Introduction

Today, with the advancements in dialysis machines, mechanical ventilators, artificial pacemakers and artificial feeding devices, as well as in processes such as direct current counter shock, the human lifespan has increased and healthcare providers encounter more ethical and moral challenges than before (1, 2). The word “euthanasia”, derived from the Greek words “eu” (good) and “thanatos” (death), literally means “good death” (1). Many define it as the “mercy killing” of people suffering from fatal diseases, injuries, incapacities or extreme pain and the ending of life in as painless a way as possible (3). Euthanasia is generally classified as either active or passive, and voluntary or involuntary. Active euthanasia is defined as the commission of specific actions, ie the use of a lethal injection, to cause the patient’s death. Passive euthanasia is usually defined as the withdrawal of medical treatment with the deliberate intention of causing the patient’s death. Voluntary euthanasia involves a request by the patient that action be taken to end their life, while in involuntary euthanasia, the patient’s life is ended without their knowledge and consent (4, 5).

Healthcare professionals’ attitudes to euthanasia may influence their behaviour in situations in which this issue arises. This is particularly important in the case of nurses because they are in constant contact with patients (6) and, therefore, are often confronted with the issue of euthanasia (7). Several studies have been conducted in different countries on the prevailing attitudes to euthanasia. In a study carried out in a hospice in north-eastern Poland in 2012, Mickiewicz et al examined the attitudes to euthanasia of nurses, nursing students, hospice workers and the family members of patients (8). Of the 565 participants in the study (covering 183 nurses, 175 nursing students, 103 hospice workers and 104 family members), nearly 50% of nurses, 49.6% of nursing students, 71.8% of hospice workers and 45.2% of patients’ family members did not approve of euthanasia (8). In another study, Suen et al explored the preferences of older Taiwanese adults and family caregivers regarding life-sustaining treatments (9). The results showed that only a minority of the elderly adults was in favour of life-sustaining treatment in most health scenarios, and more family caregivers preferred such treatment. Moreover, in the case of both study groups, the most important factors influencing treatment decisions were the prognosis and the patient’s state of consciousness (9). The results of a study in Iran that examined the attitudes of physicians and patients to euthanasia (10) showed that the majority of the participants approved of at least one type of euthanasia. This attitude was displayed by more Persian patients than physicians (10).

Several studies have also examined the attitudes of medical students to euthanasia. Leppert et al explored the attitudes of 588 medical students who had completed compulsory courses in palliative medicine at two Polish universities (11). They reported that the majority of the medical students did not support the practice of euthanasia. Moreover, it appeared that the courses on palliative medicine had had little influence on the students’ views on euthanasia (11). In Iran, Zarghami et al examined the attitudes and knowledge of 321 medical students (interns and residents) regarding euthanasia (12). Their study revealed that 86% of Persian medical students had some knowledge of euthanasia, while14% had none. The study also showed that 49% of the participants supported the practice of euthanasia and 51% were opposed to it. Zarghami et al found that interns and residents with deep religious beliefs displayed greater disapproval of the practice (12).

As in the case of medical students, it is important to examine the attitudes of nursing students to euthanasia because they, too, may encounter situations related to the practice during their clinical courses. However, there are few studies in this area. In a study in 2013, Bakalis et al examined Greek nursing students’ attitudes to euthanasia. The majority of the participants had a low level of knowledge of euthanasia. Further, most of them had a negative attitude towards the relevant legalisation (13). In another study in 2014, Verghese et al evaluated the knowledge and attitude of Indian postgraduate and LLB students regarding euthanasia in India (5). In contrast to the findings of Bakalis et al, Verghese et al found that most Indian nursing students had a positive attitude towards euthanasia (5, 13).

It should be noted that Islam is the majority religion in Iran and according to it, euthanasia is not allowed and is considered a major sin. Religious leaders have discouraged the practice. To the best of our knowledge, there is no study on nursing students’ attitudes to euthanasia in the Iranian context. The aim of our study is to examine Iranian Muslim nursing students’ attitudes to euthanasia.

Methods

This study was approved by the Shahrekord University of Medical Sciences Research Ethics Committee and was conducted during July–October 2013 in two nursing colleges in western Iran.

Academic nursing education in Iran

In Iran, programmes for the education of nurses are offered through two different systems. The first system consists of the state-sector medical science universities, which are affiliated with and supervised by the government. The state-sector system provides everyone, irrespective of wealth and income level, with an equal opportunity to study at an Iranian medical university. In the state-sector medical science universities, nursing education is offered free of charge to nursing students. The second system is the non-government nationwide Azad University. To study in Azad University, nursing students have to pay a tuition fee. Due to the large number of general applicants for the limited number of university seats in Iran, applicants to all courses, including medical and paramedical (such as nursing), have to pass the competitive National Higher Education Entrance Examination (NHEEE). Although there is no passing grade for the NHEEE, those who attain a high rank are more likely to be admitted to the university and pursue the courses of their choice. Generally, students who attain a high rank select the socially more prestigious fields, such as dentistry, pharmacy and medicine. The lower ranked students have limited choices and often select fields such as nursing and midwifery (14, 15).

For this study, considering the relatively small study population, sampling was conducted using the census method. All nursing students doing their internship (n=132) were invited to participate in the study. The participants were requested to fill in a questionnaire, before which the authors gave them some oral information on the study. Participation in the study was voluntary and the respondents’ anonymity was assured. The participants filled in the questionnaires individually and submitted them to the researchers. In this study, euthanasia was defined as “a medical term which refers to easy and intentional termination of the life of a patient suffering from an incurable disease, with no hope of recovery”. The nursing students’ attitude to euthanasia was measured using the Euthanasia Attitude Scale (EAS) (16, 17). The scale consists of 21 items, categorised into four domains: ethical considerations (11 questions), practical considerations (four questions), treasuring life (four questions) and naturalistic beliefs (two questions). The questionnaire was scored on a five-point Likert scale, ranging from strong disagreement 1 to strong agreement 5. The total scores ranged from 21 to 105. Higher scores indicated a more positive attitude to euthanasia. The validity and reliability of the Persian version of the EAS were determined in a previous study by Aghababaei (Cronbach’s = 0.85). This is an acceptable level (18). A demographic questionnaire was used to collect background information on the respondents, including their sex, age, marital status, extent of religiosity and economic condition. To determine the extent of religiosity, the demographic questionnaire contained specific questions on the participants’ relationship with religion and religious beliefs (for example, “Question: Your relationship with religion? Options: Low, medium, high”).

Descriptive statistics, Pearson’s correlation coefficient, the independent sample t-test and one-way ANOVA were applied to analyse the data. All statistical analyses were performed using SPSS software (v17.0; PASW Statistics) and a variable was considered statistically significant if p<0.05.

Results

Of the 132 nursing students, nine (six females and three males) did not participate in the study. As they did not complete the questionnaire, no details are available on them. A total of 123 students participated in the study (response rate of 93.1%). Of these, 65.8% (n=79) were female and 34.2% (n=41) male. Three of the questionnaires returned were incomplete and excluded, so the analysis was performed on120 questionnaires. The mean age of the students was 23.1±1.6 years (range 19–28 years). Of the 120 students, 68.3% (n=82) were single and 31.7 % (n=38) married. A low, moderate and high economic status was reported by 8.3%, 65.8% and 25.8% of the students, respectively. All the participants were Muslim. Of them, 49.2% and 50.8% reported a high and moderate level of religious belief, respectively.

In our study, 52.5%, 2.5%and 45% of the students reported a negative, neutral and positive attitude to euthanasia, respectively. Among the four categories, the highest mean score came from the category of ethical considerations (mean=2.97±0.94) and the lowest from that of practical considerations (mean=2.39±0.84). In the former, the higher and lower scores were related to these items: “A person with a deadly illness has the right to decide to die” and “Inducing death for a merciful reason is wrong”, respectively. In the category of practical considerations, the higher and lower scores were related to the items: “If a person with a deadly illness or injury is increasingly concerned about the burden that the deterioration in his/her health is placing on his/ her family, I will support his/her request for euthanasia” and “Euthanasia will lead to abuses”, respectively. In the category of treasuring life, the higher and lower scores were related to the items “One of the key elements of the professional ethics of physicians is to prolong lives, not to end lives” and “One’s job is to sustain and preserve life, not to end it”, respectively. Finally, in the category of naturalistic beliefs, the higher and lower scores were related to the items “A person should not be kept alive by a machine” and “A natural death is a cure for suffering”, respectively. Figure 1 shows the mean scores of the students’ attitudes in the four domains.

Fig. 1: Mean scores of students’ attitudes in four domains of euthanasia

The Pearson correlation test showed a significant correlation between the scale of the students’ scores on attitude and their age (r=0.219, p<0.01). According to the results of the independent t-test, males had a more positive attitude to euthanasia than females (3.04±0.53 vs. 2.7±0.64). The difference between the sexes was statistically significant (p=0.01). Table 1 shows the mean scores of male and female students’ attitudes in the four domains of the EAS, as well as those of students with a lower and higher extent of religiosity.

The mean score of the single students’ attitude to euthanasia was 2.85±0.6, and that of married students, 2.83±0.6. According to the independent t-test, the difference between the two groups was not statistically significant (p>0.05). The mean score of the attitude of students with a relatively higher extent of religiosity was lower than that of students with a relatively lower extent of religiosity (2.6±0.61 vs. 2.9±0.59) that was statistically significant (p=0.009) (Table 1).

The mean scores for attitude to euthanasia were 3.05±0.66, 2.82±0.58 and 2.82±0.70, respectively, for students of low, moderate and high economic status. According to the results of the one-way ANOVA, the difference between the groups was not statistically significant (p>0.05).

Discussion

The objective of our study was to examine Iranian nursing students’ attitudes to euthanasia. According to our findings, 52.5%, 2.5% and 45%of nursing students reported a negative, neutral and positive attitude, respectively. Further, the results showed that younger female students and those with a relatively greater degree of religiosity had a more negative attitude to euthanasia.

To the best of our knowledge, this is the first study in Iran that has examined nursing students’ attitudes to euthanasia. However, some studies have examined the attitudes of other groups of Iranian students to this issue. In one such study, Kachoie et al explored medical students’ attitudes to euthanasia (19). As in our study, 50% of students in the study of Kachoie et al did not support euthanasia. Similarly, their study found that male students have a more positive attitude to euthanasia than female students (19). In another study carried out in 2014, Davoodzadeh et al explored the attitude of Iranian anaesthesia students to euthanasia (20). The results showed that 51.43%, 9.76% and 38.7% of the students had a negative, neutral and positive attitude, respectively (20). Another ethical issue related to end-of-life decisions, the “do not resuscitate (DNR)” order (21), was the subject of a study by Abdollahzadeh et al in Iran. The authors examined the attitudes of 186 Iranian Muslim nursing students to the DNR order and reported that the participants’ attitude was negative. In their opinion, culture and religion are the two main factors that affect Iranian nursing students’ view of the DNR order (21).

As in Iran, there are limited previous studies of nursing students’ attitudes to euthanasia in other countries. The findings of Bakalis et al were similar to those of our study, with the majority of nursing students opposing the idea of euthanising patients with end-stage conditions (13). The three crucial factors that influenced Greek nursing students’ decisions on euthanasia were the patient’s decision, the department’s protocols and their own personal beliefs (13). In contrast to our results, the study carried out by Mickiewicz et al (8) found that 43.6%, 34.4% and 12.6% of the participants were in favour of stopping resuscitation, withdrawing life support and administering a lethal injection, respectively. The authors also reported that most of the nursing students wanted euthanasia to be legalised (8). Similarly, the study of Verghese et al found that of a total of 80 participants, 65% of postgraduate nursing students and 57.5% of LLB students were in favour of euthanasia (5). The differences between the findings of our study and those of the studies of Mickiewicz et al and Verghese et al could be attributed to the differences in the religious beliefs of and cultural and sociodemographic factors affecting Iranian nursing students, on the one hand, and Polish and Indian nursing students, on the other. Further, the differences could be related to the different types of instruments used in the various studies. Studies have shown that questionnaires used in a country should be in accordance with the religious beliefs prevalent in that country, in order for it to reflect the reality closely (18). It is noteworthy that in Iran, many studies have been carried out to assess nurses’ attitudes to euthanasia, which have often been found to be negative. One such study is that of Asadi et al, which covered 205 nurses in the fields of oncology and intensive care. Most of these nurses were not in favour of euthanasia (22).

This study showed that the more devout participants were less inclined to support euthanasia. The findings of previous studies among Persian students have been similar. In a study in 2014, Aghababaei et al examined the relationship between the personalities of Persian students and their attitudes to euthanasia. They reported that religiosity, honesty–humility, agreeableness and extraversion made for negative attitudes to euthanasia (23). The results of other studies in the Iranian context indicated that religion plays an important role in people’s thinking about end-of-life issues, death and euthanasia (24). Notably, a study conducted in the UK yielded very different results. The study, carried out by Hains and Hulbert-Williams, examined the attitudes of 151 undergraduate students (early-stage nursing training, late-stage nursing training and non-nursing controls) to euthanasia, and reported a significant positive correlation between a higher level of religiosity and a positive attitude to euthanasia (25). The differences between the findings of this study and our study could be related to the differences in the religious beliefs of nursing students in the UK and those in Iran. All the participants in our study were Muslim, and in Islam, the termination of a patient’s life, whether through voluntary, involuntary, active or passive euthanasia, is judged as an act of disobedience against God (26). Muslims believe that death is only a transition between two different lives (27, 28). Reward in the next life is the goal of every Muslim.

Euthanasia is among the most common morally controversial issues in end-of-life care. Traditionally, nurses have played a key role in caring for patients at the end of life in multiple care settings, such as hospitals, hospices, long-term care facilities and the home. Thus, they should be well educated in this area. A part of this education is obtained through training in nursing schools and colleges. When drawing up the curriculum for nursing courses, a knowledge of the attitudes of nurses is imperative.

Conclusion

Iranian laws deem the practice of euthanasia a crime, and this is seconded by the perspective of Islam and the religious leaders. These two factors might have an important influence on students’ attitudes and opinions. Besides, research has shown that attitudes to euthanasia depend to a large extent on the context in which people are trained. In the medical sphere, there are several factors that make euthanasia one of the most challenging issues and there is no consensus among experts in this field. Therefore, we feel that this issue should be explored more carefully and deeply, in all its aspects, especially in terms of determining the patient’s rights. This would help students and doctors to express their opinions more confidently. Finally, further studies are recommended to understand the various aspects of nursing students’ attitudes in this area.