The ethical relevance of nursing care in euthanasia and assisted suicide

The recent passing of organic Law 3/2021 governing euthanasia recognises that in Spain people who wish it and who comply with certain requisites, may request assisted dying. The Law broadens the provisions a person may qualify for at their end-of-life stage.¹ In addition to palliative care, which constitutes the care professionals may offer at this life stage reality, people who are experiencing severe suffering due to illness or a health problem now have the opportunity themselves to request help in bringing forward their death.

The Law recognises two circumstances: euthanasia, the direct administration of a substance to a person by a healthcare professional and assisted suicide, which is the prescription or administration of a substance which the person may self-administer. Both are activated only provided that the request is made by the interested party, with greater recognition of autonomy at the end of life, beyond the consent to palliative care proposals. This situation is a highly fragile one for the person and the family who experience it, due to the magnitude of the help required and, in turn, it is also a significant ethical complexity for healthcare professionals, among whom are the nurses.

However, on the basis that euthanasia forms part of end-of-life medical decisions, the law does not clearly or explicitly encompass the work of nurses, thereby creating doubts as to their professional role in this process. Studies undertaken in countries with experience in the provision of euthanasia, such as Belgium, the Netherlands and Canada, show that nurses are an essential link between the person requesting it, their family or close relatives, the physician and the rest of the healthcare team. They also confirm that despite that the law, except in Canada, does not provide them with a specific role, they actively take part in the entire process of euthanasia, from the phase prior to formal formulation of the petition to the care of families after the death of the requesting person.² Nursing care forms part of the process of the care for people who request euthanasia.

This presence of care in different countries, environments and contexts, whether legally recognised or not, confirms the solidness of care provided by nurses who, anywhere and at any life stage, revolves around:

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  respect for the person and their way of understanding life.

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  accompaniment in the experience of falling ill, getting better, chronicity, or the end of life.

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  the central importance of assistance.

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  the search for favourable contexts which promote co-responsibility between the person requesting care and the person giving it.

Nurses can offer much to the process of assisted dying. At the end of life, the person is particularly fragile and dependent and unless their autonomy is recognised, their dignity may be compromised. The essential aspect of care is that in it the person is an autonomous being, and their active participation is an inherent part of the caring process. In keeping with the ethics of care, morale is built up in relation to others: in close interpersonal, group or community relationships people may consolidate and formulate their ethical values and consequently take decisions. As a result, in a request for euthanasia, caring is, above all, establishing the relational link that guarantees the creation of sufficient well-being so that the person may express their feelings and wishes, their fears and uncertainties, and may take the decision to ask for help to die in keeping with their own values and life history. Whilst this process lasts, either at the request for euthanasia or help in assisted suicide, they receive the care required. For this, nurses are key professionals due to their person-and-family-centred care guidance, their continuity, proximity and of course the knowledge they have gained in palliative care in satisfying end-of-life needs, particularly in pain management, everyday well-being and emotional support for the person and their family.³

Notwithstanding, helping someone to die is no simple matter, and acting in accordance with a preference to bring forward death may lead to ethical conflicts. Although nurses frequently occupy positions where their responsibility in direct care is very high, they command little room in care option decision-making. This may lead to them having to take actions on occasions to cover medical prescriptions which they are doubtful about or even disagree with, be it due to indication, dosing, time of administration, etc. These objections are linked to care where the nurse has a collaborating role and they are difficult to resolve, especially in highly hierarchical institutions or teams, where their participation in the decision to accept or not the request for euthanasia or help with assisted suicide is very small or non-existent. However, the nurse must be convinced that they are doing the right thing and it is ethically reprehensible that they may be forced to carry out actions under these circumstances. Here, the participative, inclusive philosophy related to the ethics of care constitutes a good framework for rethinking institutional democracy and that of healthcare teams, thereby resulting in the process of euthanasia or assisted suicide being multidisciplinary and interprofessional. Thus, together with the other team members, the nurse may fulfil their ethical duty in giving their evaluation and participating in the decision-making process. This duty is, for example, included in art. 29 of the Catalan nursing code of ethics.⁴

Objection may, however, stem from personal conscience. These are situations where the nurses cannot accept their participation in shortening someone’s life, regardless of the request, due to the conflict of values the situation represents for the nurse on a personal level. Conscientious objection is regarded as an ethical conflict between the individual’s right to their request and the nurse’s right to preserve their own personal values. Both rights depend upon each other, and they therefore cannot be respected at the same time, unless another professional, who is a non-objector, interjects. This is a legal and ethically correct solution if the individual is not abandoned. However, placing value on proximity, solidarity, and reciprocity, the ethics of care begs to question the third party’s scope in the confrontation between personal beliefs in anticipating death, and suggests the possibility of going beyond the self in being able to help the individual in what they are requesting. It is possible that this could be the setting to facilitate the objector nurse to participate in the deliberative process and in care after death. This is a decision that only the nurse may make, who must always weigh up what their conscience dictates against the satisfaction of the requirements for help of the person making the request.

Lastly, one has to consider that nurses work in institutions which may help or hinder the ethical dimension of their work, depending on directives and organisation. It is thus the ethical responsibility of institutions to develop policies which cover the whole process, where both palliative care and interdisciplinary cooperation are essential factors. Whatever its scope, the institution must explicitly recognise and promote the work of nurses and their leadership in care, clearly reflecting in multidisciplinary directives the roles and responsibilities of each profession. They should offer practical guides on communication to explore the wish to die, stimulate cooperation and interdisciplinary collaboration, and describe good care practice proposals.

To sum up, consideration of the ethical dimensions of nursing care is a guarantee of a good euthanasia or assisted suicide process, which finds its ethical meaning and content, as suggested by Ramón Bayés, in “relieving as much as possible avoidable suffering, trying to preserve life which, in the person’s view, deserves to be lived”, or in keeping with Virginia Henderson “assisting the individual to meet their needs as they ordinarily would”.