Nurses’ attitudes towards euthanasia: a cross-sectional study in Iran

The present study aimed to examine Iranian Muslim nurses’ attitudes towards euthanasia. The Euthanasia Attitude Scale (EAS) was used to assess the nurses’ attitude towards euthanasia. The majority of Muslim nurses were found to have negative attitudes to euthanasia. We recommend that future studies should be conducted to examine Muslim nurses’ attitudes to euthanasia in different cultures to determine the role of culture and religious beliefs in attitude to euthanasia.

494 International Journal of Palliative Nursing 2015, Vol 21, No 1
© 2015 MA Healthcare Ltd
Abstract
Aim: Nurses have an important role in caring for terminally ill patients.
They are often confronted with euthanasia but little is known about
their attitudes towards it. The present study aimed to examine Iranian
Muslim nurses’ attitudes towards euthanasia. Methods: In this
exploratory cross-sectional study, all qualified registered nurses working
in two teaching hospitals (Kashani and Hajar hospitals) in Iran were
invited to participate. The Euthanasia Attitude Scale (EAS) was used to
assess the nurses’ attitude towards euthanasia. Of 266 nurses who fit
the criteria, 190 participated in the study (response rate 72.9%); 91.1%
(n=173) were female and 8.9% (n=17) were male. Results: In total,
57.4%, 3.2% and 39.5% of nurses reported a negative, neutral and
positive attitude to euthanasia respectively. Nurses reported most
negative attitude to domain ‘practical consideration’ with mean of
2.36±0.9 and most positive attitude to the domain ‘treasuring life’ with a
mean EAS score of 2.85±0.4. Conclusion: The majority of Muslim
nurses were found to have negative attitudes to euthanasia. We
recommend that future studies should be conducted to examine Muslim
nurses’ attitudes to euthanasia in different cultures to determine the
role of culture and religious beliefs in attitude to euthanasia.
Key words: Euthanasia l Nurses l Muslim l Religion
l End-of-life care
This article has been subject to double-blind peer review.
With the expertise and medical technol-
ogy available in today’s world, most
diseases can be treated, extending
human lifespan and creating a number of moral
and ethical problems (Zarghami et al, 2009;
Tang et al, 2010; Kamath et al, 2011;
Aghababaei, 2014). One of the most important
topics related to these problems is that of eutha-
nasia, a subject that has received attention of
experts from varied disciplines (Zarghami et al,
2009; Mousavi et al, 2011; Aghababaei, 2014).
Euthanasia has been classified as either ‘active’
or ‘passive’ (Parpa et al, 2010; Aghababaei,
2014). In the active type, the patient is the deci-
sion-maker and would ask the physician to end
his/her life, which is done by an ‘act’ such as
injection of a lethal medicine. For example the
physician injects a quick-acting sedative intrave-
nously followed by a paralytic agent to halt res-
piration (Aghababaei, 2014). Active euthanasia
may be voluntary (when the patient has
requested to end their life), involuntary (when
the patient has expressed a wish to the contrary),
or non-voluntary (when the patient who is being
killed has made no request to end their life)
(Rastegari et al, 2010). In the passive type, the
patient would refuse his treatment to hasten
death without any specific activity to end life
(Aghababaei, 2014).
As part of the health-care team, nurses have an
important role caring for terminally ill patients.
They are often confronted with euthanasia but
little is known about their attitudes towards it
(De Bal et al, 2006; Inghelbrecht et al, 2009;
Moghadas et al, 2012). In this regard, Ryynänen
et al (2002) conducted a study in Finland, exam-
ining physicians, nurses and the general publics’
attitude towards physician-assisted suicide, active
voluntary euthanasia and passive euthanasia in
five imaginary patient scenarios (incurable cancer,
severe dementia, mental retardation, depression
and paralysis). In Finland, assisted suicide is not
considered a crime under the Penal Code
(Ministry of Social Affairs and Health, 2012).
The results showed that passive euthanasia was
largely accepted among Finnish medical profes-
sionals and the general public. Their study also
showed that all forms of euthanasia were more
often accepted among nurses with a higher level
of religious beliefs compared to other nurses
(Ryynänen et al, 2002).
Similar to Netherlands and Luxembourg,
euthanasia has been legislated in Belgium
(Gastmans et al, 2004; Inghelbrecht et al, 2010).
In Belgium, legislation allows physicians only to
perform the euthanasia (Inghelbrecht et al,
2010). In one study in Belgium (Inghelbrecht et
al, 2010), researchers investigated the role of
nurses in the decision-making, preparation and
administration of life-ending medications with a
patient’s explicit request (euthanasia) or without
an explicit request. The results of the study
Research
Nurses’ attitudes towards eutha
a cross-sectional study in Iran
Ladan Naseh, Hossein Rafiei, Mohammad Heidari
Ladan Naseh,
Department of Medical–
Surgical Nursing,
School of Nursing and
Midwifery, Shahrekord
University of Medical
Science, Shahrekord,
Iran; Hossein Rafiei,
Department of Intensive
and Critical Care,
School of Nursing and
Midwifery, Qazvin
University of Medical
Science, Qazvin, Iran;
Mohammad Heidari,
Department of Medical–
Surgical Nursing,
Borojen School of
Nursing and Midwifery,
Shahrekord University
of Medical Science,
Shahrekord, Iran
Correspondence to:
Hossein Rafiei
hosseinrafiei21@yahoo.
com

International Journal of Palliative Nursing 2015, Vol 21, No 1 495
Research
© 2015 MA Healthcare Ltd
showed that in 12% of the cases of euthanasia
and in 45% of the cases of assisted death without
an explicit request the life-ending medications,
were administered by the nurses. Belgian nurses
acted according to the physicians’ orders, but
mostly without the physicians’ presence. In
another study, van Bruchem-van de Scheur et al
(2008) examined nurses’ attitudes towards eutha-
nasia and physician-assisted suicide from 1509
hospitals, home-care organisations and nursing
homes in The Netherlands. More than half of the
nurses who participated in this study mentioned
that preparing euthanatics and inserting an infu-
sion needle to administer the euthanatics should
not be accepted as nursing tasks (van Bruchem-
van de Scheur et al, 2008). A survey by
Mickiewicz et al (2012) studied nurses (with and
without experience on hospice wards), nursing
students and family members of patients' atti-
tudes towards euthanasia. They reported that the
majority of their respondents were not interested
in participating in the process of euthanasia.
They also reported that legalisation of euthanasia
was rarely favoured by the hospice workers
(Mickiewicz et al, 2012).
Iran is a middle eastern country with approxi-
mately 77 million residents. Most religions are
represented in Iran but the major faith tradition
in the country is Islam (Iranmanesh et al, 2010)
and death is one of the crucial subjects in Islam
(Razban et al, 2013). According to Islamic views,
the patient does not have the right to die volun-
tarily (Zahedi et al, 2007). The use of devices or
medications aimed at ending human life are also
not allowed in Islam. Muslims believe that life on
earth and death is only a transition between two
different lives (Sarhill et al, 2001; Razban et al,
2013). To have a better situation in life after
death is the goal of every Muslim. There is very
little available information about attitudes
towards euthanasia in Islamic countries, espe-
cially in Iran (Mousavi et al, 2011; Aghababi et
al, 2011). Moghadas et al (2012) examined
Iranian critical care nurses' attitudes towards
euthanasia. The study showed that the majority
of critical care nurses (83.5%) had a negative
attitude towards euthanasia. The authors also
reported that nursing work experience and age
were negatively associated with attitude to eutha-
nasia (Moghadas et al, 2012). Interestingly, in
another study, Kachoie et al (2011) examined
medical students' attitudes towards euthanasia
and 50% of the participants reported a positive
attitude towards euthanasia.
Studies about Iranian nurse’s attitudes about
euthanasia are scarce. The aim of the present
study was to examine Iranian Muslim nurses’
attitudes towards euthanasia.
Methods
Participants
This study employed a descriptive design and
was conducted in two teaching hospitals,
Kashani and Hajar, in Shahrekord, west Iran.
Using convenience sampling, all qualified regis-
tered nurses (n=266) working in 15 different
wards at the two teaching hospitals were invited
to participate in the study.
In Iran, the government regulates nursing educa-
tion. Students can study nursing across all educa-
tion levels from bachelor to doctoral; however,
unlike some western countries, Iran does not dif-
ferentiate by rank within licensed nursing person-
nel. Registered nurse (RN) is the only
professionally recognised rank. On successful com-
pletion of nursing educational programs, gradu-
ated nurses are automatically granted the status of
RN, which is the minimum legal and educational
requirement for professional nursing practice. RNs
must complete a 4-year bachelor’s degree at a nurs-
ing college (Iranmanesh et al, 2013).
Data collection
Data were collected from March to May 2013.
Questionnaire packages containing a covering
letter describing the aims of the study, a demo-
graphic variables questionnaire, and the
Euthanasia Attitude Scale (EAS) that includes a
definition of euthanasia, were distributed to par-
ticipants. Euthanasia was defined as:
‘a medical term which refers to easy and inten-
tional termination of a person’s life who suffers
from an incurable disease with no hope of
recovery. It can be divided into two major
types: active and passive euthanasia. In active
euthanasia, the patient asks the doctor to end
his/her life, which is done by performing an
action such as lethal injection, while in passive
euthanasia, the patient refuses medications
thereby accelerating his/her death without any
specific action being carried out.’ -ref?
Participants answered the questionnaire and EAS
individually during hours of work and returned
the test to their head nurse. At the end of the
shift work, the researcher collected the question-
naires.
The Euthanasia Attitude Scale (EAS)
The EAS was originally developed by Tordella
and Neutens to examine the attitude to euthana-
sia among college students (Tordella and
Neutens, 1979). Rogers et al (1996) modified
❛According to
Islamic views,
the patient
does not have
the right to die
voluntarily...❜

496 International Journal of Palliative Nursing 2015, Vol 21, No 1
Research
© 2015 MA Healthcare Ltd
and edited the EAS items for assessing social val-
ues and ethical judgment of euthanasia. In 2005,
Chong and Fok categorised the 21 items of EAS
in four domains: ethical consideration, practical
consideration, treasuring life and naturalistic
beliefs (Chong and Fok, 2005). The scoring
method used in this study was the same as the
original design, meaning items ranged from 1 to
5, with 5 indicating strong support for euthana-
sia, 3 indicating neutral, and 1 indicating strong
opposition to euthanasia (Aghababaei, 2012).
Ethical consideration
Consent was implicit by respondent's decision
to return the completed questionnaire.
Participants were assured that all data would
remain anonymous, kept confidential and be
stored safely. Ethical approval was obtained
from both Shahrekord University of Medical
Sciences and the heads of the two hospitals affil-
iated to the university prior to the collection of
any data.
Data analysis
Descriptive statistics, Pearson correlation coeffi-
cient and independent sample T-test were used
for data analysis. All statistical analyses were per-
formed using SPSS software (v17.0; PASW
Statistics) and a variable was considered to be
statistically significant if P< 0.05.
❛LCP allowed
unnecessary
clinical
observations to
be stopped❜
Table 1. Nurses responses to items of the Euthanasia Attitude Scale (EAS) (n=190)
Strongly
agree
Agree Neutral Disagree Strongly
disagree
Ethical consideration (11 items)
1 - A person with a terminal illness has the right to decide to die52 (27.4%) 39 (20.5%) 21 (11.1%) 33 (17.4%) 45 (23.7%)
2 - Inducing death for merciful reasons is wrong 65 (34.2%) 36 (18.9%) 42 (22.1%) 37 (19.5%) 10 (5.3%)
3 - Euthanasia should be accepted in today’s society 22 (11.6%) 57 (30%) 26 (13.7%) 42 (22.1%) 43 (22.6%)
4 - There are never cases when euthanasia is appropriate38 (20%) 28 (14.7%) 24 (12.6%) 72 (37.9%) 28 (14.7%)
5 - Euthanasia is helpful at the right time and place (under the right
circumstances)
33 (17.4%) 68 (35.8%) 20 (10.5%) 35 (18.4%) 34 (17.9%)
4 - Euthanasia is a human act 16 (8.4%) 25 (13.2%) 44 (23.2%) 51 (26.8%) 54 (28.4%)
7 - Euthanasia should be against the law 50 (26.3%) 43 (22.6%) 49 (25.8%) 32 (16.8%) 16 (8.4%)
8 - Euthanasia should be used when the person has a terminal illness29 (15.3%) 59 (31.1%) 22 (11.6%) 32 (16.8%) 48 (25.3%)
9 - The taking of human life is wrong no matter what the circumstances58 (30.5%) 39 (20.5%) 42 (22.1%) 43 (22.6%) 8 (4.2%)
10 - Euthanasia is acceptable in cases when all hope of recovery is gone29 (15.3%) 61 (32.1%) 23 (12.1%) 36 (18.9%) 41 (21.6%)
11 - Euthanasia gives a person a chance to die with dignity25 (13.2%) 42 (22.1%) 38 (20%) 39 (20.5%) 46 (24.2%)
Mean of total score for section 2.81± 1.08
Practical consideration (3 items)
1 - Euthanasia is acceptable if the person is old 8 (4.2%) 18 (9.5%) 41 (21.6%) 64 (33.7%) 59 (31.1%)
2 - If a terminally ill or injured person is increasingly concerned
about the burden that his/her deterioration of health has placed on
his/her family, I will support his/her request for euthanasia
16 (8.4%) 42 (22.1%) 37 (19.5%) 45 (23.7%) 50 (26.3%)
3 - Euthanasia will lead to abuse 57 (30%) 65 (34.2%) 42 (22.1%) 18 (9.5%) 8 (4.2%)
Mean total score for section 2.36± 0.90
Treasuring life (4 items)
1 - There are very few cases when euthanasia is acceptable18 (9.5%) 68 (21.1%) 29 (15.3%) 40 (35.8%) 35 (18.4%)
2 - Euthanasia should be practiced only to eliminate physical pain
and not emotional pain
10 (5.3%) 31 (16.3%) 50 (26.3%) 47 (24.7%) 52 (27.4%)
3 - One’s job is to sustain and preserve life, not to end it 76 (40%) 61 (32.1%) 28 (14.7%) 17 (8.9%) 8 (4.2%)
4 - One of the key professional ethics of physicians is to prolong
lives, not to end lives
70 (36.8%) 62 (32.6%) 30 (15.8%) 18 (9.5%) 10 (5.3%)
Mean total score for section 2.85± 0.40
Naturalistic belief (2 items)
1 - A person should not be kept alive by a machine 24 (12.6%) 35 (18.4%) 46 (24.2%) 50 (26.3%) 35 (18.4%)
2 - Natural death is a cure for suffering 62 (32.6%) 68 (35.8%) 33 (17.4%) 17 (8.9%) 10 (5.3%)

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Results
Out of 266 nurses, 194 participated in the study.
There were four returned questionnaires which
were incomplete and thus excluded from the
study, therefore analysis was performed on 190
questionnaires (response rate 72.9%). Of the 190
nurses, 91.1% (n=173) were female and 8.9%
(n=17) were male. The mean age of participants
was 33.3±6.3 years and mean years of experience
was 9.2±0.9 years. Some 75% of nurses were
married and the rest were single. All nurses who
participated in the study were Muslim; 75.3%
considered themselves as very religious and the
rest reported to have a moderate level of religious
beliefs.
In total, 57.4%, 3.2% and 39.5% of nurses
reported a negative, neutral and positive attitude
to euthanasia respectively. Nurses reported the
most negative attitude to the EAS domain ‘practi-
cal consideration’ with a mean score of 2.36±0.9
and the most positive attitude to the domain
‘treasuring life’ with mean of 2.85±0.4. Tables 1
and 2 show nurses’ responses to the 4 domains
and the 21 items of EAS in detail.
The Pearson correlation test showed no signifi-
cant correlation between mean score of nurses’
attitude toward euthanasia and nurses’ age
(p=0.94). Results of this test also showed no sig-
nificant correlation between mean score of
nurses’ attitude toward euthanasia and nurses’
years of experience (p>0.05). According to the
results of the independent T-test, male nurses
showed most positive attitudes compared to
female nurses (2.96±0.74 vs 2.69±0.75) but the
difference was not statistically significant
(p=0.171) (Table 3). The results of this test also
showed no significant difference in attitude to
euthanasia between married and single nurses;
although the mean score of attitudes of single
nurses were higher (2.77±0.76 vs 2.70±0.75) (p=
0.614) (Table 3). Independent T-test also revealed
no significant difference between nurses with
high and moderate level of religious beliefs;
although the mean score of attitudes were higher
in nurses with a moderate level of religious
beliefs (2.83±0.81 vs 2.62±0.72) (p=0.24).
Discussion
In Iran, end-of-life care is still a new topic
(Razban et al, 2013) and information about atti-
tudes to euthanasia in Iran is scarce. The present
study examines Iranian Muslim nurse’s attitudes
towards euthanasia. According to the findings,
most Iranian nurses (60.2%) did not have a posi-
tive attitude to euthanasia.
Previous studies in Iran showed similar find-
ings to the results of the present study. Rastegari
et al (2010) examined the attitudes of nurses
towards euthanasia who had experience of caring
for dying patients in different wards such as
oncology, intensive care unit, neurology and
hemodialysis. Similar to our findings, Rastegari et
al, reported that most Iranian nurses have a nega-
tive attitude toward euthanasia. In their study,
67.7%, 73.5%, 40% and 80% of nurses
reported a negative attitude to active voluntary
euthanasia, active non-voluntary euthanasia, pas-
sive voluntary euthanasia and passive non-volun-
tary euthanasia respectively (Rastegari, et al,
2010). In another study using the EAS,
Moghadas et al (2012), examined Iranian critical
care nurses’ attitudes to euthanasia and reported
that most Iranian nurses have negative attitude to
euthanasia. Similar to euthanasia, ‘do not resusci-
tate’ (DNR) order is another ethical issue related
to end-of-life decision-making that health-care
Table 2. Mean EAS score of nurses attitudes to euthanasia in each of the four domains
Attitude domains Less than three: negative attitudeThree: neutral attitudeMore than three: positive attitude
Ethical consideration 97 (51.1%) 5 (2.6%) 88 (46.3%)
Practical consideration 135 (71.1%) 11 (5.8%) 44 (23.2%)
Treasuring life 84 (44.2%) 69 (36.3%) 37 (19.5%)
Naturalistic belief 114 (60%) 52 (27.4%) 24 (12.6%)
Table 3. Mean EAS score of nurses’ attitude to euthanasia with regards to nurses sex and marital
Attitude domains Men Women p value Single Married p value
Ethical consideration 3.20±1.11 2.77±1.01 0.122 2.93±1.14 2.77±1.06 0.374
Practical consideration2.49±0.96 2.34±0.89 0.539 2.25±0.79 2.39±0.93 0.354
Treasuring life 2.86±0.49 2.85±0.41 0.819 2.83±0.45 2.86±0.40 0.660
Naturalistic belief 2.52±1 2.49±0.89 0.861 2.51±0.90 2.48±0.90 0.890
Total score 2.96±0.74 2.69±0.75 0.171 2.77±0.76 2.70±0.75 0.614

498 International Journal of Palliative Nursing 2015, Vol 21, No 1
Research
© 2015 MA Healthcare Ltd
team members in Islamic country face.
Mogadasian et al (2014) examined the attitude
of 306 Iranian Muslim nurses towards DNR
order, and concluded that most Iranian nurses
have negative attitudes towards this (Mogadasian
et al, 2014).
Studies from other countries with large Muslim
populations have reported similar results with
regards to attitudes to euthanasia. A study in
Sudan (Ahmed et al, 2001) examined Sudanese
physicians' attitudes towards euthanasia and
assisted suicide. Some 98% of 248 physicians
participating in the study were Muslim. Similar
to findings of the present study, most participants
(85%), reported disagreement over euthanasia
and assisted suicide. A study in Pakistan (Afzal et
al, 2010) investigated attitudes of Muslim junior
and senior Pakistani physicians towards euthana-
sia and assisted suicide. The results showed that
the majority of Pakistani physicians strongly dis-
agree with the practice and legalisation of eutha-
nasia and assisted suicide.
Previous studies conducted among European
countries about nurses’ attitudes towards eutha-
nasia have shown different results. In one study,
Inghelbrecht et al (2009), examined Belgian
nurses’ attitudes towards end-of-life decisions in
medical practice. In contrast to the findings pre-
sented here, the majority of nurses participating
in Inghelbrecht et al’s study agreed with the
practice of euthanasia (92%), practice of with-
holding/withdrawing potentially life-prolonging
treatments and decisions to alleviate symptoms
with possible life-shortening side-effects (96%)
(Inghelbrecht et al, 2009). In another study,
Bendiane et al (2007), examined French district
nurses’ opinions towards euthanasia and affect-
ing factors. They reported that 65% of French
nurses favoured legalisation of euthanasia. The
authors also reported that nurses who discuss
end‐of‐life issues with end-stage patients (con-
sidered as competent patients and should always
be aware of their prognosis) and who appreciate
the role of skilled directors and surrogates in the
end‐of‐life decision-making for incompetent
patients, were more in favour of legalising
euthanasia (Bendiane et al, 2007). A study in
Finland (Ryynänen et al, 2002) examined physi-
cians, nurses and the general public attitude
about physician-assisted suicide, active volun-
tary euthanasia, and passive euthanasia. This
study reported that 46% of 582 nurses who
participated in the study agreed that euthanasia
would be acceptable in some situations. The
results of the study also showed that non-reli-
gious nurses and nurses under the age of 50
years accepted euthanasia more often than reli-
gious or elderly nurses (Ryynänen et al, 2002).
The differences between the results of the
present study and studies in European countries
could be related to the differences in religious
beliefs between these populations. Also, the dif-
ferences might also be related to different types
of instruments used in various studies.
Limitations
The respondents were predominantly female,
which limits the generalisability of the results. As
this study was based on a convenient sample and
the participation was voluntary, there might have
been a selection bias which might affect the pos-
sibility to generalise the results to all nurses.
Conclusion
Iran is a country governed by Islamic rules, and
according to these rules, euthanasia is strongly
abhorred and outlawed. Among health-care team
members, nurses have an important role in end-
of-life care, and this study aimed to examine
Muslim nurses’ attitudes towards euthanasia.
The study found that the majority of Muslim
nurses have a negative attitude to euthanasia. We
recommend that future studies should be con-
ducted to examine Muslim nurses with similar
religious beliefs but different cultural attitudes to
euthanasia, to determine the role of culture and
religious beliefs in attitudes to euthanasia among
Muslim nurses.
Acknowledgment
The authors would like to thank the nurses for their coop-
eration and thoughtful responses. We also thank the
research center of Shahrekord University of Medical
Science for their financial support to perform this study
(research code: 1376).
Declaration of interests
The authors have no conflicts of interest to declare
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❛Previous
studies
conducted
among
European
countries
about nurses’
attitudes
towards
euthanasia
have shown
different
results❜

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❛Iran is a
country
governed by
Islamic rules,
and according
to these rules,
euthanasia
strongly
abhorred and
outlawed. ❜