Nursing and euthanasia: A narrative review of the nursing ethics literature

Medical assistance in dying

Medical Assistance in Dying was legalized in Canada in 2016 by an amendment to the Criminal Code that removed its prohibition. This legalization, which allows Nurse Practitioners to be both assessors and providers of Medical Assistance in Dying, was the catalyst for the current review. Under the Canadian legislation, two actions to medically aide the dying are permissible: (1) administering a substance to a person at their request that causes their death (commonly referred to as euthanasia) or (2) prescribing or providing a substance to a person at their request so that they may self-administer the substance and in so doing cause their own death (commonly referred to as assisted suicide). ¹ To date, seven countries around the world offer a type of euthanasia. ² As in Canada, the Netherlands, Belgium, Columbia and some US states have adopted assistance in dying into law. In others (i.e. Switzerland, Luxembourg), medical procedures that aid-in-dying have been decriminalized or are allowable under certain, predetermined circumstances. ²

In Canada, the term Medical Assistance in Dying was chosen carefully to reflect Canadian context and values. However, terminology around the world varies to reflect the specific practices in that country. For example, physician-euthanasia is the terminology used in the United States, a term which reflects the limits of a client-administered death. Euthanasia is the term used most commonly in the international context. Specifically, euthanasia is defined as an ‘active and intentional act of putting to death, in a relatively painless way, of persons suffering severely from medical conditions that are incurable, untreatable, or irreversible…at that person’s explicit request’ (para. 1). ³ In this article, the term euthanasia will be used to represent euthanasia, medical assistance in dying and assisted suicide or physician-euthanasia.

Euthanasia in relationship to nursing practice

The legalization of euthanasia has presented regulated nurses with a complex array of ethical and moral decisions as they relate to determining one’s level of involvement in this new care option. At one end of the spectrum is full conscientious objection, whereby nurses choose to be relieved of all care for reasons related to preserving moral integrity. At the other end of the spectrum is full involvement in the euthanasia process. In between are levels of involvement in care which may, or may not, be directly related to the actual provision of euthanasia (e.g. ongoing care for persons receiving euthanasia and bereavement support for family). ⁴ Although the right for nurses to conscientiously object is enshrined in Canadian law, ¹ regulatory policies specify that this act cannot be taken lightly. For example, the regulatory document for nurses in Manitoba suggests that a position of conscientious objection should only be taken based upon long and deeply held values and beliefs. ⁵ Furthermore, nurses have a commitment to proactively inform employers of their conscientious objection, preferably prior to the start of a new employment contract. ⁴ In Canada, health region policies may require nurses to remain involved in euthanasia in non-related care even if they do conscientiously object to euthanasia. This requires nurses to engage in thoughtful and dedicated periods of reflection about their ability to participate, or not, in euthanasia.

Evidence from nurses’ experiences with euthanasia in countries outside of Canada suggests that this can be a rewarding, albeit morally complex, ambiguous and emotionally laden experience. ⁶ A recent publication detailing nurses’ involvement with euthanasia in the first 6 months of its implementation in the Canadian context offered similar findings. ⁷ In light of the moral and ethical complexity of this act, a number of authors have encouraged nurses to engage in discussions around euthanasia. ^8,9 To do so, nurses require knowledge of the issues they should be considering, time to reflect on the breadth of the issues at hand and a substantive body of literature to draw upon to stimulate reflection. The most recent review of the ethical literature we could locate was published in 2009. This was an arguments-based review of the ethical literature and nurses’ involvement in euthanasia (1987–2007). ¹⁰ Our article provides a narrative review of the ethical arguments surrounding euthanasia in relationship to nursing practice which includes papers published up to 2018.

Nature of nursing

Twenty-three articles provided ethical arguments for and against euthanasia based upon the nature of nursing. Of these 23 articles, 14 focused exclusively on a nursing standpoint and nine discussed the nursing standpoint alongside other arguments (e.g. principle-based, societal consequences). Eleven articles did not take a position in relation to euthanasia, nine argued against and three argued for. Three assumptions about the nature of nursing were used to position arguments related to euthanasia: the nature of nursing’s moral ontology; nurses’ unique relational space with patients; and the consequence of euthanasia on nurses’ personhood and nursing as a profession.

The first set of assumptions concerned the nature of nursing’s moral ontology. As Mathes ¹⁷ asked, ‘is there something intrinsic to the nursing role that makes it ethically impermissible for a nurse to aid a patient in committing suicide even if the suicide itself were ethically acceptable?’ (p. 262). For example, in arguing against euthanasia, Ferrell and Rivera (citing Coyle) ¹⁸ appealed to nursing’s tacit values of alleviating suffering, preserving dignity, addressing meaningfulness, guarding sanctity of life and acting with compassion. ¹⁹ Compassion was commonly cited as a foundational and enduring nursing value that could be used to argue both for and against euthanasia. ^{20 –22} This ontological morality of nursing was further described as altruistic beneficence in which the nurse’s goal is to work on behalf of the good of their patients and to avoid doing harm; again an argument that could be used to support positions both for and against euthanasia. ^20,23 These values were accompanied by moral goals of practice that included improving patient quality of life; ^19,22 healing; ^{17,22,24 –26} and preserving, protecting and respecting life. ^24,27,28 Those against euthanasia argued that euthanasia, as the act of killing, is a violation of this ontological morality and so nurses should not take part. In taking part, nursing as a discipline would be perceived as killers rather than healers resulting in the erosion of public trust. ^20,27,29,30

However, in defence of euthanasia, White ³¹ argued that this ontological morality is subject to interpretation. She stated that there is justified harm in the context of nursing practice, that nursing’s social trust might include euthanasia if the public sees it to be in its best interest and that euthanasia could be viewed as relieving pain and suffering. As such, White argued that, although there may be an ontological morality, how that morality works itself out in practice is subject to interpretation. This argument was revealed in the way that authors used common concepts, such as compassion, to argue for different end points.

Likewise, Newham ³² argued against an ‘internal morality’ (p. 109) of nursing on the basis that there is no agreed upon outcome or ‘end of nursing’ (p. 115). Without a definitive end of nursing, it is impossible to have an internal morality robust enough to address challenging ethical problems. Rather, he suggested that any claim to an internal morality is most useful as a ‘heuristic for people entering the profession of nursing’ (p. 115). Ultimately, he argued that the ‘moral agent is and must be one person’ (p. 115).

Others questioned whether the moral ontology of nursing remains stable or should respond to social change. For example, in arguing against euthanasia, McCabe ²⁵ suggested that nurses must resist a social contract in which nursing becomes nothing more than a profession which adheres to patient wishes in the guise of autonomy. Without explicitly arguing a position in regard to euthanasia, Thiele and Dunsford ²⁶ argued that nursing’s ontology needs to be fluid in response to a changing world.

A second set of assumptions that had implications for nurses’ ethical relationship to euthanasia was the nature of the nurse–patient relationship. Several authors opposing euthanasia argued that nurses have a unique relationship with patients because of the intense and continuing nature of their interaction. This relationship was characterized as genuine, caring, founded on mutual respect and inclusive of family as the unit of care. ¹⁹ Exemplary relationships are characterized by nurses’ abilities to see patients as persons, by the ability to generate meaning for both patients and nurses, ³³ and by a duty of promise-keeping or faithfulness. ³⁴ Without coming to a position, Wurzbach discussed the implications of nurses being the ones who ‘stay with patients’ ³⁵ during the dying process. Furthermore, nurses are viewed as ‘chief witnesses’ ¹⁹ in that they can understand the context within which patients make medical decisions ^19,36 and so can advocate on behalf of their patients to the larger team. ^19,36 However, this unique relationship was seen to have unique challenges in the context of euthanasia. Young, ³⁷ citing Jameton, ³⁸ described this as the ‘nurse in the middle’ (p. 12) phenomenon whereby nurses have a responsibility for care that does not match their power to influence decisions about care. In the context of euthanasia, she acknowledged the paradox that although nurses do not order medication for symptom management, they are in the position of delivering and titrating that medication to alleviate suffering. A nurse in the middle may be the ‘chief witness’ ¹⁹ to suffering without the means to relieve that suffering. As such, euthanasia may have unique moral implications for nurses. The acknowledgement of this special relationship between nurses and patients was used to argue both for ^30,36 and against ^19,33 euthanasia.

The third assumption in this body of literature was the potential impact that engaging in euthanasia could have on the nursing profession and on nurses’ personhood. In her argument for euthanasia, Young ³⁷ suggested that a nurse’s integrity is an essential part of professional practice. As such, nurses must do the difficult work of examining ‘competing demands carefully and making decisions that are congruent with their personal beliefs and within professional guidelines’ (p. 12). Beyond that, she argued that professional integrity must support patient self-determination and hence, requests for euthanasia. In contrast, Zimbelman and McCabe ³⁹ argued that professionalism means much more than simply supporting autonomy through state-enacted legislation. Arguing against euthanasia, Zimbelman suggested that nursing is a social institution whose ‘power, status, [and] role’ (p. 164) in society must transcend both individual interests of its practitioners and private choices of patients. ⁴⁰ Without arguing a position in relation to euthanasia, other authors suggested that euthanasia may have consequences that could exacerbate the sense of failure and loss that nurses often feel after a patient death, ⁴¹ or harm nurses if their values and beliefs are challenged or ignored, ²¹ which in turn, can affect the nature of the nurse–patient relationship.

Ethical principles, concepts and theories

Eighteen articles drew upon ethical principles, concepts and theories to provide arguments for or against the ethical permissibility of euthanasia in the context of nursing practice. The majority of articles grounded ethical arguments and discussions in one or more of the four main tenets of biomedical ethics: autonomy, beneficence, nonmaleficence and justice. ⁴² Four authors argued in support of euthanasia, six were in opposition and the remaining eight authors took no position. Articles that provided a descriptive overview will be addressed first, followed by articles that argued using principle-based ethics and finally, articles that drew upon ethical theories, such as consequentialism, virtue ethics, relational ethics and care ethics.

Four articles addressed focused ethical questions by providing a descriptive landscape of the ethical principles, concepts and theories that are being discussed in the existing literature on euthanasia in the context of nursing practice. ^{43 –46} Interestingly, the majority of arguments raised within this body of literature presented what Snelling ⁴⁷ would call ‘intuitive arguments’; opinions related to ‘feelings’, such as mercy, ‘understanding that sometimes death is preferable to life’ (p. 352), respecting autonomy, and, conversely, ‘the feeling that it is wrong to kill’ (p. 352). All four articles incorporated – to varying degrees – Beauchamp and Childress’ ⁴² principles for biomedical ethics into their respective discussions on euthanasia from a nursing perspective. In two of the four articles, the main tenets of biomedical ethics were presented in a way that elucidated the tension and malleability that exists within and between the principles. ^43,46 For instance, Benedict et al. ⁴³ highlighted the tension that exists between respecting an individual’s autonomous decision to request euthanasia and upholding one’s professional duty to prevent harm. Other ethical issues raised included arguments related to ethical concepts, such as the sanctity of life, quality of life, suffering, pain management and the ‘slippery slope’. ^i,44,45

Nine articles drew upon principles of biomedical ethics to construct arguments for and against the justification of euthanasia in the context of nursing practice. Most often, arguments in favour of euthanasia were grounded in rights-based language; for example, the ‘right to die’, the ‘right to self-determination’, ⁴⁸ or the ‘right to die with dignity’. ⁴⁹ A number of authors argued that upholding an individual’s right to die fosters human flourishing and in turn, facilitates a dignified and autonomous death. ^21,48,50,51 These arguments can be summarized by the perspective that respect for persons requires respect for individuals’ autonomous decision-making. ²¹ Such arguments are predicated on the belief that individuals’ ‘own’ their death, just as they have ‘owned’ their life. ^21,50,51 For instance, Farsides ⁵¹ argued that requests for euthanasia are not an indication of failure of healthcare professionals’ abilities to provide care, but rather an expression of autonomy or the right of an individual to make a ‘choice that they consider consistent with the person that they are and the life that they have led’ (p. 104). However, despite a firm commitment to upholding patient autonomy, a number of authors acknowledged and indeed emphasized, that the principle of autonomy ought not to be considered in isolation, such that it is seen without any limits. ^21,50 For example, Begley, ⁵⁰ as well as Kopala and Kennedy, ²¹ emphasized that, in upholding a patient’s autonomous decision to participate in euthanasia, the autonomy of the healthcare provider who is involved in caring for that patient must also be respected. As Begley ⁵⁰ stated, ‘…consenting adults should not be prevented from availing themselves of beneficent voluntary active euthanasia if another consenting [emphasis added] adult (a medical doctor) is available and capable of carrying out their wishes’ (p. 224). This perspective takes into consideration that the involvement of at least one other person is required should an individual seek to end his or her life through euthanasia. ⁵²

Conversely, a number of authors provided arguments in opposition to euthanasia, using the principle of autonomy to highlight their view that other biomedical principles, such as nonmaleficence and beneficence, ^21,53,54 can outweigh an individual’s claim to self-determination. For instance, in an argument against the absolutism of autonomy, and in particular, against obligations to always fulfil autonomous requests, Friend ⁵³ argued,

[i]ndividual autonomy is not a supreme ethical doctrine and does not deserve to be weighted more heavily than the physician’s duty to ‘above all do no harm’. Although respect for patient self-determination is important, especially when deciding to withhold and withdraw life-sustaining treatments, it does not mandate a right that others help them end their lives. (p. 115)

Kopala and Kennedy, ²¹ Kowalski, ²⁹ and King and Jordan-Welch ⁵⁴ put forth arguments which refuted the claim that requests for euthanasia are part of a truly autonomous and rational decision-making process. For example, instead of seeing requests for euthanasia as extensions of a patient’s right to self-determination, King and Jordan-Welch argued that an individual’s true autonomy is upheld when nurses help patients to find meaning in life even in times of suffering and when nurses explore questions such as ‘why is the patient asking for assistance in dying?’ (p. 52). ⁵⁴

Five articles drew upon ethical theories to discuss euthanasia in the context of nursing practice. Two authors raised consequentialist arguments. ^47,56 Snelling ⁴⁷ discussed the contradictory nature of absolute deontological positions (i.e. referring to the law in the United Kingdom), which claim that consideration of consequences cannot justify killing in the form of euthanasia because it is always morally wrong to kill an innocent life. In particular, he contended that the credibility of the prohibition against euthanasia depends on distinguishing it from other legally and morally sanctioned end-of-life care practices (i.e. omissions, refusal of extraordinary measures or letting die). These distinctions depend on consequentialist considerations so it is inconsistent to claim that the prohibition on euthanasia cannot consider consequences. Snelling ⁴⁷ argued that just as increased doses of opioids (at levels that are potentially life-shortening) can be morally and legally acceptable under certain conditions, so might be an injection of potassium chloride (i.e. a lethal injection). In each circumstance, the consequences have been weighed, a thoughtful decision to shorten the individual’s life has been reached, and in the end ‘the consequences are the same’ (p. 356). ⁴⁷ In contrast, Praskwiecz ⁵⁵ focused on the sub-category of assisted suicide, which she defines as requiring ‘both patient request and patient action’ (p. 37), to contrast to some forms of euthanasia. She ⁵⁵ contended that some moral justification for assisted suicide might be provided by act utilitarianism – a consequentialist theory whereby the consequences of an action are weighed in the context of a particular situation. Praskwiecz ⁵⁵ argued that, because the consequences of legalized assisted suicide are difficult to fully understand and predict, rule utilitarian analysis cannot determine whether legalization would lead to ‘maximum balance of good over evil’ (p. 38) ^54,55 and, thus is ethically unjustified from a rule utilitarian perspective. Praskwiecz ⁵⁵ further argued that assisted suicide could not be justified by Kantian or natural law theories, and concluded that nurses should focus on other approaches to improving end-of-life care.

From another ethical perspective, Begley ⁵⁷ suggested that, in comparison to a strictly principled approach to analysis, a virtue ethics approach to analysing euthanasia widens the field of moral appraisal. Indeed, she argued that in virtue terms, euthanasia facilitates ‘eudaimonia (living well, flourishing) because dying is a life event, and not dying well frustrates the goal of flourishing and well-being for both client and professional’ (p. 441). ⁵⁷ In a different, albeit not entirely unrelated argument, Rich and Butts ⁵⁸ suggested that coherence in ethical positions opposing and supporting euthanasia can be achieved through an ethic of care. In opposition to a more legalistic approach inherent in absolutist principles, an ethic of care invites nurses and other healthcare providers to consider ‘where boundaries lie in the imposition of one’s morality on others’ (p. 275) ⁵⁸ when we ‘care’ for another person. For instance, if the act of caring involves ‘feeling with’ the other (Noddings, ⁵⁹ as cited in Rich and Butts), ⁵⁸ euthanasia can be ethically justified if the actions of the individual requesting aid in dying are rational and do not infringe on the rights of others. ⁵⁸ Finally, in an application of the four core elements of relational ethics – mutual respect, engagement, environment and embodiment – Thiele and Dunsford ²⁶ argued not about the ethical or moral permissibility of euthanasia, but rather, how relational ethics can provide nurses and nurse leaders with a framework for thinking through the moral complexity that has accompanied the legalization of euthanasia in Canada. ²⁴

Moral consistency

Seven articles examined the ethical permissibility of euthanasia from the perspective of moral consistency across acts. Such arguments sought to elucidate the moral difference, if any, between one practice and another related practice. Five authors sought to clarify the moral distinction between a ‘passive’ and ‘active’ euthanasia through an examination of the role of causation, and more specifically, the philosophic differences between ‘killing’ and ‘letting die’, ^41,47 and in some cases, using the acts and omissions doctrine. ^47,52,60,61 In addition, a number of authors examined the role of intention – either in isolation or alongside other arguments. ^47,52,56,61 From the standpoint of consistency (i.e. if one type of euthanasia is ethically justified, then why isn’t the other), five of the seven authors argued in support of euthanasia, one author argued against and another author did not take a position on the topic.

Several articles sought to elucidate the moral difference between ‘killing’ versus ‘letting die’ ^47,62,41 or, as Dines ⁶⁰ refers to it, ‘killing’ versus ‘going along with nature’. Such arguments often centred on the ambiguous nature of what ‘letting die’ or ‘going along with nature’ entailed, and in particular, how it is morally distinct from an act that also causes death, albeit in a more direct way. For instance, Dines ⁶⁰ argued that the moral distinction between causing death and ‘going along with nature’ is not a ‘water tight barometer of moral acceptability’ (p. 914), and that if it were, then many attempts to redress suffering (i.e. pain and symptom management) would be immoral as a result of their unnatural interference with the dying, or indeed living, process. Kuhse ⁶² argued to a similar position; however, she arrived at more of a direct conclusion,

you may refuse treatment and then ‘nature’ will look after the rest – you will be dead in a few hours, a few days, or at the very latest in a few weeks, [this] is an approach unfit for a humane and rational society. It imposes on those patients a mode of dying that they find unacceptable, much unnecessary suffering, and all that for no good reason. (p. 12)

Four authors examined the role of direct versus indirect intention, and more specifically, the doctrine of double effect. ^47,52,56,61 The doctrine of double effect seeks to describe the circumstances in which harmful actions (or omissions) are permitted ‘in the overall pursuit of good’ (p. 355). ⁴⁷ However, in order to satisfy these requirements – so as to justify the ‘two effects of one act (or omission)’ (p. 870) ⁵² – the following conditions must be met:

1. The action itself must not be intrinsically bad; 2. The good effect must not be a direct consequence of the bad effect; 3. The good effect must be ‘directly intended’; the bad effect only ‘indirectly intended’, or ‘tolerated’; 4. The good effect must be equal to or greater than the bad effect. (p. 85) ⁶⁵

Nature of the social good

Six articles raised ethical questions in relation to the possible impact that the legalization of euthanasia might have on society more broadly. By ‘social good’, we are referring to what is perhaps more commonly known as ‘the common good’: ‘those facilities – whether material, cultural or institutional – that the members of a community provide to all members in order to fulfill a relational obligation they all have to care for certain interests that they have in common’ (para. 1). ⁶⁶ Four of the six articles argued against euthanasia based upon the nature of the social good, while two articles did not take a position on the topic.

Articles in this theme focused on questions such as ‘does assisted suicide harm society?’ (p. 22). ²¹ Central to many of these arguments was an exploration of the existing social context upon which euthanasia would be layered. For instance, authors examined how existing social fragilities, such as vulnerable populations, ^21,27,46,67 fragmented healthcare teams, ⁶⁷ threats of cost containment, ^18,21,27,67 poor public understanding of euthanasia, ⁶⁷ and perceptions of burden at the end-of-life, ^21,27,67 would be affected should euthanasia be legalized. A number of articles examined the intersection of such concerns. For instance, Ericksen et al. ⁶⁷ argued that in an era of cost containment, euthanasia policies put vulnerable groups, such as the disabled, women, older people and the impoverished, at an ever-heightened risk for exploitation and harm. The authors stated, ‘there is a very real danger that patients and their family members will opt for euthanasia because of inadequate resources for care rather than because of well-informed, autonomous decision-making’ (p. 32). ⁶⁷ This concern for resources was echoed by Goodman ⁵⁶ who situated her argument within the good of palliative care. She questioned the rightness of alleviating suffering through euthanasia when many patients and families do not have access to high-quality palliative care or understand its goal of improving quality of life. Throughout these articles, there was a recognition of the complexity of interacting factors that would ultimately influence the goodness of euthanasia in a social context.