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Nursing Ethics
DOI: 10.1177/0969733007086016
2008; 15; 186 Nurs Ethics
Ruud ter Meulen
Ada van Bruchem-van de Scheur, Arie van der Arend, Frans van Wijmen, Huda Huijer Abu-Saad and
Dutch Nurses' Attitudes Towards Euthanasia and Physician-Assisted Suicide
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Nursing Ethics 2008 15 (2) © 2008 SAGE Publications 10.1177/0969733007086016
Address for correspondence: Ada van Bruchem-van de Scheur, Department of Health, Ethics &
Society, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Tel: ⫹ 31 43
38 82 145; Fax: ⫹ 31 43 38 84 171; E-mail: a.vanbruchem@zw.unimaas.nl
DUTCH NURSES’ATTITUDES TOWARDS
EUTHANASIA AND
PHYSICIAN-
A
SSISTED S
UICIDE
Ada van Bruchem-van de Scheur, Arie van der Arend,
Frans van Wijmen, Huda Huijer Abu-Saad
and Ruud ter Meulen
Key words: attitudes; decision making; euthanasia; nurses; physician-assisted suicide
This article presents the attitudes of nurses towards three issues concerning their role
in euthanasia and physician-assisted suicide. A questionnaire survey was conducted
with 1509 nurses who were employed in hospitals, home care organizations and nurs-
ing homes. The study was conducted in the Netherlands between January 2001 and
August 2004. The results show that less than half (45%) of nurses would be willing to
serve on committees reviewing cases of euthanasia and physician-assisted
suicide. More than half of the nurses (58.2%) found it too far-reaching to oblige
physicians to consult a nurse in the decision-making process. The majority of the nurses
stated that preparing euthanatics (62.9%) and inserting an infusion needle to adminis-
ter the euthanatics (54.1%) should not be accepted as nursing tasks. The findings are
discussed in the context of common practices and policies in the Netherlands, and a
recommendation is made not to include these three issues in new regulations on the
role of nurses in euthanasia and physician-assisted suicide.
Introduction
Conceptual issues
In this study, euthanasia was defined as the administration of drugs by a person other
than the patient with the explicit intention of ending the patient’s life at his or her
explicit request. Physician-assisted suicide was defined as the prescribing or supply-
ing of drugs with the explicit intention of enabling the patient to end his or her own
life. The concepts are different in the way in which they are carried out.
In euthanasia, someone administers the euthanatics. In physician-assisted suicide, the
patient himself or herself takes the lethal drugs as prescribed by the physician. In this
study, euthanasia and physician-assisted suicide are considered as one phenomenon.
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Nurses’ attitudes towards euthanasia and physician-assisted suicide 187
Nursing Ethics 2008 15 (2)
The Dutch law on euthanasia and physician-assisted suicide
After 30 years of public discussion in the Netherlands, the Law on the Termination
of Life on Request and Assisted Suicide (Euthanasia Act) came into force in April
2002. This states that physicians who perform euthanasia or assist in a suicide are
exempt from prosecution and punishment if their actions meet two conditions:
1) They fulfil the due care requirements that stipulate the physician must: (a) be
convinced that the patient’s request is voluntary and well considered; (b) be
convinced that the patient’s suffering is hopeless and unbearable; (c) have informed
the patient about his or her situation and prospects; (d) be convinced, together
with the patient, that there is no other reasonable solution; (e) have consulted
at least one other independent physician, who has also seen the patient, and has
provided a written assessment of the due care requirements listed in points a–d
above; and (f) have carried out euthanasia or assisted in the suicide with due
medical care.
2) They report an unnatural death to the municipal coroner and submit a reasoned
report on the euthanasia or physician-assisted suicide to a regional euthanasia
review committee. This committee will consist of a legal expert, a physician and
an ethicist, and will assess whether the physician has complied with the due
care requirements of the law.
1
Attitudes of nurses
The number of publications about the attitudes of nurses towards euthanasia is
increasing. Verpoort et al.
2
conducted a literature review, which included 15 relevant
documents published between 1990 and 2002. An important obstacle to inclusion was
authors’ definition of euthanasia. In all retrieved articles, euthanasia had illegal over-
tones during the data gathering, including the Dutch study by The.
3
However, while
The
3
was carrying out her study, euthanasia was decriminalized if physicians ful-
filled ‘the due care requirements’. Euthanasia was still illegal during later quantita-
tive studies carried out by Ryynänen et al.
4
among physicians, nurses and the general
public in Finland, and qualitative studies by Verpoort et al.
5
and Dierckx de Casterlé
et al.
6
among palliative care nurses.
In the nursing literature,
2,4–6
attitudes are related to two main themes: the legal-
ization of euthanasia with arguments for or against its justification
2,4,5
and the
involvement of nurses in the various stages of the euthanasia process of request,
6
decision making,
6
administration
2,6
and aftercare.
6
In some articles characteristics are identified that influence nurses’ opinions, such
as age,
2,4
religion
2,4
and nursing specialty.
2
This complex reality of attitudes has been
further developed by Berghs et al.
7
These authors found that age, nursing specialty
and religion have important roles in the formation of arguments for or against
euthanasia. For example, younger nurses tended to accept euthanasia more often
than older nurses. Part of the complexity of nurses’ attitudes arises out of their need
for education in: palliative care, communication skills, giving a place to emotions,
decision making, ethical guidelines, professionalism and policymaking.
In the Netherlands, not much was known about the attitudes of nurses with regard
to the acceptability of euthanasia and their role in euthanasia and physician-assisted
suicide. Only a few studies indirectly paid attention to the attitudes of nurses in this
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188 A van Bruchem-van de Scheur
Nursing Ethics 2008 15 (2)
area. In The’s study,
3
nurses were asked how they viewed their tasks, and in the
study by Van de Scheur and Van der Arend,
8
nurses were asked to identify their
ideal role in euthanasia.
Although studies into attitudes of nurses with regard to their role may help to
define the future role of nurses in euthanasia and physician-assisted suicide, in the
Netherlands joint guidelines for physicians and nurses have played an important
part in clarifying nurses’ role.
9
These guidelines describe the collaboration and
demarcation of tasks between physicians and nurses in the various stages of the
euthanasia process.
Apart from the general need to clarify the role of nurses in euthanasia and
physician-assisted suicide, the Dutch nursing associations raised three particular
issues:
1) With the establishment of five regional euthanasia review committees in 1998,
discussion arose about whether nursing should be represented on these com-
mittees.
2) During debates related to the Bill on the Termination of Life on Request and
Assisted Suicide, the question was raised whether consultation with nurses dur-
ing the decision-making process should be added to physicians’ due care
requirements.
3) After the Law on the Termination of Life on Request and Assisted Suicide came
into force in April 2002, a debate developed about whether nurses should be
allowed to carry out activities such as preparing the euthanatics and inserting
an infusion needle for their administration.
However, the Minister of Health decided that, before any decision could be made
about legislation or regulation of the role of nurses in euthanasia, their actual role
should be clarified. For this reason, the Minister commissioned a study into the role of
nurses in medical end-of-life decisions in hospitals, home care and nursing homes. Van
Bruchem-van de Scheur et al.
10
described the results of this study in an extensive
report (in Dutch) to the Minister, and have since published an article on the role of
nurses in euthanasia and physician-assisted suicide in home care.
11
Although the
study focused on actual practice, the nurses were additionally asked for their atti-
tudes to the three issues noted above, which are now reported in this article.
Method
Aim
The aim of the study was to investigate the role, perceptions, responsibilities and
problems of nurses in medical end-of-life decisions in order to advise the Dutch gov-
ernment on legislation and policymaking concerning the role of nurses.
Design
The role of nurses in medical end-of-life decisions in Dutch hospitals, home care
organizations and nursing homes was investigated using both qualitative and quan-
titative research methods. During the qualitative phase of the study, nurses were
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interviewed to explore their practices and attitudes concerning a number of issues
about euthanasia and physician-assisted suicide. The interview data contributed
significantly to the construction of a questionnaire used for the quantitative phase
of the study, especially with regard to the actual role of nurses. Qualitative data
about their attitudes were less useful because of limitations in number and scope.
A well-considered attitude was often lacking, and some issues appeared to be very
remote from the nurses’ daily practice.
The quantitative data are presented in this article, thus the methodological
description concerns the quantitative part of the study.
Recruitment of participants
All general and academic hospitals, all accredited home care organizations, all nurs-
ing homes caring for medical patients and combined nursing homes (medical and
psychogeriatric patients) in the Netherlands were approached by telephone with a
request to participate in the study.
A total of 488 institutions were approached; 191 agreed to participate: 73 hospitals,
55 home care organizations and 63 nursing homes.
Reasons given for non-participation were: workload; other priorities; being
swamped with studies; reorganization; sensitivity of the subject; no interest among
nurses; no nurses employed in the organization; participation in other studies; sick-
ness of the manager; research fatigue; a policy on euthanasia was in the making,
therefore the organization considered itself not suitable for participation; no or rare
experience with requests for euthanasia/physician-assisted suicide, which in a num-
ber of cases were related to the philosophical character of an organization and/or
the philosophy of life of the patient population.
Contact persons in the organizations recruited the respondents. The research
group held the view that a randomly drawn sample would give a limited response
to the study and therefore decided that the research sample should consist only of
nurses with experience with euthanasia or physician-assisted suicide.
The inclusion criteria were that respondents:
1) Had more than two years’ working experience as a registered nurse;
2) Had more than two years’ bedside experience;
3) Were employed for at least 50% of a full-time working week;
4) Had experienced a request for euthanasia or physician-assisted suicide and/or
its administration no more than two years previously.
This last criterion was expected to be critical in the search for a sufficient number of
respondents. However, the Dutch study among physicians by Van der Wal and Van der
Maas
12
indicated that, in 1995, 9700 explicit requests for euthanasia or physician-assisted
suicide were made known, of which an estimated 3600 (37.1%) were performed.
The contact persons recruited 1509 nurses, who all received a questionnaire. The
absolute response rate was 82.0%, and 78.1% (1179) were suitable for analysis (i.e.
questionnaires with at least one section that could be used for analysis).
There was an expected poor recruitment of nurses in nursing homes. Qualified
caregivers were therefore recruited in such homes if they worked as team leaders or
co-ordinators.
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190 A van Bruchem-van de Scheur
Nursing Ethics 2008 15 (2)
Data collection
Data were collected by questionnaire in 2003. The results of the qualitative study,
data from previous studies, and insights from ethics and law, formed the basis of
the questionnaire used in this quantitative study.
In order to promote content validity, the questionnaire was presented to a num-
ber of experts in the different fields. It was then tested in a pilot study among 106
nurse volunteers. Their response rate was 85%. The research team discussed the out-
comes of the questionnaire, adapted it where necessary, and again tested it with
three more nurses.
The final version of the questionnaire was divided into two parts. Part one, the
most extensive, concerned euthanasia and physician-assisted suicide. The second
part dealt with issues of pain and other symptom control that had as an additional
aim the ending of a patient’s life. Both parts indicated the types of medical decisions
made at the time.
In addition to questions on the actual role of nurses in euthanasia and physician-
assisted suicide, the participants were also asked for their attitudes regarding that
role, including their participation in the reviewing process, their role in the phys-
ician’s decision-making process, and their involvement in preparatory activities for
the administration of euthanatics.
Validity and reliability
Much attention was paid to interpretation of the different types of medical end-of-
life decisions by respondents in order to improve the validity of the results. The
qualitative study and the pilot study were important in reducing variation in the
respondents’ interpretation of such decisions in the survey.
Because of the variety of organizations, their national spread, and the large number
of nurses involved in this study, the results were considered to be representative of
Dutch nurses who have had experience with euthanasia and physician-assisted suicide.
Ethical considerations
The research ethics committee of the Academic Hospital Maastricht and Maastricht
University approved the study.
As the subject was considered to be highly sensitive, participation was promoted
by the guarantee of anonymity for both organizations and respondents, and by con-
tact persons as well as respondents receiving a copy of a letter from the Minister of
Justice in which participation was recommended and the explicit promise was given
that respondents were protected against criminal prosecution if they disclosed infor-
mation on illegal practices.
Data analysis
The data were analysed using SPSS version 11.5 for Windows. The questionnaire
included a relatively large number of open answer categories and open questions.
These answers were recorded in a text file and subsequently numerically coded to
allow analysis. They were very helpful for extracting additional data and interpreting
the results.
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Results
Characteristics of respondents
A total of 1179 of the returned questionnaires included at least one section useful
for analysis. In almost all the questionnaires (1172) the section on attitudes could be
analysed. The largest group of respondents (527) were employed in hospitals, fol-
lowed by 407 in home care, and 238 in nursing homes.
The demographic characteristics of the respondents are shown in Table 1. Most
respondents (87.9%) were women, with the highest percentage working in home care
(92.4%). Respondents’ ages ranged from 21 to 63 years (mean 40.6); and the highest
percentage of respondents aged 50 or more worked in home care. The respondents
had a mean of 16.5 years’ work experience as registered nurses/qualified caregivers,
with the longest work experience being in home care (mean 19.4 years).
The inclusion criteria stipulated more than two years’ working experience as a
registered nurse/qualified caregiver, but 18 respondents (1.5%) had less than two
years’ working experience. However, the research team decided to include these
questionnaires for analysis because of their utility.
Membership of nurses on regional euthanasia review committees
The nurses held diverging opinions about membership of regional euthanasia review
committees: 45% out of the 1172 nurses supported membership of nurses on these com-
mittees, 8.9% were against, and 41.6% had no opinion about the issue (Table 2).
Differences between the work sectors were relatively small.
Table 1 Demographic characteristics of respondents
Characteristic Hospital Home care Nursing home Total
% (n ⫽ 527) % (n ⫽ 407) % (n ⫽ 238) % (n ⫽ 1172)
Sex
Female 85.6 92.4 85.3 87.9
Male 14.4 7.6 13.9 11.9
Unknown – – 0.8 0.2
Age (years)
21–29 25.2 10.8 17.6 18.7
30–49 58.8 59.7 61.8 59.7
50–65 15.9 29.0 20.2 21.3
Unknown – 0.5 1.4 0.3
Mean (range) 38.2 (21–59) 43.8 (22–63) 40.4 (22–61) 40.6 (21–63)
Working experience (years)
⬍2 1.9 1.0 1.7 1.5
2–9 35.3 14.7 29.8 27.0
10–24 44.4 48.4 45.0 45.9
ⱖ25 18.0 34.9 22.7 24.8
Unknown 0.4 1.0 0.8 0.7
Mean (range) 14.5 (0–38) 19.4 (1–41) 16.2 (0–40) 16.5 (0–41)
Nurses’ attitudes towards euthanasia and physician-assisted suicide 191
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192 A van Bruchem-van de Scheur
Nursing Ethics 2008 15 (2)
The nurses’ responses showed that many of them had insufficient knowledge to
discuss the issue adequately. This was confirmed by the answers to another question,
for which 35.5% of nurses did not know what disciplines were represented on regional
euthanasia review committees, and 12.5% had never heard of such representation.
A legal regulation to oblige physicians to consult a nurse
Almost a quarter (22.6%) of the nurses approved of the proposal to regulate phys-
icians’ obligation to consult a nurse before making their decisions about situations
where a nurse is involved in the daily care of the patient (Table 3). More than half
of the nurses (58.2%) found this too far-reaching, while 14.0% had either an unclear
opinion or an opinion with an unclassifiable meaning. The differences between the
work sectors were not large.
Preparatory activities for the administration of euthanatics
A minority (40.8%) of nurses stated that inserting an infusion needle to administer
euthanatics could be an acceptable nursing task (Table 4). A majority (54.1%) believed
that this should not be part of their role. There were considerable differences
between home care and nursing homes on one hand, and hospitals on the other.
Almost one third (31.9%) of the nurses stated that preparing euthanatics could be
an acceptable nursing task, while the majority (62.9%) were opposed to this (Table 5).
Considerable differences existed between nurses working in home care and nursing
homes on one hand, and hospitals on the other.
Discussion
Membership of nurses on regional euthanasia review committees
Although the nurses’ professional organizations were promoting the participation of
nurses on regional euthanasia review committees, only a minority of those (45%) in
our study were in favour of such membership. Their associations argued that nurses
should be represented on review committees because of their wide experience in
observing and supporting patients. Their membership would be an acknowledge-
ment of the fact that nurses observe from close quarters how patients come to their
Table 2 Necessity of nurses’ membership of regional euthanasia review committees
Response Hospital Home care Nursing home Total
% (n ⫽ 527) % (n ⫽ 407) % (n ⫽ 238) % (n ⫽ 1172)
Yes 47.6 43.5 41.6 45.0
No 8.9 8.1 10.5 8.9
No opinion 39.7 42.5 44.2 41.6
Unclear 2.2 2.7 1.7 2.3
Unknown 1.5 3.2 2.1 2.2
(Adapted from Van Bruchem-Van der Scheur et al.,
10
with permission.)
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decision to request euthanasia. Nurses are well-trained professionals and their
expertise and experience should be used.
13
This study confirms the view that nurses
in general are closely involved in the provision of care and support for patients
requesting euthanasia or physician-assisted suicide. However, the task of regional
euthanasia review committees is to consider only the question of whether physi-
cians have followed the due care requirements, and not to evaluate the process of
care and support of patients given by nurses. Their evaluation concerns the legal
and moral assessment of a medical action, not the ‘ethics of care’. Nurses may there-
fore be involved in such committees but they have no specific tasks in law that
would make their presence necessary.
The relatively high percentage (41.6%) of nurses with no opinion about nurses’
membership of regional euthanasia review committees may therefore show that the
issue is of only moderate interest. However, this is probably only one part of the
argument because such issues demand close study before a well-considered point
Table 5 Preparing euthanatics as a task for nurses
Response Hospital Home care Nursing home Total
% (n ⫽ 527) % (n ⫽ 407) % (n ⫽ 238) % (n ⫽ 1172)
Yes 39.3 24.8 27.7 31.9
No 55.2 71.3 65.5 62.9
No opinion 0.9 2.2 5.5 2.3
Unknown 4.6 1.7 1.3 2.9
(Adapted from Van Bruchem-van der Scheur et al.,
10
with permission.)
Table 3 Necessity for a legal regulation to oblige physicians to consult a nurse in
the decision-making process
Response Hospital Home care Nursing home Total
% (n ⫽ 527) % (n ⫽ 407) % (n ⫽ 238) % (n ⫽ 1172)
Yes 26.8 18.2 21.0 22.6
No 53.5 64.4 58.3 58.2
No opinion 4.2 3.2 7.1 4.4
Unclear
a
14.8 13.5 13.0 14.0
Unknown 0.8 0.7 0.4 0.7
a
Or an opinion with an unclassifiable meaning.
(Adapted from Van Bruchem-van der Scheur et al.,
10
with permission.)
Table 4 Inserting an infusion needle to administer euthanatics as a task for nurses
Response Hospital Home care Nursing home Total
% (n ⫽ 527) % (n ⫽ 407) % (n ⫽ 238) % (n ⫽ 1172)
Yes 54.8 28.0 31.5 40.8
No 41.7 66.3 60.9 54.1
No opinion 0.9 3.2 6.3 2.8
Unknown 2.5 2.5 1.3 2.3
(Adapted from Van Bruchem-van der Scheur et al.,
10
with permission.)
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194 A van Bruchem-van de Scheur
Nursing Ethics 2008 15 (2)
of view can be developed. From a perspective of knowledge it is not surprising that
these nurses indicated no opinion. Other data from our study showed that nurses
in general lack sufficient knowledge on the subject of euthanasia and physician-
assisted suicide.
A legal regulation to oblige physicians to consult a nurse
A majority of the nurses (58.2%) did not consider it necessary to make consultation
with a nurse a legal requirement for physicians’ decision making. These nurses
showed that the decision to grant euthanasia or physician-assisted suicide is a med-
ical one and that a line should be drawn between their areas of responsibility and
those of physicians. The nurses may have been aware of the heavy responsibility of
physicians in this instance and did not want to interfere by formalizing their input
in the decision-making process.
However, there are also practical objections to coercing physicians into consulting
a nurse. Such legal constructs may become problematic if the situations on which
they are to decide constantly change. Problems of interpretation may easily arise, for
example, with regard to unsound definitions or differences of opinion on who is the
nurse ‘involved’ and whether he or she should represent only his or her own opin-
ion or also those of other nurses who had taken part in caring for the patient.
Nevertheless, involvement by nurses in the decision-making process is still prefer-
able, as also stated in joint guidelines for physicians and nurses:
when a nurse is involved in the daily care of a patient who made a request for
euthanasia, it is highly desirable that the nurse is involved in the decision-mak-
ing process. Because of her daily involvement and her specific expertise, she
could contribute to a careful decision-making by the physician.
9
Reference to this role is made on the form that physicians are obliged to complete
and to send to the regional euthanasia review committee after performing euthana-
sia or physician-assisted suicide. Physicians are explicitly asked: ‘Did you consult the
nursing staff/the patient’s carers about terminating the patient’s life? If so, who did
you consult and what was their view? If not, why not?’
Nurses observe and experience patients daily and have contact with relatives.
Their contribution may therefore also concern the social and psychological aspects
of a request for euthanasia or physician-assisted suicide. Nurses may be able to
answer questions such as:
1) Is the patient’s request voluntary and well considered?
– Nurses could check whether the request actually originated with the patient
himself or herself. Relatives and others may have influenced the patient’s feel-
ings and opinions about terminating his or her life. This may happen, for
instance, when relatives are no longer able to cope with the situation.
2) Could there be a hidden appeal for help? Reasons could be related to:
– Physical aspects, such as pain, breathlessness, urinary or faecal incontinence,
or ulcerating tumours;
– Mental aspects, such as fear of future suffering, fear of the unknown, depres-
sion, confusion;
– Social aspects, such as loneliness, feeling a burden to relatives, quarrelling;
– Spiritual aspects, such as feelings of aimlessness, bitterness, loss of meaning.
14
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By their professional involvement, nurses may provide essential information in
the decision-making process that may substantially differ from information held by
physicians.
Here the Dutch situation differs from that in Belgium, where the legal regulation of
euthanasia stipulates that a physician must discuss a patient’s euthanasia request with
members of the nursing team who are directly involved in caring for the patient.
15
However, to date no Belgian evaluation data have become available on this issue.
Preparatory activities for the administration of euthanatics
The majority of nurses stated that inserting an infusion needle (54.1%) and prepar-
ing euthanatics (62.9%) are not part of their tasks. A frequent argument among
nurses is about preparatory activities being part of the administration of euthanatics.
The underlying idea is that those who carry out the activity should also make the
preparations. The fragmentation of tasks could cause confusion about responsibil-
ities. Another explanation could be that nurses consider preparation for the action
too emotionally draining, given its ultimate aim.
The percentages obtained for this issue were much lower in hospitals compared
with home care organizations and nursing homes. One explanation for this differ-
ence may be that preparatory activities are more common nursing activities in hos-
pitals than elsewhere.
One of the due care requirements in the Dutch Euthanasia Act stipulates that
physicians carry out termination of life or assist in a suicide, with due medical care.
This clarifies that the administration of euthanatics is the exclusive task and respon-
sibility of physicians. Delegation of this task to a nurse is not legal. Nurses who
administer euthanatics or assist in a suicide risk both criminal prosecution and dis-
ciplinary measures.
Competence with regard to preparatory activities has not been laid down in law.
Physicians and nurses have established their views in joint guidelines.
9
A distinction
is made there between various preparatory activities: preparing euthanatics is not con-
sidered a task for nurses, but inserting an infusion needle could be a task for nurses.
The guidelines also state that collaboration between physicians and nurses should
be transparent: it is recommended that physicians supply a written assignment to
nurses in which openness is observed with regard to the intended euthanasia. This
gives nurses the opportunity of appealing to conscientious objection if they wish to
do so, and/or assessing whether they are able to assist in the euthanasia. Preferably,
nurses who carry out preparatory activities have also been involved in the decision
making around the euthanasia request. When this is not possible, nurses should be
sufficiently previously informed about the patient by physicians.
The insertion of an infusion needle by nurses often seems a pragmatic choice. An
inexperienced physician could always ask a pharmacist to dissolve the solution in
advance. However, inserting an infusion needle may create serious practical prob-
lems to physicians, especially those who are insufficiently skilled in this activity, such
as general practitioners in the Dutch health care system. In these cases, nurses may
be asked to insert the infusion needle but there are doubts whether this is morally
acceptable. It is argued that physicians, and not nurses, should carry out this
preparatory activity because of several contentions.
First, euthanasia and physician-assisted suicide do not belong to regular medical
practice. Consequently, nurses’ activities in this area are not regular practice either,
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196 A van Bruchem-van de Scheur
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even when they concern only preparatory activities. Such activities have an extra-
ordinary moral character that, strictly speaking, falls outside the professional domain
of physicians and nurses. Nevertheless, although they may be practised under cer-
tain conditions, they remain the exclusive task and responsibility of physicians.
Second, from the perspective of article 33 in the Individual Health Care
Professions Act,
16
the area of expertise of nurses is deemed to cover: ‘performing
procedures in the areas of observation, monitoring, nursing and care; [and] on the
instructions of an individual health care professional, performing procedures accord-
ing to the professional’s diagnostic and therapeutic work.’
16
Because euthanasia and physician-assisted suicide are neither diagnostic nor thera-
peutic procedures, preparatory activities in this area do not belong to the profes-
sional responsibility of nurses.
Third, the national code of ethics for nurses and caregivers,
17
which describes the
moral aspects of professional practice, states that the work of nurses and caregivers
aims to promote and maintain health, to prevent illness and disability, to contribute
to restoring health, and to relieve suffering and discomfort. This description excludes
the ending of life of patients as the work of nurses and other caregivers.
When nurses refuse to insert an infusion needle for this purpose, they can appeal
to their professional responsibility with regard to these three points. Nurses have
the right to refuse such activities by means of conscientious objection. The Dutch
national code of ethics for nurses and caregivers
17
states that nurses or caregivers
may refuse (assistance with) activities if these bring them into serious conflict with
their personal philosophy of life or sense of values and norms.
It should be noted that nurses, when requested by physicians, may be competent
and are allowed to insert an infusion needle for regular medical indications or inter-
ventions. When the same infusion system is later used for administering euthanatics,
inserting such infusion needles is not counted as an activity preparatory to euthana-
sia. The activity of the nurse is not in any sense related to the administration of the
euthanatics.
Conclusion
This article raises new questions concerning the role of nurses in euthanasia and
physician-assisted suicide. As no similar studies have been identified in the litera-
ture, the results cannot be compared with data from elsewhere.
The findings show differences between work sectors, especially in the issue of
preparative activities. This concerns a concrete activity for which skills and work
practice influence the attitude of nurses.
With regard to issues such as a legal regulation to oblige physicians to consult a
nurse in the decision-making process and the involvement of nurses in regional
euthanasia review committees, the differences between the health care work sectors
were small and a relatively large number of nurses did not have an opinion on these
topics or had an unclear opinion. This is understandable because these issues, espe-
cially involvement of nurses in regional euthanasia review committees, are far
removed from daily practice and require close study for developing an opinion. Based
on our findings it could be suggested that the nurses gave their opinions about
specific issues, but they had insufficient knowledge to discuss them adequately,
which might have biased the results.
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All respondents had experience of requests for euthanasia or physician-assisted
suicide and/or its administration. Although not studied, it is conceivable that such
practical experience influenced the attitude of the nurses.
The findings also indicated that the nurses hesitated to extend their role into the
issues described. The research team did not discern any necessity to extend the role
of nurses, partly because the professional responsibility of Dutch nurses is laid down
by law. However, this does not change the fact that nurses could have an important
role in the various stages of the processes of euthanasia and physician-assisted suicide.
Discussion of the three issues may have relevance for a wider audience than in
the Netherlands. It may help nurses in other countries where these issues may
become legalized to define their role in euthanasia and physician-assisted suicide.
Acknowledgements
We thank the Dutch Ministry of Health, Welfare and Sports, who funded the study.
We also express our thanks to the nurses who participated, and to those whose prac-
tices and attitudes formed the core of our study.
Ada van Bruchem-van de Scheur, Arie van der Arend and Frans van Wijmen, Maastricht
University, Maastricht, The Netherlands.
Huda Huijer Abu-Saad, American University of Beirut, Beirut, Lebanon.
Ruud ter Meulen, University of Bristol, Bristol, UK.
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