turkish health professional's attitude toward euthanasia - CiteSeerX

OMEGA, Vol. 57(1) 93-112, 2008

TURKISH HEALTH PROFESSIONAL’S ATTITUDE TOWARD EUTHANASIA

& GÜLTEN KARADENIZ EMRE YANIKKEREM Celal Bayar University, Turkey & INÇC & EDIBE PIR I& RAMAZAN ERDEM Firat University School of Health Services, Turkey AYNUR ESEN Ege University School of Nursing, Turkey ( & GÜL KITAPÇIO GLU Ege University Faculty of Medicine, Turkey

ABSTRACT

The cross-sectional study was administrated between April and September 2006. Participants are doctors, nurses, and midwives. Between these dates we met only 750 health staff (doctor, nurse, and midwife). Six hundred thirty-two of them responded to our questionnaire, 122 of them were in Manisa city, and 510 of them in Erciyes. We sought to identify variables that contribute to euthanasia attitude, including demographics, in order to demonstrate Turkish doctors’, nurses’, and midwives’ attitudes toward euthanasia and to compare their attitudes in this regard. The data was collected by a two-part questionnaire. The first part included questions about the health personnel; the second part comprised the euthanasia (Medical Staff’s Attitude toward Euthanasia) scale. The scale was developed by the researcher to measure the 93 Ó 2008, Baywood Publishing Co., Inc. doi: 10.2190/OM.57.1.e http://baywood.com

94 / KARADEN¤Z ET AL.

attitude of healthy staff euthanasia. The SPSS was used to analyze the data. Student t-test, ANOVA, Mann Whitney U, and Kruskal Wallis were used to evaluate the data. The p value 0.05 (95% confidence interval) was accepted as significant. In our study, professional groups are compared with all the factors but there is a significant difference only between social cost and professional groups.

INTRODUCTION The progress made in medical science and in the application of medical technology has resulted in people living longer (Ramabele, 2004). For many patients this signifies a prolonged life which in turn raises the question of whether such treatment is a benefit or a burden. Having created a situation in which lives are consistently saved or prolonged by medical intervention we can hardly act as if the process of dying should be left to nature (Mahommed, 1998). Such simplistic clichés about death by nature’s work might have had more general truth 50 years ago as “while there is life there is hope” or “killing is killing” are insufficient to deal with the present state of medical knowledge which is capable of keeping damaged patients alive who in the recent past would not have stayed alive at all. According to Brogden (2001) the increasing elderly population poses many economic and ethical questions for modern society. One of the most current and controversial of these is the debate about euthanasia (Brogden, 2001). According to Brogden, euthanasia is most commonly concealed in the home or in the care institution, a situation which is attracting increasing professional attention. Today the question “what is euthanasia?” may be answered by a simple phrase “mercy killing.” Exactly which words one chooses to include in a definition or description of euthanasia frequently reflects one’s attitude toward the practice (Peck, 1997). In an article published by AcaDemon (2004) it was stated that whether euthanasia should be legal is one of the hotly debated questions that revolve around attitudes and choices. It was also mentioned that the controversy regarding the practice of euthanasia is essentially a controversy about ethics and morality. The debate about euthanasia is a value debate among people who weigh values differently and who also see the nature of the world and the place of humans in that world differently (Brock, 1992). According to Hobbes (1999) the main reasons that the debate about euthanasia has been so hotly debated and contested is because it challenges the value systems of people. According to Taylor, Peplau, and Sears (2003) a concept closely related to attitude strength is value and important attitudes are ones that reflect fundamental values. It was mentioned by LeBaron (1999) that the way people deal with and respond to issues of life, their attitudes and values about life and death, serve to shape the nature of a society. This is why society must attempt to decide what is right and what is ethical conduct for the various actors in communities when

ATTITUDE TOWARD EUTHANASIA /

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faced with death. A person might argue that all available medical technology ought to be brought to bear in the preservation of life; but the pain and financial burdens that family members, patients, or society might have to endure could be so great that although the person might want to go on living, it would be in the best interest of the patient, family, or of the society if the individual chose instead to die (LeBaron, 1999). Like other moral issues, the problem of euthanasia has a long history of philosophical discussion. However, seeing that it is also a social phenomenon it is imperative to know what their perceptions about euthanasia are. In South Africa, the study conducted by Nortjè (2001) failed to prove that culture has a significant effect on a person’s views or attitudes regarding euthanasia. The primary aim of this study is therefore to do an investigation into the attitudes of the elderly toward euthanasia. Euthanasia is a terribly troubling word, meaning literally, according to some, “a good death,” but according to others a morally outrageous death (Fergusson, 1997). According to Saunders (1994), euthanasia is the act of taking the life, for reasons of mercy, of a person who is hopelessly ill. A basic distinction is made between two kinds of euthanasia, namely passive and active (Gillett, 1994). Active euthanasia is identical with mercy killing and involves taking direct action to end a life, for example, intentionally giving a person a lethal dose of a drug to end a painful and prolonged period of dying (Oehmichen & Meissener, 2000). Passive euthanasia is allowing a patient to die when he or she could have been kept alive by the appropriate medical procedures (Vere, 1997). According to Caddell and Newton (1995), active euthanasia can be defined as any treatment initiated by a physician with the intent of hastening the death of another human being who is terminally ill and in severe pain or distress with the motive of relieving that person from great suffering. Passive euthanasia can be defined or considered as discontinuing or not starting a treatment at the request of the patient (Caddell & Newton, 1995). Further distinction is made between voluntary, involuntary, and non-voluntary euthanasia (Gillett, 1994). According to this distinction, voluntary euthanasia occurs when the decision to terminate life by the physicians corresponds with the patient’s desire to do so and the patient willfully gives consent of its implementation. Involuntary euthanasia occurs when the decision to end life is implemented against the patient’s wishes. Non-voluntary euthanasia refers to cases where patients are unable to make their wishes known, for example a person who is brain dead and in a permanent or irreversible coma (Gillett, 1994). According to Muller and Kriegsman (1997) active voluntary euthanasia and physician-assisted suicide are often combined and mentioned in one breath. They defined active voluntary euthanasia as the deliberate termination of life, by someone other than the patient, at the patient’s request and physician-assisted suicide as intentionally helping a patient to end his or her life at his or her request.


According to Uhlmann (1998) the euthanasia debate is part of a larger issue concerning the right to die. He mentioned that individuals’ attitudes toward euthanasia differ. Those in favor of euthanasia argue that with specific safeguards and in certain circumstances the taking of a human life is merciful and that all of us are entitled to end our lives when we see fit. Opponents argue that euthanasia is not an act of mercy and should therefore not be performed (Uhlmann, 1998). According to Leichtentritt and Retting (1999), the legalization of euthanasia would cause a general weakening of public and social morality. Many doctors in South Africa favor mercy killing (Landman, 2001). According to Landman (2001) a number of doctors in South Africa would be willing to perform euthanasia at the request of their patients once the controversial practice was legalized in the country. He reported that while there is no scientific data available to indicate exactly how many doctors were in favor of euthanasia or physician assisted suicide, informal questionnaires distributed to doctors have shown positive results. Attitudes toward the ethics and legality of physician-assisted death, especially voluntary euthanasia (VE), have gradually been changing over the past decade. Some countries and states, including the Netherlands and the U.S. state of Oregon, have begun to accept VE and/or physician-assisted suicide. The Northern Territory of Australia also legalized VE and assisted suicide in 1996 but the federal government overrode the legislation in 1997 (Ganzini et al., 2000; Kissane, Street, & Nitschke, 1998; Kuhse, Singer, Baume, Clark, & Richard, 1997). Japan is not an exception. One of the district courts in Japan in 1995 determined that there were four criteria for legally permissible VE although no higher court has discussed this particular issue so far. According to these four criteria: the patient must suffer from unbearable physical pain; the death of the patient must be unavoidable and imminent; all possible palliative care must have been given and no alternatives to alleviate the patient’s suffering must exist; and the patient must explicitly request doctors to help him or her to hasten their death (Sakamoto & Kitazawa, 1996). While there have been extensive studies about the attitudes of the general community and health professionals toward various forms of euthanasia, research investigating these issues among in our country is limited. The primary aim of this study is therefore to do an investigation into the attitudes of the health professionals toward euthanasia. The influence of a number of independent variables such as gender and religious beliefs will also be investigated. METHOD Design and Participants The cross-sectional study was administrated between April and September 2006. Between these dates we met only 750 health staff (doctor, nurse, and


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midwife). Six hundred thirty-two of them responded to our questionnaire, 122 of them were in Manisa city and 510 of them in Elazi. We have chosen these cities in order to compare the different points of views between the two regions. This research was undertaken in the provinces of Manisa and Elazi, Turkey. The area of Manisa is 13,810 km square and the total population is 1,261,643 (Manisa Director of Health Statistics, 2003). Manisa is located in the western part of Anatolia, between the Spil Mountain and Gediz River. Manisa is a developed city, with agriculture, trading, and industry. However, it also has many immigrants from eastern Turkey. Elazi is a city in eastern Turkey. Total area of the province spans 9,281 km square, 826 km square of which is covered with water from dams and natural lakes. The city’s altitude from sea level is 1,067 meters. Contemporary Elazi was founded by moving the city to the arable fields of Harput in 1834. City population is recorded as 440,808, 498,225, and 569,616 in the years 1980, 1990, and 2000 respectively. City is divided into 10 towns: Ain, Alacakaya, Aricak, Baskil, Karakoçan, Keban, Kovancilar, Maden, Palu, and Sivrice (http://www.elazig.org) Five hundred ten health staff declined to participate in the study. The researchers visited the working place. Therefore, the study simple included 632 health staff and 80.7% response rate. Questionnaire A two-part questionnaire was used to collect data. The first part included questions about the health staff’s background, such as educational level, marital status, their occupation, gender, city, institution, and the meeting situation with the patients who require the euthanasia used. The second part comprised the Euthanasia Attitude Questionnaire was developed by the researcher to measure the attitude of healthy professionals euthanasia. From the literature on euthanasia it was predicted that peoples’ attitudes toward euthanasia would differ in terms of race, gender, and religious beliefs. On the other hand not much information on the literature is available which relate to attitudes of the health professionals toward euthanasia among different cultures/races or cross-culturally. In the light of the above, we developed euthanasia attitude scale in order to assess in our country. Internal reliability of questionnaire was determined by use of the Cronbach coefficient alpha and split half method. Multiple expert opinions, factor analysis assessed the face validity of the questionnaire. The principle component analysis with a varimax rotation produced six factors. The results of the validity and reliability analysis were successful. This scale was developed to assess the health professional’s attitude toward end of life decisions. The scale consisted of 62 questions. Euthanasia Attitude Questionnaire is a 30-item Likert-scale questionnaire, which measures attitudes toward euthanasia. The scale also has five response categories, namely “definitely


agree,” “agree,” “moderate agree,” “disagree,” and “definitely disagree.” The scale provides a total score which may range between 32 and 160. The Euthanasia Attitude Questionnaire’s questions deal with a variety of issues surrounding both active and passive euthanasia, such as the status of brain dead persons, life extending technology, ethics, and legal issues. According to this, the questionnaire has excellent psychometric properties, such as, stability, internal consistency, discriminate validity, and test-retest reliability. The test was standardized for the Turkish population and the reliability for this specific study using Euthanasia Attitude Questionnaire had an alpha coefficient of 87.3. The six factors explained for total variance 59.4%. The questionnaire uses a Likert scale containing 1 to 5 points. The answers were rated as 1 (definitely disagree), 2 (disagree), 3 (undecided), 4 (agree), and 5 (completely agree). The possible scares range from 0 (30) to 150 (180) Medical Staff’s Attitude toward Euthanasia. Interview and Ethics of Research We explained the purpose of the research to the health staff and, before each interview, we reminded the women that they could withdraw from the interview at any time and that confidentiality and anonymity would be protected at all times. Participation in this study was on a voluntary basis and an availability sample was used. The researcher individually interviewed each participant in the privacy of his or her own room to ensure confidentiality and objectivity. No names or any other personal information were recorded. The researchers interviewed health staff and conducted face-to-face questionnaires at their place of work. Manisa and Elazi national health directorate gave permission to conduct the research. The interview was conducted after obtaining a formal verbal informed consent. Analysis The SPSS was used to analyze the data. Student t-test, ANOVA, Mann Whitney U, and Kruskal Wallis were used to evaluate the data. The p value 0.05 (95% confidence interval) was accepted as significant. RESULTS The Characteristics of Health Workers Characteristics of responding health workers are shown in Table 1. Their age (mean ± SD) was 31.4 ± 7.0 (17-58) years old. Occupations included 209 (33.0%) doctors, 332 (52.5%) nurses, and 91 (14.4%) midwives. Type of institution of the personnel included 202 government hospital, 112 (17.7%) birth government hospital, 17 (2.7%) child health hospital, 192 (30.4%) university


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Table 1. The Characteristics of Health Workers Characteristics

Number

Percentage

Region Manisa Elazi

122 510

19.3 80.7

Gender Women Men

477 155

75.5 24.5

Marital status Married Unmarried

422 210

66.8 33.2

Group of occupation Specialist doctor General practitioner Nurse Midwifery

114 95 332 91

18.0 15.0 52.5 14.4

Working place Government hospital Maternal and child hospital Child hospital University Private hospital Psychiatric hospital

202 112 17 192 71 38

32.0 17.7 2.7 30.4 11.2 6.0

Participant of scientific meeting about euthanasia Participant Non-participant

54 578

8.5 91.5

Meeting patient who needs euthanasia during professional life Meeting Not meeting

207 425

32.8 67.2

Total

632

100.0


hospital, 71 (11.2%) special status hospitals, and 38 (6.0%) psychiatric hospital. Entering status of educational congress related with euthanasia of the group was 54(8.5%). Meeting with requested euthanasia patients was 207 (32.8%) of the group. Numbers of respondents to this study were 155 (24.5%) males and 477(75.5%) females. Attitudes of Health Personnel toward Euthanasia Table 2 displays the attitudes of health personnel toward euthanasia. Whereas 38.4% of the health personnel utterly agree to the definition of euthanasia as an act or practice of painlessly putting to death a person suffering from an incurable disease at his or her will, 11.2% of them express their absolute objection to the definition. While 46.7% of them fully support the idea that religious beliefs affect the decision to undergo euthanasia, 28% support the idea simply, and 4.3% of them don’t support the idea at all. The idea that life support to a patient should be decreased if he or she expresses his wish to undergo euthanasia is rejected by 35.4% of them, but welcomed by 28.2%. However, 18.7% of them were undecided; 40.7% of them completely disagreed to the idea that a patient should not be fed if he or she expresses his wish to undergo euthanasia; 33.9% simply disagreed the idea; and 15% were undecided. The patient’s wish to undergo euthanasia if he or she cannot live without a life support is rejected by 27.9% of them, whereas 25% of them are undecided. The view that euthanasia should be a legal procedure in all countries is supported by 16.5% and rejected by 29.3%. However, 24.4% of them are undecided. Those who say they will not perform euthanasia at all even if it becomes a legal procedure comprise 43.4% of them; while 5.7% say they can; and 23.9% of them are undecided. That the decision to undergo euthanasia should be given by the patient himself or herself is completely rejected by 21.7%; supported by 24.8%; and 19.9% are undecided. The percentages of health personnel who utterly disagree and who simply disagree to the opinion that the life of a patient should be terminated if he or she is in the vegetative state are the same: 26.6%. Those who are undecided are 28.2%; 42.4% of them say that they themselves would undergo euthanasia, while 17.9% of them say they would not; 5.7% of them were undecided. Association between Socio-Demographic Characteristics and Attitudes of Health Personnel Regarding Euthanasia Table 3 shows socio-demographic characteristics and attitudes of health personnel regarding euthanasia. There was not a statistically significant difference between the regions (Manisa and Elazi) regarding Factor 1 (attitude of the euthanasia application), Factor 2 (attitude of the right to terminate the life), Factor 3 (family’s participation in euthanasia decision), Factor 4 (social cost), Factor 5 (right to live decently), and Factor 6 (influence of the religion). The differences between Factor 4 and gender, between Factor 3 and marital status,


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between Factor 6 and marital status, and between Factor 4 and professions are statistically significant. There is a statistically significant difference between participation in the scientific convention and the factors 1, 2, and 3. The difference between a possibility to encounter patients needing euthanasia and the factors 1, 2, and 3 is statistically significant. We sought to identify variables that contribute to euthanasia attitude, including demographics in order to demonstrate Turkish doctors’ and nurses’ and midwives’ attitudes toward euthanasia and to compare their attitudes in this regard. Attitudes of the health staffs regarding the euthanasia and distributions of factor were shown in Table 2. Medical staff’s attitude toward euthanasia scale consisted of six factors. These factors are as follows: attitude on the practice of euthanasia; attitude on termination of life rights; attitude on family’s decision on euthanasia; attitude on the public cost; attitude on the right to quality life; attitude on the religious effects. Table 3 shows the socio-demographics features of the research groups and relation of the euthanasia attitudes. We have found a statistical significance between the participants of scientific meeting about euthanasia and factor 1, 2, and 6. We also have found a statistical significance between the ones meeting patients that need euthanasia during professional life and factor 1, 2, 3, 4. DISCUSSION Euthanasia practices and the meaning of euthanasia have long been discussed. It is generally accepted that euthanasia should be performed on patients suffering from an incurable and painful disease in order to alleviate their pain but not on other patients (&Inceolu, 1999; Turla, Özkara, Ozkanli, & Alkan, 2006-2007). Attitudes of different social groups toward euthanasia in several countries have been investigated. In their study including 1,525 adults, Jorgenson and Neubecker investigated their attitudes to euthanasia and found out that men and white people support the idea of euthanasia more than do women and black people. They stated that while religion displays a negative attitude toward euthanasia, different social classes display a positive attitude (Jorgenson & Neubecker, 1980). Our study is based on the improvement of a scale of attitudes toward euthanasia. The scale improved by us includes six factors used to compare the characteristics of the group participating in the study. At the end of our study we found that there were no differences between regional distinctions and religious views. However, Jorgenson and Neubecker stated that religious factors negatively affect the views regarding euthanasia (Jorgenson & Neubecker, 1980). Ramabele (2004) determined attitudes of the elderly toward euthanasia. According to this study finding, religious beliefs and gender were not found to have a significant correlation to euthanasia, but race was influenced on the attitudes of the elderly toward euthanasia. An American study of the association between the self-reported participation of intensive care nurses and their social

119 (18.8) 140 (22.2) 190 (30.1)

139 (22.0) 121 (19.1) 153 (24.2)

108 (17.1) 119 (18.8) 144 (22.8)

163 (25.8) 179 (28.3) 99 (15.7)

224 (35.4) 257 (40.7)

178 (28.2) 214 (33.9)

118 (18.7) 95 (15.0)

83 (13.1) 43 (6.8) 23 (3.6)

If a patient wants euthanasia, nutrition support should be stopped

103 (16.3)

A person should decide for his right to live

79 (2.5) 106 (16.8) 139 (22.0)

188 (29.7)

29 (4.6)

120 (19.0)

Patients with an incurable disease should not be allowed

63 (10.0) 98 (15.5) 135 (21.4)

215 (34.0)

If a patient wants euthanasia, his life support should be lessened

121 (19.1)

Patients with an incurable disease should not live half dead because of suffering and being hopeless

64 (10.1) 105 (16.6)

118 (18.7)

215 (34.0)

46 (7.3)

130 (20.6)

Patients without hope should not suffer

25 (4.0) 59 (9.39)

58 (9.2)

254 (40.2)

27 (4.3) 43 (6.8)

90 (14.2)

177 (28.0)

If a patient informs a doctor of his euthanasia wish, the doctor should help him die unless it is painful

236 (37.3)

Fear of death shows differences due to religious beliefs

71 (11.2)

76 (12.0)

49 (7.8)

193 (30.5)

73 (11.6)

295 (46.7)

Decision for euthanasia is affected by religious beliefs

Definitely disagree

Disagree

Undecided

Agree

Euthanasia is not killing a person, it is helping him to die

243 (38.4)

Completely agree

Euthanasia is the voluntary death of a person who has an incurable disease

Expressions

Table 2. Percentage of Health Staff’s Attitude toward Euthanasia


65 (10.3) 36 (5.7)

Euthanasia should be legalized in all countries

If legalized, I might want euthanasia

32 (5.1)

160 (25.3) 107 (16.9)

82 (13.0)

42 (6.6)

63 (10.0) 55 (8.7)

Euthanasia should be applied to a patient who is incapable of giving this decision himself

Euthanasia decision should certainly be consulted to families

Application of euthanasia to a patient who can’t decide himself should be consulted to families

In order to protect the dignity of a person who has an incurable disease, he should have the right for euthanasia

Life of a person who is in persistent vegetative state should be ended

CPR application is not convenient during terminal period

It is a burden for relatives to take care of a patient who is in terminal period and who will die

110 (17.4)

96 (15.2)

I wouldn’t like to live unless there is life support

Euthanasia decision should be given by the patient

66 (10.4)

When a patient wants euthanasia, CPR should not be applied in case of sudden respiration and heart stop

148 (23.4)

109 (17.2)

76 (12.0)

129 (20.4)

176 (27.8)

196 (31.0)

48 (7.6)

157 (24.8)

60 (9.5)

104 (16.5)

129 (20.4)

97 (15.3)

134 (21.2)

177 (28.0)

178 (28.2)

138 (21.8)

91 (14.4)

80 (12.7)

102 (16.1)

126 (19.9)

151 (23.9)

154 (24.4)

158 (25.0)

123 (19.5)

154 (24.4)

149 (23.6)

168 (26.6)

129 (20.4)

103 (16.3)

80 (12.7)

178 (28.2)

102 (16.1)

111 (17.6)

124 (19.6)

132 (20.9)

161 (25.5)

141 (22.3)

134 (21.2)

168 (26.6)

154 (24.4)

155 (24.5)

116 (18.4)

272 (43.0)

137 (21.7)

274 (43.4)

185 (29.3)

117 (18.5)

185 (29.3)

ATTITUDE TOWARD EUTHANASIA / 103

57 (9.0)

34 (5.4)

29 (4.6)

32 (5.1)

36 (5.7) 23 (3.6)

79 (12.5)

It is a burden for medical staff to take care of a patient who is in a terminal period and who will die

To end his life, deadly medicine should be given to a patient who is conscious and can decide himself for euthanasia

An unconscious patient’s life should be ended with the approval of his family

I would like euthanasia to be applied on me

I would like euthanasia to be applied to one of my family members

Application of euthanasia lessens people’s confidence in medicine

Completely agree

It is a burden for health organizations to take care of a patient who is in a terminal period and who will die

Expressions

Table 2. (Cont’d.)

130 (20.6)

42 (6.6)

62 (9.8)

98 (15.5)

55 (8.7)

92 (14.6)

92 (14.6)

Agree

123 (19.5)

120 (19.0)

153 (24.2)

115 (18.2)

123 (19.5)

77 (12.2)

87 (13.8)

Undecided

155 (24.5)

138 (21.8)

113 (17.9)

168 (26.6)

177 (28.0)

225 (35.6)

216 (34.2)

Disagree

145 (22.9)

309 (48.9)

268 (42.4)

219 (34.7)

248 (39.2)

204 (32.3)

180 (28.5)

Definitely disagree



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and professional characteristics showed that older, more religious nurses, nurses working in the cardiology unit, and nurses with less positive attitudes toward euthanasia are less likely to report having cooperated in performing euthanasia (Stevens & Hassan, 1994). The authors observed that the effect of the sex and religion of the nurses is probably mitigated by attitudes (Asch & Dekay, 1997). Reasons cited by the nurses for performing euthanasia without a physician’s authorization include a feeling of responsibility for the patient’s well-being and the wish to relieve the patient of his or her suffering (Kuhse, 1993). In South Africa Muslims made a declaration that active euthanasia where patients may end their lives by lethal injection is impermissible under any circumstances and that passive euthanasia where patients may withhold treatment or artificial life support is only permissible if a trustworthy, reliable opinion and specialist feels that there is no hope of survival (Ulama, 1999). Our study reveals that there is not a statistically significant difference between the social cost (factor 4) and gender. Garret and Harris (1993) found that women wanted life-sustaining treatments less often than did men. In a study that was conducted by Canneto (2002) about euthanasia and women, when mercy killings occur they are usually administered by men for women, with two-thirds of those being female. She also reported that women are over-represented in assisted suicide and euthanasia reports. Callahan (1999) suggested that women will be affected most by euthanasia simply because they live longer and have fewer resources than men. According to her, countries that have data on poverty by age and sex show that older women are more likely to be poor than older men and therefore favor euthanasia. The data obtained as a result of the study shows that there is a statistically significant difference between professions and the social cost (factor 4), and between the possibility to encounter patients requesting euthanasia and social cost (factor 4). In the study conducted by Oehmichen and Meissener (2000), it was argued that economic factors play a role in the individuals’ request for euthanasia. They mentioned that as medical treatment at the end of life becomes more expensive than ever, health insurance above all in the United States are beginning to question the economic soundness of providing long-term treatment to terminally ill patients. Our study also shows that there is a statistically significant difference between participating in a scientific meeting and attitude toward euthanasia (factor 1). This may suggest that health personnel, both physicians and nurses, may be affected by the pain suffered from the patients they encounter. In a study conducted in Turkey, it is reported that 77% of the physicians state that every individual has a right to decide on his or her own life (Özkara et al., 2002). In another study this rate among the students majoring in law is 56.7% (Özkara, YemiÕcigil, & Dalgic, 2001). In our study, professional groups are compared with all the factors but there is a significant difference only between social cost and professional groups. There


Table 3. Association between Socio-Demographic Characteristics of Health Workers and Point of Health Staff’s Attitude toward Euthanasia Scale Factor 1 n

Mean (SD)

Region Manisa Elazi

122 510

35.6 (11.7) 34.3 (12-22)

Gender Women Men

477 155

Marital status Married Unmarried

Factor 2 Test

Mean (SD)

Test

t = 1.033 df = 630 p = 0.302

6.9 (2.9) 6.69 (3.1)

t = 0.844 df = 630 p = 0.399

34.4 (11.7) 35.2 (13.5)

t = –0.671 df = 233.5 p = 0.503

6.8 (3.0) 6.7 (3.1)

t = 0.192 df = 630 p = 0.848

422 210

33.9 (12.4) 35.8 (11.6)

t = –1.771 df = 630 p = 0.077

6.7 (2.9) 6.9 (3.1)

t = –0.919 df = 630 p = 0.358

Group of occupation Specialist doctor General practitioner Nurse Midwifery

114 95 332 91

34.8 (13.3) 34.3 (12.0) 34.5 (11.9) 34.8 (11.7)

Participant of scientific meeting about euthanasia Participant Non-participant

54 578

38.4 (11.3) 34.2 (12.1)

t = 2.411 df = 630 p = 0.016

7.8 (2.9) 6.6 (3.0)

t = 2.743 df = 630 p = 0.006

Meeting patient who needs euthanasia during professional life Meeting Not meeting

207 425

37.6 (12.2) 33.1 (11.8)

t = 4.386 df = 630 p = 0.000

7.1 (3.1) 6.6 (2.9)

t = 2.115 df = 630 p = 0.035

F = 0.057 df = 3 p = 0.982

6.8 6.4 6.8 6.7

(3.2) (2.9) (3.0) (2.9)

F = 0.485 df = 3 p = 0.693

are quite a lot of studies reflecting the views of physicians and nurses in the world. However, there is no data about to the frequency of euthanasia and the rate of people who asked for euthanasia in Turkey. In a large scale study from Turkey, 19% of the physicians noted that they were asked to perform euthanasia (Özkara et al., 2004). Another study shows only 7.9% of the health professionals were requested to perform euthanasia. This can be explained by that fact that the study included not only physicians but also other health professionals (Turla et al., 2006-2007). The findings are similar in this study. In ethical debates about euthanasia, the focus is often exclusively on the involvement of physicians and involvement of nurses is rarely given much attention (Young, 1993). The role


107

Table 3. (Cont’d.) Factor 3 Mean (SD)

Test

Factor 4 Mean (SD)

Test

Factor 5 Mean (SD)

Test

Factor 6 Mean (SD)

Test

t = 0.434 12.1 (3.9) df = 630 11.9 (4.3) p = 0.665

t = –1.326 t = 0.744 7.0 (2.9) df = 630 10.2 (3.0) df = 630 7.5 (3.2) p = 0.185 9.9 (3.1) p = 0.457

t = 1.061 12.1 (4.1) df = 630 11.7 (4.5) p = 0.289

t = –2.461 t = –0.782 t = –0.823 7.2 (3.1) df = 235.3 9.9 (3.1) df = 630 11.7 (2.5) df = 630 8.0 (3.5) p = 0.015 10.2 (3.1) p = 0.411 11.9 (2.2) p = 0.434

t = 2.617 11.7 (4.2) df = 630 12.6 (4.1) p = 0.009

t = –1.147 t = 3.258 t = –1.397 7.3 (3.2) df = 630 11.9 (2.4) df = 630 9.9 (3.1) df = 630 7.6 (3.2) p = 0.252 10.3 (2.93) p = 0.163 11.3 (2.4) p = 0.001

F = 1.397 11.9 (4.5) df = 3 11.2 (3.9) p = 0.243 12.1 (4.3) 12.3 (3.6)

F = 6.646 F = 1.079 8.4 (3.4) df = 3 10.2 (2.2) df = 3 7.9 (3.5) p = 0.000 9.8 (2.9) p = 0.358 7.0 (2.9) 10.1 (3.1) 6.9 (3.0) 9.6 (3.0)

t = 0.612 12.3 (3.8) df = 630 11.9 (4.2) p = 0.541

t = 1.710 t = –3.128 t = –0.910 8.1 (3.1) df = 630 6.8 (2.1) df = 630 9.6 (2.4) df = 630 7.3 (3.2) p = 0.088 10.0 (3.1) p = 0.363 11.9 (2.4) p = 0.002

t = 3.268 12.8 (4.3) df = 630 11.6 (4.1) p = 0.001

t = 3.281 t = 1.597 7.9 (3.5) df = 630 10.3 (3.1) df = 630 7.1 (2.9) p = 0.001 9.9 (3.1) p = 0.111

t = –1.322 11.5 (2.5) df = 630 11.8 (2.4) p = 0.187

F = 1.080 12.1 (2.1) 11.9 (2.2) df = 3 11.7 (2.5) p = 0.357 11.6 (2.7)

t = –1.575 11.6 (2.2) df = 630 11.9 (2.5) p = 0.116

played by the nurse in carrying out euthanasia can vary from simple presence in person to the actual administration of the lethal medication (Asch, 1996). In those surveys, between 0% and 73% of responding doctors and between 0.4% and 88% of responding nurses answered that they would approve of VE or thought that there were some situations in which VE was justified (Asai, Miura, Tanabe, Kurihara, & Fukuhara, 1998; Chiyo & Tanaka, 1993; Miyashita, Hashimoto, Kawa, & Kojima, 1999; Sakamoto & Kitazawa, 1996). Asai et al. (2001) found that a total of 54% of the responding doctors and 53% of the responding nurses had been asked by patients to hasten death, of whom 5% of the former and none of the latter had taken active steps to bring about death.


Although 88% of the doctors and 85% of the nurses answered that a patient’s request to hasten death can sometimes be rational, only 33% and 23% respectively regarded VE as ethically right and 22% and 15% respectively claimed they would practice VE if it were legal. Logistic regression model analysis showed that the respondents’ profession was not a statistically independent factor predicting his or her response to any question regarding attitudes toward VE. The most widespread controversy on euthanasia in the world is on the legal aspect. Of all the participants in our study, 29.3% disagree that euthanasia should be legal in all countries whereas 16.5% agree and 24.4% are undecided. Currently, the only country where euthanasia is performed legally is the Netherlands. Other countries display different attitudes to the issue. While such countries as Germany and France clearly prohibit euthanasia, the United States winks at euthanasia practices performed with certain methods (Bernheim, 2001; Horton, 2001; &Inceolu, 1999; Özkara et al., 2001). In our country, euthanasia, although not clearly defined in the penal code, is generally considered as murder or assisted suicide. In a draft bill, euthanasia is defined as assisting a seriously sick person to commit suicide in order to end his or her pain and it suggests that the person who assists euthanasia be sentenced to one to three year imprisonment (Özkara , 2001). This punishment is quite lenient compared to the present laws. It is considered that the draft has been prepared in the light of general attitude to euthanasia in the world and that the physician performs the practice in order to help his or her patient. The regulations issued by the Ministry of Health on patients’ rights also prohibit euthanasia (Turkish Republic Government, 1998). There are several views and studies suggesting that euthanasia practices should be legalized. The results published by McLean and Britton (1996) in the United Kingdom (UK) revealed strong support for the legalization of physician-assisted suicide among the medical profession, and the population at large. The study revealed that a majority of medical practitioners (54%) are in favor of changing the law to allow physician assisted suicide in some circumstances, with only 36% of the respondents opposing such a change and 55% felt that this should be permissible if the person had a terminal condition or was in a state of extreme mental or physical suffering. According to Jowell and Curtice (1996), not only do euthanasia and assisted suicide already have the support of a substantial majority of the UK population, but also this support is actually growing. A 75% majority in favor of permitting medical assistance in the ending of life of a sufferer from a painful, incurable disease in 1984 increased to 79% in 1989, and 82% in 1994 (Jowell & Curtice, 1996). In a journal article published by De Beer and Gastmans (2004), it was reported that since April 2001, the Netherlands has had a legal regulation of euthanasia, making it the world’s first country to place euthanasia within a legal framework. In Belgium, after years of debate, the law governing euthanasia came into force on September 23, 2002. Before this date, euthanasia was illegal in Belgium. Euthanasia is illegal in every state of the United States, and does not have a prominent place in the debate on the end of life that is


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conducted in the United States (De Beer & Gastmans, 2004). According to Nortjè (2001), South Africa is currently facing proposed changes to the legislation on euthanasia. He reported that the South African Law Commission (SALC) (1997) released a discussion paper suggesting changes to legislation. Their request favors voluntary euthanasia as opposed to the current position, which is anti-euthanasia. There is not one single attitude appropriate for all countries concerning euthanasia. Thus, whereas it is prohibited in some countries, it is legally performed in other countries (&Inceolu, 1999; Özkara, 2001). Of course, the best approach is the one which best fits the country’s conditions. The most convenient solution for our country can only be found by determining the data after a detailed investigation. We have conducted our research so that it should cover both the physicians and the nurses. As we mention in our findings, only 16.55% of the health personnel supported the fact that euthanasia should be legalized. However, 43.4% of them say that they will not perform euthanasia even if it becomes a legal procedure. On the other hand, while investigating our conditions, it would be valuable to enlighten the public and to inquire their views on the issue. REFERENCES AcaDemon, N. I. (2004). The philosophies and legalization of euthanasia. Retrieved October 28, 2004, http://www.academon.com/lib/paper/49191.html Asch, D. A. (1996). The role of critical care nurses in euthanasia and assisted suicide. New England Journal of Medicine, 334(21), 1374-1379. Asch, D. A., & Dekay, M. L. (1997). Euthanasia among US critical care nurses: Practices, attitudes and social and professional; correlates. Retrieved October 28, 2004, http://jme.bmjjournals.com/cgi/content/full30/5/494 Asai, A., Miura, Y., Tanabe, N., Kurihara, T., & Fukuhara, S. (1998). Advance directives and other medical decisions concerning the end of life in cancer patients in Japan. European Journal of Cancer, 34, 1582-1586. Asai, A., Ohnishi, M., Nagata, S. K., Tanida, N., & Yamazaki, Y. (2001). Doctors’ and nurses’ attitudes towards and experiences of voluntary euthanasia: Survey of members of the Japanese Association of Palliative Medicine. Journal of Medical Ethics, 27(5), 324-330. Brock, D. (1992). Voluntary active euthanasia. Retrieved September 15, 2004, http://www.cariboo.bc.ca/ae/php/phil/MCLAUGHL/students/phil433/brock_1.htm Brogden, M. (2001). Genocide: Killing the elderly. London: Jessica Kingsley Publishers. Bernheim, J. L. (2001). Euthanasia in Europe. Lancet, 357, 1038. Caddell, D. P., & Newton, R. R. (1995). Euthanasia: American attitudes toward the physician’s role. Social Science and Medicine, 40(12), 1671-1681. Callahan, S. (1999). Euthanasia and women. Retrieved June 1, 2003, http://www.spuc.org.uk Canneto, S. (2002). Euthanasia and women. Retrieved June 1, 2003, http://www.spuc.org.uk


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