Introduction

Euthanasia and assisted suicide are controversial issues that can be analyzed from different perspectives such as legal, ethical, medical, bioethical, among others. In most cases they are difficult to address because few countries include them in their legislation and because of the need for some patients to have access to them without any major repercussions for them, their families and health personnel^1,2.

The United Kingdom's National Health System defines assisted suicide as the act of deliberately assisting another person to commit suicide. In the Netherlands, euthanasia is defined as a premeditated act to end one's life at one's request¹.

Health professionals traditionally strive to understand the pain of each patient and to treat it; however, sometimes they do not pay much attention to understanding suffering. Some authors have analyzed the meaning and significance of suffering. And in recent years they have begun to investigate when suffering becomes unbearable for a person, and therefore asks for help to die with dignity².

The term "euthanasia" has an etymological origin in Greek: eu (good) and thanatos (death), shown by Francis Bacon as a noble medical duty that consists of alleviating the suffering of the terminally ill as part of health care. From the 20th century onwards, he clarified the markedly negative relationship of the concept, deforming its definition of "good death" and using a new semantic thesis, which refers to the practice that aims at death caused by a health care provider³.

In a study conducted at the Santa Terezinha University Hospital in Brazil, a survey was applied to 354 health professionals in 2016. Eleven percent had received a request for help to hasten the death of a patient while 89% never received such a request⁴.

The general objective is to carry out a systematic review of the perspective on assisted suicide and euthanasia, for which the specific objectives are to describe the generalities of euthanasia and assisted suicide found in the different studies reviewed, to analyze the perspectives from the point of view of different professions on these terms, to identify the pros and cons of both practices and to analyze whether a particular religion or belief influences the perception of these practices.

Methodology

Type of research

A systematic review of the published scientific literature was carried out following the recommendations of the PRISMA statement.

Search strategies

The research was carried out by searching for information in scientific databases such as PubMed, SciELO, SCOPUS, Taylor and Francis, Google Scholar and Web of Science.

For the search, keywords related to the expected objectives were used, according to the terms Mesh and DeCs: "perception", "nursing", "euthanasia", "assisted suicide", "dignified death", "terminal patient", "health personnel", "nursing", "perception", "euthanasia" and "assisted suicide", "terminal patient", "dignified death", "health personnel". The intersection between these descriptors, using Boolean AND and OR connections, will be considered. Observational reports (cross-sectional, retrospective and prospective studies) on the perception of health personnel in intensive care units with critically ill patients will also be considered.

Inclusion and exclusion criteria

To select the sample, the following inclusion criteria were used: languages: Spanish, English and Portuguese, articles published from 2005 to 2021, original research or review articles, qualitative or mixed studies, and articles published from 2005 to 2021.

Articles and duplicate or repository publications, articles that do not have the expected scientific quality, articles with impossibility to retrieve the full text of the article and articles that cannot be downloaded were excluded.

Procedure

For the first stage, the topic and the formulation of the research question in the acronym PICO (Population, Intervention, Control and Outcome) format were identified: "What are the generalities about euthanasia and assisted suicide?", "What is the perception of health professionals about these practices?", "What are the pros and cons regarding these practices?" and "What is the influence of religion and beliefs on these issues?"

For the second stage, original articles and reviews related to the perception of nursing personnel on euthanasia and assisted suicide, published in Spanish, English and Portuguese with a full text and online, were established as inclusion criteria. In the exclusion criteria, thesis-type studies (undergraduate, graduate and doctoral), monographs and argumentative essays will be added.

Then, for the third stage, perform the primary selection of publications by verifying the reading of the title and abstract. For the fourth and fifth stages, the studies were evaluated with more criteria (according to my objectives), and the interpretation of the results achieved.

For the sixth stage I formed the discussion and synthesis of knowledge. We tried to offer a systematic review with inexorable and exhaustive scientific information with studies with more and better timely information, without introducing information or publication bias, in such a way as to contribute to the scientific community.

Results

Figure 1

Prepared by the authors.

Table 1. Articles selected by the systematic review.

Discussion

Based on the systematic review, 20 articles were selected that respond to these objectives: to describe generalities of euthanasia and assisted suicide, to analyze the perspectives from the point of view of health personnel on these terms, to identify the pros and cons of both practices, and to analyze whether a certain religion or belief influences their perception.

The practices of euthanasia and assisted suicide lack a universal definition, however they always generate emotional debates due to their ethical implications5. It is based on the bioethical principle of autonomy, according to which the patient has the right to decide how and when to die⁴.

Euthanasia was presented by Francis Bacon as a noble medical duty that consists of alleviating suffering in people in terminal processes⁶ referring to ending life in an effective, quick and painless way⁷ in people who suffer physical or psychological suffering as a result of a terminal disease and live in an unacceptable way^8,9.

This can be active, which implies the action of another who is the one causing death, while passive refers to the omission of resources such as: medication or devices to cause death. It can also be voluntary when the patient must give consent and involuntary when it is not necessary¹⁰.

However, in recent years the concept of euthanasia has been evolving, making it clear that what is required is a limitation of therapeutic effort or respect for the patient's decision not to receive any treatment⁸, thus detracting from the practice whose purpose is death caused by a health professional¹¹.

In contrast, assisted suicide is used when a mentally competent adult with a terminal or irreversible illness expresses his or her will to end his or her life, then takes medication prescribed by a physician, always after meeting strict legal safeguards^1,12.

In the United Kingdom, if a family member helps a loved one to end his or her life, he or she can be punished with up to 14 years in prison, and if this practice is performed by a physician, he or she can be charged with involuntary manslaughter or even murder, which is punishable with life imprisonment¹³.

Likewise, the Code of Ethics of Nursing Professionals prohibits promoting euthanasia or participating in the practice, in bioethics it is discussed whether it is possible to have a "good death" from resources of therapeutic adequacy, without abbreviation of life¹¹.

On the other hand, organizations such as Dignity in Dying campaign to allow mentally competent adults who are terminally ill to have the option of an assisted death⁵. Dignitas, a Swiss organization, ensures a dignified life and death for its members and accepts terminally ill people from all over the world¹³. However, there are doubts as to whether this practice can be abused when the motivation is other than altruism to reduce the patient's suffering⁷.

Currently assisted suicide is legal in four European countries. In Holland, Luxembourg, Colombia and Canada these practices are legal in patients in an irreversible condition⁴. On the other hand, Belgium is the only country in the world where child euthanasia is legal, provided that the child understands the implications and actively requests this practice^6,13.

For example, in a survey on euthanasia carried out by the Spanish Sociological Research Center in 2002, 7% of physicians agreed with the practice ^8. However, their role and desire to participate vary from individual to individual, from country to country and from the context of their practice^12.

Perception about something is a recognition and interpretation of sensory information, not attitudes, which are general evaluations that people have regarding a subject¹². Thus, health personnel believe that euthanasia is a right since it is a procedure that aims to protect the will of the patient, in a terminal state, to die with dignity⁷.

Now, it is of vital importance the concept that health professionals have about a terminal patient, which must meet these characteristics: being a carrier of a serious diagnosed disease, the same must be progressive and irreversible and fatal¹⁴, at the time of diagnosis there must be no cure for it⁷.

Such is the case that, in a survey carried out by the Official College of Physicians of Barcelona in 1988 among its members, 82% expressed the need for a cure for the disease. Eighty-two percent expressed the need for a law regulating the practice of euthanasia, while 17% were opposed to the drafting of such a law⁸.

However, there is no consensus among nurses about euthanasia or assisted suicide and the factors that may influence their participation in this process¹². The question to be resolved in these cases is whether the patient decides to live or die, to live under what conditions or to die in what way⁷.

For example, a study on the perception of eight intensivist nurses of a Regional Hospital revealed that, regarding euthanasia, three of them identified it as "good death", but the others stated that it was an illegal practice because it is the premature provocation of death, supported by the Code of Ethics of Nursing Professionals^11.

Finally, when questioned about the practice of euthanasia, all of them denied that it occurs in their area of work, stating that orthothanasia is recurrent and that even distanasic processes can be identified¹¹. On the contrary, in a study from New Zealand, nurses support these practices arguing that it will increase patient autonomy^5,6.

On the other hand, the perception on these issues changes when the professional puts himself in the place of the patient, such a case was reflected in a study conducted in a hospital in Brazil in 2018, where 354 participants, including students and health professionals, were questioned about whether they would undergo these practices if they had a terminal illness, 15.3% answered "decisively yes", 47.7% "probably yes", 24.3% "probably no", and 12.7% "decisively no". When asked about the reasons for their disagreement, 41.9% answered "personal reasons", 28.6% "moral/legal principles", 10.6% "religious principles", and 18.9% "other reasons" ⁴.

Thus we can say that among the factors influencing the acceptance of these practices are: avoidance of extreme uncontrollable pain, unbearable suffering or other distressing experiences of the patient, the legality of euthanasia and the patient's right to die^12,15. While the factors that determined the opposition to these practices are: religion, moral and ethical dilemmas⁵, the gender role of the health professional and the opinion that palliative care is deficient¹².

It should be noted that it is important to understand that the human being's opinion regarding euthanasia is conditioned to the thought that killing is wrong and should be confronted and banished by society⁶. For some health professionals the emotional burden and fear of psychological consequences is the main cause of opposition¹⁶, since participation may contrast with the perception of the professional role, personal perception and responsibilities¹⁷.

It should be noted that among health personnel there are factors that cause euthanasia to be taken as unfavorable such as: lack of self-education and lack of knowledge, myths, incomplete laws or lack of legislation and religion¹⁸.

As for religion, this is a factor that has a significant influence, since those who oppose euthanasia and assisted suicide have ethico-religious reasons^2,12, arguing that it is neither ethical nor right to help someone to die4 and that life should be treated as sacred and inviolable¹⁰.

Likewise, people's views on euthanasia are strongly influenced by moral traditions. For the Judeo-Christian moral tradition, the opinion regarding euthanasia is that all human life is sacred, it is a gift given by God, so we cannot dispose of it, hence the law not to kill¹⁹.

Such is the case that in a study carried out at the University of London among pharmacy students, 70% said they were religious, 80% of these said that they currently practice their religion and 58.2% believe that their belief has a significant influence on their opinions on assisted suicide^13.

If we appeal to a simile, a study by the BBVA Foundation in 2004 on the perceptions of 3,000 university students, 45% of whom declared themselves Catholics, were surveyed on eight issues of moral debate and euthanasia had a score of 7.5 on a scale ranging from 0 (never justifiable) to 10 (always justifiable)⁸.

Another example is a study carried out at the University of Greenwich where 297 people participated, of whom 64.2% said they had no religion, 86.6% of them support euthanasia and assisted suicide. Of these, 23% identified themselves as Christians and 30.8% as Muslims, who defended the idea that they did not support these practices. Sixty percent of Jewish and Hindu people defend the approval of a law allowing these practices⁵.

Even so, the Andalusian law of "rights and guarantees of the dignity of the person in the process of death" does not regulate the discussion of conscience and encourages health professionals to refrain from imposing management criteria based on personal, moral, religious and philosophical opinions and beliefs²⁰.

Conclusions

Medicine over the years has evolved from the desire to cure and treat to (a more comprehensive one) of “to prevent, care and alleviate”. In this aspect, preventing or treating the suffering that many people have to deal with must be vital.

For patients in a terminal state or with illnesses that cause great suffering and do not have a good prognosis, it is of vital importance to try not only to maintain life at all costs but also to value the quality of life that is being offered to them.

Suggestion: vital importance to weigh out the decision whether to try to maintain life at all costs or to value the quality of life being offered and proceed in consequence.

In these cases, euthanasia and assisted suicide could be management alternatives. This is why health personnel should have sufficient knowledge about these issues to understand the patient and be able to provide adequate information. Although these practices are not yet legislated in most countries, there are international organizations to which patients can have access.

In Ecuador, since there is no law that enables these practices, it is necessary to emphasize quality palliative care in a timely manner. It is the only alternative to alleviate some of the suffering of people who come to us in the hope of receiving help. It is proposed that research be carried out on palliative care in countries where euthanasia and assisted suicide are not legislated, as well as its influence on patients with terminal illnesses.

References

1. Sulmasy DP, Travaline JM, Mitchell LA, Ely EW. Non-faith-based arguments against physician-assisted suicide and euthanasia. The Linacre Quarterly [Internet] 2016; 83(3):246–57. Disponible en: https://pubmed.ncbi.nlm.nih.gov/27833206/

2. Ramos-Pozón, S. Sufrimiento insoportable, salud mental y eutanasia. Apuntes para las enfermeras. Cultura de los Cuidados [Internet] 2020; 24 (58). Disponible en: https://culturacuidados.ua.es/article/view/2020-n58-sufrimiento-insoportable-salud-mental-y-eutanasia-apuntes-para-las-enfermeras

3. Padovani AM, Clemente ME. Eutanasia y legislación. Cuad bioética [Internet]. 1992;3(9):59–60. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1561-31942008000200016

4. Brandalise VB, Remor AP, Carvalho D de, Bonamigo EL. Suicídio assistido e eutanásia na perspectiva de profissionais e acadêmicos de um hospital universitário. Rev Bioética. [Internet] 2018;26(2):217–27. Disponible en: https://www.scielo.br/j/bioet/a/xrL9mwvtSGqvv3G9KFjv9KB/?lang=pt

5. Pentaris P, Jacobs L. UK Public’s Views and Perceptions About the Legalisation of Assisted Dying and Assisted Suicide. Omega (United States) [Internet]. 2020. Disponible en: https://journals.sagepub.com/doi/abs/10.1177/0030222820947254?journalCode=omea

6. Alves AA, Mendes FK, Cardoso F, Meira BR, Almeida A, Gonçalves JF, Alves JM, Parrela A. Percepção de profissionais da saúde sobre eutanásia. Rev Bioética. [Internet] 2020;28(1):111–8. Disponible en: https://www.scielo.br/j/bioet/a/H4jVtjCFbd7sRyjZQggtmXL/?lang=pt

7. Aristizabal LE. Eutanasia hoy: precisiones y dudas. Cult Cuid enferm [Internet]. 2015;12(1):83–91. Disponible en: https://dialnet.unirioja.es/servlet/articulo?codigo=6003064

8. De Miguel C, López A. Eutanasia y suicidio asistido: Conceptos generales, situación legal en Europa, Oregón y Australia (I). Med Paliativa [Internet]. 2006;13(4):207–15. Disponible en: https://derechoamorir.org/wp-content/uploads/2018/04/eutanasia-y-suicidio-asistido-conceptos-generales-y-situacion-legal.pdf

9Bogado F. Conocimientos y actitudes acerca de la eutanasia y el suicidio asistido en estudiantes y profesionales del área de salud del hospital de clínicas, San Lorenzo, Paraguay [Internet]. 2020;4(1):10–7. Disponible en: https://www.medicinaclinicaysocial.org/index.php/MCS/article/view/115/152

10. França JL, Carneiro ER, dos Santos RL. Social representations on euthanasia between students of law and medicine: A comparative analysis. Trends Psychol. [Internet].2019;27(3):805–18. Disponible en: https://www.scielo.br/j/tpsy/a/tqJ4PQVqpnLZYv9YgVTkTsh/?lang=en

11. Souza R, de Souza CL, Duarte R, do Nascimento GP, Alencar ChL, Grudka G. Percepción de las enfermeras intensivistas de un hospital regional sobre distanasia , eutanasia y ortotanasia [Internet]. 2016;24(3):153–66. Disponible en: https://www.scielo.br/j/bioet/a/P4Bg7cT5qmj3XFhKKrVsDXN/abstract/?lang=es

12. Betancourt P, Alessandro M. La eutanasia y la muerte digna en el ordenamiento jurídico ecuatoriano. Revista Digital de Ciencias Jurídicas de UNIANDES [Internet]. 2020;3:65–76. Disponible en: https://core.ac.uk/download/pdf/288220193.pdf

13. Clayton BV., Nabhani-Gebara S. When is it acceptable to allow a terminal patient to die? Pharmacy students’ views from a London University. J Oncol Pharm Pract. [Internet]. 2021;27(3):521–30. Disponible en: https://pubmed.ncbi.nlm.nih.gov/32393103/

14. Sarmiento MI, Vargas SL, Velásquez CM, Sierra M. Problemas y decisiones al final de la vida en pacientes con enfermedad en etapa terminal. Rev Salud Publica. [Internet]. 2012;14(1):116–28. Disponible en: https://www.scielosp.org/article/ssm/content/raw/?resource_ssm_path=/media/assets/rsap/v14n1/v14n1a10.pdf

15. Cayetano-Penman J, Malik G, Whittall D. Nurses’ Perceptions and Attitudes About Euthanasia: A Scoping Review. J Holist Nurs [Internet]. 2021;39(1):66–84. Disponible en: https://journals.sagepub.com/doi/abs/10.1177/0898010120923419

16. Bouthillier ME, Opatrny L. A qualitative study of physicians’ conscientious objections to medical aid in dying. Palliat Med. [Internet]. 2019;33(9):1212–20. Disponible en: https://pubmed.ncbi.nlm.nih.gov/31280666/

17. Kelly B, Handley T, Kissane D, Vamos M, Attia J. An indelible mark the response to participation in euthanasia and physician-assisted suicide among doctors: A review of research findings. Palliat Support Care. [Internet]. 2020;18(1):82–8. Disponible en: https://pubmed.ncbi.nlm.nih.gov/31340873/

18. Rios CM, De Benedictis GA, Córdova GJ, Contreras ML, Contreras LV. Conocimiento y percepción sobre eutanasia en estudiantes de medicina de diecisiete países latinoamericanos, 2017. Memorias del Inst Investig en Ciencias la Salud. [Internet]. 2018;16(3):58–65. Disponible en: http://scielo.iics.una.py/pdf/iics/v16n3/1812-9528-iics-16-03-58.pdf

19. Goic A. Apuntes sobre la eutanasia. Rev Med Chil. [Internet]. 2005;133(3):371–5. Disponible en: https://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000300014#:~:text=En%20el%20tema%20de%20la,deber%C3%ADa%20estar%20jur%C3%ADdicamente%20permitida%20o

20. Monedero P, Navia J. Limiting therapeutic intervention and euthanasia: making decisions and resolving conflicts in end-of-life-care. Rev Esp Anestesiol Reanim [Internet]. 2010;57(9):586–93. Available from: http://dx.doi.org/10.1016/S0034-9356(10)70286-3