely to the nursing team.^1,2,9,12

Despite the significant role of nurses and the need for information about their viewpoints in this matter, the ongoing debate is still very much focused on the perspectives of the physicians and general public. Finnish physicians’ attitudes towards euthanasia have become more positive during the last 10 years,¹³ congruently with the results of a notable recent study which suggest that attitudes to euthanasia in general have turned to a more liberal direction in Western Europe.¹⁴

By contrast, nurses’ attitudes to euthanasia and the factors which influence these views are under-represented in the current literature.^3,7,8,15,16 However, a number of Finnish nurses consider the legalization of euthanasia to be likely at some point in the future, which would potentially affect more than 100,000 of them in Finland.^16,17 This perception, combined with the fact that the last time nurses’ attitudes towards euthanasia in Finland were reported was as far back as 2002,¹⁸ underlines the contemporary importance of this study.

Ethical aspects of nurses’ attitudes towards euthanasia

The professional ethics of nurses are based on moral values, which also guide their arguments for or against euthanasia. These ethics are documented in the international and national guidelines.^2,19
–21 The guidelines emphasize the respect for autonomy. In addition, they highlight the fact that the nurse does not have to agree with an individual’s choices, but must simply respect each patient as a person.^19
–21

Respect for patients’ autonomy, including their wish to die, is also emphasized among the proponents of euthanasia.^{7,15,16,22

–26} Moreover, the proponents of euthanasia refer to the nurses’ duty to alleviate suffering^19
–21 and regard euthanasia as an extreme remedy. Furthermore, supporters of euthanasia value the quality of life more than its length.^16,22,25,27 On the other hand, the ethical guidelines emphasize the obligation of nurses to protect human life and human rights, which include everyone’s right to life and security of person.^19
–21

Those who reason against euthanasia often refer to its possible misuse and employ the argument of the ‘slippery slope’. Opponents are concerned that if euthanasia were to be approved the practice could be extended to persons who are unable to make decisions independently.^{2,12,16,18,22,24,26,28} Moreover, in the Code of Ethics for Nurses, the American Nurses Association unambiguously condemns any intent to end a patient’s life, even when it is motivated by respect for self-determination, compassion or considerations regarding the quality of a patient’s life.¹⁹ It is obvious that professional ethical codes must be in line with the country’s legal framework. However, in order to be approved by nurses, the professional ethical codes should also be in harmony with their attitudes.

It has been alleged that the general worldview and religiosity of nurses are more important than the professional ethical codes in determining their attitudes towards euthanasia.^15,29 It should be noted that the content of the ethical principles does not change, even if the individual’s approach changes.

Nurses’ religiosity

A communal manifestation of the different dimensions of religiosity presented by Stark and Glock³⁰ in 1968 can be described as religion. The individual expression of religion by contrast can be called religiosity. Nurses’ religiosity is widely recognized as a strong indicator of their attitudes towards euthanasia, correlating negatively with support for the practice.^{2,3,8,11,15,18,23,27,28,31,32}

However, many previous studies have inadequately considered the role of religion and therefore failed to fully reflect the great diversity and complexity of religion and religiosity in modern societies.^11,33,34 Moreover, the questions used to measure religion or religiosity have been too unspecific to yield significant results. The validity of these measures can be questioned due to the ambiguity of the used assessment criteria.^33,35 Hence, the relationship between nurses’ religiosity and their acceptance of euthanasia needs to be evaluated from a different, individual-oriented perspective. In this study nurses’ religiosity was understood as an interplay of five dimensions of religion: intellect, ideology, public practice, private practice and experience.^{11,30,33
–35} Furthermore, participants’ religiosity was evaluated in this study using the Centrality of Religiosity Scale (CRS), which is a multidimensional, internationally validated measurement tool.³⁵

Contradictions in previous literature

The results of previous academic studies concerning nurses’ attitudes towards euthanasia have been somewhat contradictory. This is partly explainable by cultural differences;^2,3,29 however, a wide range of definitions of euthanasia as well as the particular phrasing of addressed questions may also have caused discrepancies.^3,22 For example, a clear definition of euthanasia was lacking in some studies; moreover, some of the used definitions did not include the explicit request of the patient.^{7,15,29,31,32,36,37} In addition, different research methods and designs, including their diverse interpretations and assessments of respondents’ religiosity, make the comparison of results even more challenging.^11,33,34

Nevertheless, the previous literature does partially explain nurses’ attitudes towards euthanasia by way of several factors, including age, gender and educational level in general. Further factors of suggested relevance are professional experience (especially caring for terminally ill patients) and nurses’ own religiosity.^{2,3,8,12,16,18,23,27,29,31,36} Younger nurses are found to hold more supportive attitudes towards euthanasia than older ones.^2,18,23,36 Furthermore, males and higher educated nurses have reported more favourable attitudes towards euthanasia.^{5,23,27,28,38} Increasing work experience in general has been associated with more supportive attitudes towards euthanasia.^5,16 However, frequent contact with dying patients as well as growing knowledge and experience in palliative care seem to strengthen the disapproving attitudes towards euthanasia among registered nurses.^2,3,23,32,37

This study describes the attitudes of Finnish registered nurses towards euthanasia. Furthermore, this study explores connections between demographic and work-related factors and nurses’ euthanasia attitudes, with the ultimate aim to increase the understanding of this phenomenon.

Method

Instrument

In order to take cultural characteristics into consideration, an electronic questionnaire was designed for this study. The questionnaire consisted of four components: demographic characteristics, work-related characteristics, attitudes towards euthanasia and the CRS.

Demographic characteristics included the age, gender, marital status, most recent level of education and religious affiliation of the participant. Nurses were also asked if they had children and the region of their primary residence.

The work-related characteristics of the participants consisted of the particularities of their workplace – including the shift patterns worked (days and/or evenings, nights only, etc.) – details of work experience and information about the most common sort of patient under their care. Additionally, they were asked to assess their own expertise in pain management and end-of-life care with a four-step scale and to state how frequently they encounter dying or dead patients.

The development of statements regarding participants’ attitudes was based on previous literature.^2,23,27,39 Subsequently, a qualitative study was conducted among nurses.¹⁶ Based on these results and the literature, 13 statements were designed and discussed in an expert panel that included representatives of nursing science, medicine and theology. The nurses were asked to state their agreement with the statements using a 5-point Likert-type scale, where an increasing score indicated strengthening agreement. The fourth section of the questionnaire included the CRS, described in detail by Huber and Huber.³⁵ The CRS is available in three different lengths; the longest – CRS-15 – was used in this study due to the strong evidence of its reliability and validity.³⁵ The translation of the CRS from English to Finnish was made by the first author and discussed with the other authors. The document was subsequently translated back from Finnish to English by an authorized translator and compared with the original.

Prior to data collection, the questionnaire used in this study was thoroughly tested. In order to test the reliability and repeatability of the questionnaire, a test–retest study was conducted with 19 respondents. As a preliminary pilot study, the questionnaire was submitted to 91 nursing students in order to confirm the feasibility of the questionnaire. No changes were made to the statements based on the results of these tests. The data obtained in the pilot study were not included in this study.

Pearson’s correlation of the scores for attitudes towards euthanasia and the CRS ranged in the test–retest from 0.383 to 0.789 and from 0.620 to 0.936, respectively.

Data collection

The data were collected online over 4 weeks in October–November 2014. The study’s inclusion criteria were proficiency in the Finnish language, being a nurse and at least 18 years of age.

The number of qualified nurses in Finland is over 100,000, of which nearly 50,000 are members of the Finnish Nurses Association.^17,40 Members of the Association were informed about the study in the members’ bulletin (circulation 29,484) in October 2014. In addition, nurses were recruited via social media, with the help of the first author’s public blog, seven discussion boards, Facebook and Twitter.

Although using social media as an information channel is rather uncommon within nursing science, and may therefore raise questions of reliability, it provides access to a large population in diverse geographic areas.^41,42 It can also reach interested but unknown individuals, who may not otherwise be engaged within professional networks such as the Finnish Nurses Association.⁴² Hence, the broad and heterogeneous sample that is represented by participating nurses in this novel approach to recruitment may afford greater possibilities for generalizations, although the response rate cannot be calculated for this study.^41,42

Ethical considerations

Ethical approval (5/2014) was obtained in February 2014 from the Committee on Research Ethics of the university to which the authors were affiliated. The permission to use the CRS was obtained from its developer, S. Huber. Submission of the completed questionnaire was considered as the participant’s informed consent.⁴³ Due to the sensitive nature of the research topic, ethical considerations were particularly given to the participants’ anonymity, the voluntary nature of participation in the study and an unambiguous definition of euthanasia. The chosen strategy of data collection supported the anonymity of the participating nurses. The fact that nurses were able to complete the questionnaire at any time and place that they found convenient highlighted the fact that participation was voluntary. Additionally, these factors may have increased the authenticity of the responses and reduced the participants’ tendency to give answers that they considered to represent common and acceptable opinions.^18,41 To avoid the ambiguity that undermined previous studies, the term euthanasia was tightly defined as ‘a deliberate act intended to terminate the life of a person at his/her explicit request’ and placed before the statements regarding attitudes towards euthanasia.^3,13,16,22

Data analysis

Data analysis was conducted using SPSS 21 for Windows. Prior to the analysis, 26 records were removed due to missing information. At the individual level, the minimum amount of missing data was eight responses, with the exception of demographic and work-related characteristics. This resulted in a cut-off point of 28.5%.

The initial nine-category variable for the most recent level of education was recoded into six educational categories based on the International Standard Classification of Education (ISCED), 2011.

The scores of the five dimensions of religiosity of the CRS were computed deductively for each participant. Thereafter, nurses were categorized into the groups ‘highly religious’, ‘religious’ and ‘non-religious’ based on their total CRS scores.³⁵ Euthanasia attitudes (13 statements) in the final data were applied by principal component analysis (PCA) with orthogonal rotation (varimax) in order to reduce the number of statements. The conducted PCA revealed a weak communality (0.192) by statement 10 and weak correlations (0.038–0.193) by statements 3 and 13. The unambiguity of these statements was discussed among the authors, who decided to exclude these statements from the PCA.

Cronbach’s α was used to assess the reliability of the different components of the questionnaire.⁴⁴ The non-normality of the dependent variables was confirmed using the Kolmogorov–Smirnov test (p < 0.000) and histograms. The Mann–Whitney and Kruskal–Wallis tests were chosen to investigate the differences between the groups. p values of <0.05 were considered to indicate a statistical significance.⁴⁴

Results

Background information on participating registered nurses

In all, 1003 nurses completed the questionnaire used in this study. Their ages varied from 20 to 73 years (mean, 39.54; standard deviation (SD), 11.88). Participants represented all 19 regions of Finland, and in addition, six of them stated that their primary place of residence was abroad. Nurses were categorized into three groups according to their degree of religiosity (Table 1). The average work experience of this study’s participants in healthcare varied between 0 and 52 years (mean, 13.16; SD, 10.6). Most of them worked in specialized healthcare and encountered dying patients monthly or less frequently. Furthermore, the majority of the nurses in this study assessed their expertise as good in both pain management and end-of-life care (Table 2).

Table 1.

Characteristics of the participants.

	f	%
Age group (n = 1003)
20–29	266	26.5
30–39	256	25.5
40–49	240	23.9
50–59	187	18.6
60–69	52	5.2
>70	2	0.2
Gender (n = 1003)
Male	66	6.6
Female	933	93.0
Do not want to state	4	0.4
Marital status (n = 1000)
Single	152	15.2
Relationship	67	6.7
Cohabitation/marriage	676	67.4
Divorced	95	9.5
Widow	10	1.0
Parental status (i.e. having children? n = 995)
No	368	36.7
Yes	627	62.5
Latest education (n = 999)
Lower secondary education	13	1.3
Upper secondary education	8	0.8
Short-cycle tertiary education	227	22.7
Bachelor or equivalent level	614	61.5
Master or equivalent level	133	13.3
Doctoral or equivalent level	4	0.4
Religion (n = 998)
Buddhism	3	0.3
Islam	1	0.1
Lutheran	712	71.0
No religion	231	23.0
Orthodox	10	1.0
Other	39	3.9
Roman Catholicism	2	0.2
Religiosity (n = 1003)
Non-religious	424	42.3
Religious	510	50.8
Highly religious	69	6.9

Table 2.

Work-related characteristics of the participants.

	n	%
Work experience (n = 992)
0–9 years	449	44.8
10–19 years	265	26.4
20–29 years	164	16.4
30–39 years	99	9.9
40 years or more	15	1.5
Work place (n = 1002)
I do not work as a nurse	78	7.8
Secondary or tertiary healthcare	382	38.1
Deputizing for a nurse in different units	79	7.9
In a primary care hospital	118	11.8
In a healthcare centre	28	2.8
In a institution for older persons	96	9.6
In a private sector	77	7.7
Other	144	14.4
Working hours (n = 992)
Regular daytime job	235	23.4
Regular night work	17	1.7
Two-shift work	193	19.2
Three-shift work	468	46.7
I do not work as a nurse	79	7.9
Common patient (n = 936)
Child or adolescence	52	5.2
Working age	325	32.4
Older person	559	55.7
Encounter dying patients (n = 990)
Daily	72	7.2
Weekly	154	15.4
Monthly	300	29.9
Less than monthly	305	30.4
Never	159	15.9
Encounter death patients (n = 981)
Daily	5	0.5
Weekly	56	5.6
Monthly	221	22.0
Less than monthly	428	42.7
Never	271	27.0
Expertise in pain management (n = 990)
Very good	98	9.8
Good	657	65.5
Cannot say	152	15.2
Weak	76	7.6
Very weak	7	0.7
Expertise in end-of-life care (n = 991)
Very good	86	8.6
Good	586	58.4
Cannot say	199	19.8
Weak	112	11.2
Very weak	8	0.8

Nurses’ religiosity

The nurses’ scores on the CRS and its five dimensions ranged from 1.0 to 5.0, with higher scores indicating either a stronger level of overall religiosity or a stronger contribution of a given dimension to an individual’s religiosity, respectively.³⁵ The respondents’ mean religiosity score, based on their aggregate CRS scores, was 2.36 (SD, 0.93). The mean scores for the different components of the CRS were as follows: intellect, 2.41 (SD, 0.89); ideology, 2.89 (SD, 1.22); public practice, 2.12 (SD, 0.91); private practice, 2.29 (SD, 1.21); and experience, 2.10 (SD, 0.93).

Nurses’ attitudes towards euthanasia

The majority (74.3%) of the nurses in this study would accept euthanasia as a part of Finnish healthcare, and 68.7% of them consider it likely to be legalized in Finland in the future (Table 3). However, 37.8% of the participants were not sure if Finland would benefit from a law permitting euthanasia. Furthermore, 37% of the nurses in this study considered possible misuse as a reason for forbidding euthanasia. Still, euthanasia was regarded as a humane method of helping a sick person among 80% of the participants in this study. Most (81.9%) of the nurses believed that a person must have the right to decide on his or her own death; indeed, 77.4% of them considered it likely that they would make a request for euthanasia themselves in certain situations (Table 3).

Table 3.

Nurses’ attitudes towards euthanasia.

Statement	Strongly disagree, f (%)	Disagree, f (%)	Don’t know, f (%)	Agree, f (%)	Strongly agree, f (%)
1. I have enough information about euthanasia to take part in the discussion on the topic (n = 1003)	40 (4.0)	185 (18.4)	78 (7.8)	494 (49.3)	206 (20.5)
2. I find it easy to discuss euthanasia (n = 1003)	79 (7.9)	267 (26.6)	69 (6.9)	382 (38.1)	206 (20.5)
3. Euthanasia provokes strong reactions in me (n = 1003)	129 (12.9)	402 (40.1)	122 (12.2)	265 (26.4)	85 (8.5)
4. Euthanasia is a humane method to help a sick person (n = 1002)	60 (6.0)	63 (6.3)	73 (7.3)	343 (34.2)	463 (46.2)
5. A person must have the right to decide on his or her own death (n = 1002)	65 (6.5)	78 (7.8)	38 (3.8)	320 (31.9)	501 (50.0)
6. I accept euthanasia as a part of Finnish healthcare (n = 1001)	101 (10.1)	64 (6.4)	91 (9.1)	312 (31.1)	433 (43.2)
7. My attitude towards euthanasia is conflicting (n = 1001)	323 (32.2)	328 (32.7)	61 (6.1)	187 (18.6)	102 (10.2)
8. Euthanasia is reprehensible under any circumstances (n = 1000)	725 (72.3)	182 (18.1)	32 (3.2)	31 (3.1)	30 (3.0)
9. Finland would benefit from a law permitting euthanasia (n = 999)	92 (9.2)	73 (7.3)	214 (21.3)	319 (31.8)	301 (30.0)
10. Possible misconduct is a reason for forbidding euthanasia (n = 998)	194 (19.3)	284 (28.3)	149 (14.9)	225 (22.4)	146 (14.6)
11. I consider it likely that euthanasia will be legalized in Finland in the future (n = 1002)	43 (4.3)	137 (13.7)	133 (13.3)	423 (42.2)	266 (26.5)
12. I consider it likely that I myself would make a request for euthanasia in a certain situation (n = 1001)	87 (8.7)	59 (5.9)	79 (7.9)	309 (30.8)	467 (46.6)
13. When assessing suffering, mental and physical anguish are equal (n = 999)	55 (5.5)	162 (16.2)	122 (12.2)	329 (32.8)	331 (33.0)

The conducted PCA yielded two components with eigenvalues of 4.89 and 1.45, explaining 63.4% of the total variance. The first component was further divided in two based on the content of its included statements. The final PCA results suggest that the first component represents the acceptance of euthanasia, the second component represents the legalization of euthanasia and the third component represents euthanasia-related communication (Table 4). The scores for each component ranged between one and five, with higher scores indicating greater agreement with the statements included in that component. The mean scores for each of the euthanasia-related subareas were as follows: 4.03 for acceptance of euthanasia, 3.98 for legalization of euthanasia and 3.53 for euthanasia-related communication (Table 4).

Table 4.

Summary of PCA of attitudes towards euthanasia.

Component	Loadings
Acceptance of euthanasia (α: 0.91, M: 4.03, SD: 1.01)
Euthanasia is a humane method to help a sick person	0.87
A person must have the right to decide on his or her own death	0.84
I accept euthanasia as a part of Finnish healthcare	0.90
I consider it likely that I myself would make a request for euthanasia in a certain situation	0.80
Legalization of euthanasia (α: 0.69, M: 3.98, SD: 0.87)
Euthanasia is reprehensible under any circumstances	0.72
Finland would benefit from a law permitting euthanasia	0.80
I consider it likely that euthanasia will be legalized in Finland in the future	0.61
Euthanasia-related communication (α: 0.62, M: 3.53, SD: 0.95)
I have enough information about euthanasia to take part in the discussion on the topic	0.78
I find it easy to discuss euthanasia	0.65
My attitude towards euthanasia is conflicting	0.54

α: Cronbach’s α; M: mean; SD: standard deviation.

With the exception of primary place of residence, all factors of demographic and work-related data were examined for their possible influence on nurses’ attitudes towards euthanasia. Participants’ marital and parental status, religion, religiosity and work experience had a statistically significant connection with the acceptance of euthanasia (Table 5), legalization of euthanasia (Table 6) and euthanasia-related communication (Table 7). Single nurses were more in favour of euthanasia than other groups; they also reported the strong support for the legalization of euthanasia, whereas the support of widows and widowers was the weakest. Widows and widowers were also least prone to euthanasia-related communication or acceptance. Those nurses who had children were less approving of euthanasia and its legalization; they also reported more negative attitudes towards euthanasia-related communication compared to the childless nurses in this study. Participants with no religion reported greater acceptance of euthanasia and its legalization than those professing a religion. Furthermore, they supported euthanasia-related communication more than most of the other groups. Similarly, highly religious nurses opposed euthanasia and its legalization the most, whereas non-religious participants were most in favour of both. Euthanasia-related communication was also most supported within the non-religious nurses and least within the highly religious participants in this study (Table 7). Nurses with the least work experience held the most favourable attitudes towards euthanasia and its legalization. The most experienced participants, however, reported the strongest support for euthanasia-related communication (Table 7).

Table 5.

Statistical significant means of acceptance of euthanasia.

	M	SD
Marital status (n = 1000), p < 0.001
Single (n = 152)	4.40	0.82
Relationship (n = 67)	4.28	0.87
Cohabitation/marriage (n = 676)	3.92	1.11
Divorced (n = 95)	4.04	1.16
Widow (n = 10)	3.55	1.53
Having children (n = 995), p < 0.001
No (n = 368)	4.26	0.9
Yes (n = 627)	3.90	1.15
Religion (n = 998), p < 0.001
Buddhism (n = 3)	4.08	0.88
Islam (n = 1)	1.25	–
Lutheran (n = 712)	3.94	1.11
No religion (n = 231)	4.39	0.79
Orthodox (n = 10)	3.93	1.17
Other (n = 39)	3.66	1.42
Roman Catholicism (n = 2)	2.75	1.77
Religiosity (n = 1003), p < 0.001
Non-religious (n = 424)	4.39	0.71
Religious (n = 510)	3.96	1.02
Highly religious (n = 69)	2.30	1.52
Work experience (n = 992), p < 0.001
0–9 years (n = 449)	4.21	0.93
10–19 years (n = 265)	4.00	1.14
20–29 years (n = 164)	3.87	1.13
30–39 years (n = 99)	3.62	1.28
40 years or more (n = 15)	3.87	1.19
Latest education (n = 999), p < 0.001
Lower secondary education (n = 13)	4.33	1.00
Upper secondary education (n = 8)	4.38	0.76
Short-cycle tertiary education (n = 227)	3.76	1.25
Bachelor or equivalent level (n = 614)	4.16	0.96
Master or equivalent level (n = 133)	3.82	1.19
Doctoral or equivalent level (n = 4)	3.88	1.09
Age group (n = 1003), p < 0.001
20–29 (n = 266)	4.31	0.80
30–39 (n = 256)	4.13	1.00
40–49 (n = 240)	3.92	1.12
50–59 (n = 187)	3.76	1.26
60–69 (n = 52)	3.64	1.36
70 < (n = 2)	2.75	2.12

M: mean.

Table 6.

Statistical significant means of legalization of euthanasia.

	M	SD
Marital status (n = 1000), p < 0.001
Single (n = 152)	4.22	0.72
Relationship (n = 67)	4.25	0.71
Cohabitation/marriage (n = 676)	3.90	0.87
Divorced (n = 95)	3.93	0.96
Widow (n = 10)	3.57	1.27
Having children (n = 995), p < 0.001
No (n = 368)	4.13	0.75
Yes (n = 627)	3.90	0.91
Religion (n = 998), p < 0.001
Buddhism (n = 3)	4.56	0.38
Islam (n = 1)	1.67	–
Lutheran (n = 712)	3.92	0.90
No religion (n = 231)	4.20	0.71
Orthodox (n = 10)	3.77	0.83
Other (n = 39)	3.74	0.92
Roman Catholicism (n = 2)	3.83	0.24
Religiosity (n = 1003), p < 0.001
Non-religious (n = 424)	4.10	0.70
Religious (n = 510)	3.95	0.82
Highly religious (n = 69)	2.92	0.21
Work experience (n = 992), p = 0.012
0–9 years (n = 449)	4.09	0.76
10–19 years (n = 265)	3.99	0.88
20–29 years (n = 164)	3.84	0.97
30–39 years (n = 99)	3.75	0.95
40 years or more (n = 15)	3.91	0.68
Latest education (n = 999), p = 0.001
Lower secondary education (n = 13)	4.44	0.66
Upper secondary education (n = 8)	4.50	0.44
Short-cycle tertiary education (n = 227)	3.82	0.96
Bachelor or equivalent level (n = 614)	4.06	0.79
Master or equivalent level (n = 133)	3.78	0.97
Doctoral or equivalent level (n = 4)	4.00	0.15
Age group (n = 1003), p = 0.001
20–29 (n = 266)	4.14	0.69
30–39 (n = 256)	4.07	0.81
40–49 (n = 240)	3.88	0.93
50–59 (n = 187)	3.84	0.97
60–69 (n = 52)	3.74	0.98
>70 (n = 2)	2.50	0.71

M: mean; SD: standard deviation.

Table 7.

Statistical significant means of euthanasia-related communication.

	M	SD
Marital status (n = 1000), p = 0.030
Single (n = 152)	3.69	0.98
Relationship (n = 67)	3.66	0.90
Cohabitation/marriage (n = 676)	3.47	0.94
Divorced (n = 95)	3.62	0.95
Widow (n = 10)	3.20	1.10
Having children (n = 995), p = 0.045
No (n = 368)	3.62	0.90
Yes (n = 627)	3.48	0.97
Religion (n = 998), p < 0.001
Buddhism (n = 3)	3.67	1.20
Islam (n = 1)	2.00	–
Lutheran (n = 712)	3.46	0.93
No religion (n = 231)	3.76	0.95
Orthodox (n = 10)	2.97	0.99
Other (n = 39)	3.62	1.06
Roman Catholicism (n = 2)	2.33	0.47
Religiosity (n = 1003), p < 0.001
Non-religious (n = 424)	3.71	0.94
Religious (n = 510)	3.37	0.92
Highly religious (n = 69)	3.56	1.07
Work experience (n = 992), p = 0.049
0–9 years (n = 449)	3.57	0.93
10–19 years (n = 265)	3.56	0.96
20–29 years (n = 164)	3.54	0.96
30–39 years (n = 99)	3.25	0.97
40 years or more (n = 15)	3.69	0.96
Expertise in pain management (n = 990), p < 0.001
Very good (n = 98)	3.98	0.89
Good (n = 657)	3.52	0.93
Cannot say (n = 152)	3.40	0.99
Weak (n = 76)	3.27	0.93
Very weak (n = 7)	3.38	0.97
Expertise in end-of-life care (n = 991), p < 0.001
Very good (n = 86)	3.88	0.98
Good (n = 586)	3.53	0.96
Cannot say (n = 199)	3.47	0.94
Weak (n = 112)	3.29	0.83
Very weak (n = 8)	3.79	0.94

M: mean; SD: standard deviation.

Moreover, nurses’ latest educational attainments and age were significantly connected with the subareas of euthanasia acceptance (Table 5) and its legalization (Table 6). Nurses’ self-assessed expertise in pain management and end-of-life care both displayed statistically significant connections to their attitudes towards euthanasia-related communication (Table 7).

The religiosity of the participants correlated most strongly with euthanasia acceptance, followed by legalization of euthanasia and euthanasia-related communication. The dimension of public practice correlated most strongly with acceptance of euthanasia, whereas the correlations between the dimensions of religiosity and euthanasia-related communication were weak (Table 8).⁴⁴

Table 8.

Correlations between the dimensions of religiosity and euthanasia-related subareas.

	Euthanasia acceptance	Legalization of euthanasia	Euthanasia-related communication
Religiosity	−0.473**	−0.354**	−0.139**
Intellect (Cronbach’s α = 0.86)	−0.409**	−0.310**	−0.099**
Ideology (Cronbach’s α = 0.93)	−0.396**	−0.291**	−0.129**
Public practice (Cronbach’s α = 0.90)	−0.482**	−0.360**	−0.144**
Private practice (Cronbach’s α = 0.90)	−0.447**	−0.331**	−0.133**
Experience (Cronbach’s α = 0.93)	−0.362**	−0.279**	−0.139**

**Correlation is significant at the 0.01 level.

Discussion

Our results reveal that the majority of Finnish nurses share approval attitudes towards euthanasia and its legalization. Furthermore, most of the nurses in this study considered that they had enough information about euthanasia and were confident in discussing this topic.

Acceptance of euthanasia

The younger nurses reported greater acceptance of euthanasia than the older ones in our results, which is in line with previous studies.^2,18,23,36 Due to the missing statistical significance of the relationship between gender and all euthanasia-related subareas, our results do not confirm findings from previous literature that suggest males to be more in favour of euthanasia than females.^5,8,23,28 Interestingly, in our study, the nurses with a lower educational level were more prone to accepting of euthanasia than those with higher educational levels. This result does not support the previous literature that suggests more positive attitudes towards euthanasia are shared among people with a higher educational level.^5,27,38 Nurses’ work experience showed a statistically significant relationship with all of the euthanasia-related subareas in our results, which is in line with previous studies.^5,16 However, it is important to notice that the mean scores of different groups are relatively close to each other and they do not grow in linear fashion. Therefore, this relationship should be interpreted tentatively. The age of a person is commonly connected with their work experience. Young nurses are, for example, usually also the least experienced ones, which means that the effect of age may be reflected in work experience. Furthermore, the frequency of providing care for dying patients was not a statistically significant factor for acceptance of euthanasia or any other euthanasia-related subarea in our results. Although the previous literature suggests that frequent contact with dying patients and expertise in palliative care tend to be connected with increased rejection of euthanasia, our results do not confirm these statements.^2,3,23,32,37

The results of our study demonstrate further the statistically significant relationships between the attitudes towards euthanasia and marital status as well as having children. The former showed widows and widowers to have the most negative attitudes in all three euthanasia-related subareas. Widows and widowers represent the group of individuals that has personally experienced the death of a loved one and the grief which is attached to this loss. This may influence their attitudes towards euthanasia. On the other hand, having children is ordinarily connected with a strong emotional relationship and feelings of responsibility that usually impact the worldview of parents. It may be that nurses, like healthcare personnel in general, are more aware of the unexpected and unpredictable nature of life – including the negative aspects of it – than professionals in other areas. This awareness may explain the stronger rejection of euthanasia among nurses who have children compared with childless ones.

The minority of the nurses in this study considered possible misuse to be grounds for forbidding euthanasia; in addition, less than 1 out of 10 believes euthanasia to be reprehensible under any circumstances. Both attitudes indicate that rather weak support is given to the ‘slippery slope’ argument. Moreover, they indicate that the nurses in our study do not completely share the concerns presented in the international literature.^{2,12,16,22,24,28}

Legalization of euthanasia

A statistically significant connection between age and legalization of euthanasia was found in our results, and we are thus able to confirm previous findings in this matter.²³ However, our results did not reveal a statistically significant relation between nurses’ self-assessed expertise in end-of-life care and their attitudes towards legalization of euthanasia. This is contradictory with the literature that suggests greater experience in end-of-life care is related with rejection of legalization of euthanasia.^2,23,32,37 At the same time, this result supports findings where this relationship was not found to be significant.^2,22 Previous findings have indicated a negative correlation between expertise in pain management and support of the legalization of euthanasia.²³ Our results do not support these findings.

Euthanasia-related communication

Communication with the patient and the relatives is an essential part of nursing, especially at the end of life. Dying patients often feel themselves to be lonely due to the lack of conversation about the nature of existence and death itself.^9,10,45

According to our results, both inexperienced and the most experienced nurses viewed euthanasia-related communication positively. This may be seen as contrary to a previous study that states euthanasia to be a frightening topic of discussion for many and hence something to be avoided.¹⁶

Statistically, expertise in pain management or end-of-life care was found to be significantly related to the euthanasia-related communication but not to the other subareas in our study. This raises some questions that would require further research in order to be answered.

The relationship between nurses’ religiosity and euthanasia-related attitudes

In our results, nurses’ religiosity had a statistically significant, negative correlating relationship with all euthanasia-related subareas, which is in line with previous literature.^{2,3,8,10,11,18,23,31,32} In this study, however, participants’ religiosity was measured with an internationally validated scale, which takes the different dimensions of religiosity into account.³⁵ This strengthens our results and underlines the efforts we made to capture the true influence of religiosity on the nurses’ euthanasia-related attitudes.⁵ Nevertheless, the correlations between the various dimensions of religiosity and euthanasia-related communication as well as the legalization of euthanasia were ultimately all rather unsatisfactory. Even the strongest correlation (between the public practice of religion and acceptance of euthanasia) was only moderate.⁴⁴ Despite their respective weaknesses, these correlations indicate that religiosity forms a concrete relationship with an individual’s attitude to euthanasia, provided that all of its dimensions are taken into account in the evaluation.

Respect for autonomy and fear of death

A person’s right to decide on his or her own death and euthanasia’s role as a humane method to help a sick person found strong support among the nurses in this study. This finding supports the presented arguments of the proponents of euthanasia in previous literature^16,22,25,27 and emphasizes the nurses’ obligation to alleviate pain as stated in the ethical codes for nurses.^19
–21

Our results further confirm the value of self-determination and the ability to choose the moment and manner of one’s death, which seems to be shared among our participants. Many of them agreed strongly that they would probably request euthanasia for themselves under certain circumstances, which can be seen as an additional confirmation of respect for the autonomy of an individual.^19
–21 On the other hand, nurses encounter different kinds of deaths in their professional lives, but it may still be largely separated from their private day-to-day existence. Therefore, many of them may have become estranged from the concept and consequently frightened of a difficult and painful death. This may explain some nurses’ support for euthanasia: the prospect of requesting euthanasia may ease personal fears and give the illusion of being able to have complete control over their lives, including the time and manner of their own death.

Limitations

The validity of this study was evaluated based on the used questionnaire, recruitment strategy and the sample. Three statements regarding the attitudes towards euthanasia yielded test–retest scores below 0.5, which indicate only moderate correlation⁴⁴ and may thus limit the questionnaire’s reliability. Previous studies have, however, shown that euthanasia arouses strong feelings.¹⁸ Thus, participation in this survey may have provoked unusually deep thought processes which subsequently affected some respondents’ answers in the second round. The used sampling strategy resulted in a large and heterogeneous sample. However, nurses who had no computer or Internet connection were excluded, as is the case for all web-based surveys.^41,42 In order to examine the reliability of using social media as a recruitment channel, the data of this study were compared with the data of a previous study conducted using a random sample derived from the national register of the Finnish Nursing Association.¹⁸ The comparison showed that these two data sets do not differ from each other regarding the distribution of gender or the mean age of the participating nurses. Furthermore, it is worth noting that the participants were asked about their most recent, and not their highest, achieved level of education. This may have influenced the assessment of the relationship between educational level and nurses’ attitudes towards euthanasia. Although this is a genuine limitation, its practical relevance was estimated to be very small.

Implications for practice and future research

The knowledge produced in this study may be utilized in nursing education and in discussions about the ethical issues at the end of life at both individual and societal levels. However, more research is needed about the factors influencing nurses’ attitudes towards euthanasia. Moreover, additional statistical analyses, for example, multivariate analysis, should be used in future research in order to gain deeper understanding of the relations between attitudes and the factors influencing them.

Conclusion

This article reveals a marked conflict between nurses’ attitudes towards euthanasia and the ethical guidelines that underpin the nursing profession. Contrary to the profession’s ethical codes, many nurses seem to consider euthanasia as an acceptable alternative in accordance with the ethical principle of beneficence. In light of this evident tension, the authors of this article strongly suggest that maintaining an open and continuous dialogue about euthanasia and the values prevailing within nursing as a profession – as well as among nurses themselves – is crucial.

Footnotes

Acknowledgements

The authors would like to express their gratitude to all of the participants in this study, without whom this article would not exist. Furthermore, they thank the statistician Marja-Leena Lamidi for supporting them with her expertise during the data analysis.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the OLVI-Foundation, the Foundation of Municipal Development and the doctoral programme of the University of Eastern Finland. The authors acknowledge the support for this study through the first author’s involvement (via participation in the summer school) in the European Science Foundation Research Network Programme ‘REFLECTION’ – 09-RNP-049. However, the views expressed in this article are those of the authors and not those of the European Science Foundation. The funders had no role in study design, data collection and analysis, the decision to publish or the preparation of the manuscript.

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