Then American Nurses Association's Code of Ethics possesses an underlying emphasis on the concepts of self-determination (i.e., autonomy), benefcence (i.e., doing good), and nonmaleficience (i.e., avoiding evil) (Cassells & Redman 1989). The values reflected in his code are fundamental to baccalaureate nursing education. However, with the ever-expanding ethical demands of modern technology, nursing students will need to cope with increasingly complicated ethcal dilemmas, including physician-assisted dying (PAD) and active euthanasia, Physician-assisted dying is a medical procedure carried out by a phyisican to terminate life (Young, Volker, Rieger, & Thorpe, 1993), whereas active euthanasia is a deliberate action to hasten the death of mother being (Sumodi, 1995).
Nursing education's role in students' attitudes toward these issues and whether their attitudes are reflections of their moral values are unclear. To answer these questions, this study examined nursing students' attitudes toward PAD and its legalization. In addition, it examined the relationship between nursing students' attitudes and religious beliefs and exposure to relevant educational courses.
Among the ethical dilemmas mentioned most frequently by nursing students are those related to care of patients with terminal illnesses (Cassells & Redman, 1989). Pederson (1992), in her study of nursing students' perceptions of their skill in discussing controversial issues, found that students had the greatest difficulty reaching a consensus regarding terminally ill patients' right to end their lives.
Thrush, Stewart, and Paulus's (1985) study revealed that more than 30% of a student nurse population at a state and community college were accepting of terminally ill adult patients' right to request active euthanasia. In a study of Norwegian nursing students, 55% stated that suicide by terminally ill cancer patients would be acceptable to them (Sorbye, Sorbye, & Sorbye, 1995).
The two major variables identified in the literature that relate to student nurses' ethical behaviors when confronting ethical dilemmas are nursing education and religious beliefs. Therefore, nursing research has sought to examine the effect of these variables on ethical behavior.
Nurses have identified ethical content taught in nursing courses as the most important factor in developing ethical decision-making skills (Cassells & Redman, 1989; Gaul, 1989). Findings also have demonstrated a relationship between nursing students' ethical behavior scores and their level of education. In a study conducted in Belgium, more than 2,600 nursing students' ethical reasoning scores increased with their level of nursing education (Dierckx de Casterle, Janssen, & Grypdonck, 1996). A review of studies on nurses' moral reasoning revealed that nurses who have completed higher education (i.e., master's degree) have higher levels of moral reasoning and that nursing students' moral reasoning scores increased with each year of study (Duckett et al., 1992). In addition, although studies have shown a gap between knowing the correct ethical action and actually choosing it, the gap appears to narrow when baccalaureate nursing students complete a formal course in ethics (Gaul, 1989).
Religious beliefs also have been identified as a major variable related to attitudes toward ethical issues. This is true of both university students' and nursing students' attitudes toward active euthanasia and PAD. Weiss (1996), in his study of American college students, showed that students with higher scores on the religiosity index were significantly less likely to believe physicians should be allowed to help terminally ill patients die. Sorbye, Sorbye et al.'s (1995) study revealed that the degree of Norwegian nursing students' religious beliefs was an important predictor of their attitudes toward active euthanasia. In addition, religious affiliation may affect students' attitudes toward active euthanasia.
No research has been conducted on Israeli nursing students' attitudes toward active euthanasia and PAD. In addition, Israeli nurses' attitudes toward active euthanasia were reported in only one study, which compared the attitudes of nurses in different countries toward active euthanasia. The highest scores for active euthanasia support were among the Israeli nursing population (Davis et al., 1993). However, there was some confusion regarding participants' understanding of the term active euthanasia (Davis et al., 1993).
Purpose and Hypotheses
The purpose of this study was to survey nursing students' attitudes toward PAD and to determine the factors related to such attitudes. Two hypotheses were made:
* A relationship exists between relevant educational background and nursing students' attitudes toward PAD.
* A relationship exists between students' religiosity and their attitudes toward PAD.
One hundred ninety-two nursing students in either their first year or final year at three Israeli nursing schools were asked to participate in this descriptive study. Two of the schools were secular, academic programs. The third school was a religious, 3-year, diploma school. Both types of schools are required to teach students the same core curriculum as defined by the Israeli Ministry of Health. The primary difference between the schools is religious emphasis.
Two students refused to participate in the study due to health problems. The remaining 190 students completed the Nurses' Attitudes Regarding PhysicianAssisted Dying (NARPAD) questionnaire, which was administered during a class session by the researchers or an associate.
Physician-assisted dying was defined as a medical procedure that humanely terminates the life of a competent, terminally ill adult who freely requests the procedure. This procedure may be completed by a physician or a designee of a physician.
Attitudes Toward PAD. Students' attitudes toward PAD were measured by their responses to the NARRAD questionnaire. The questionnaire is composed of four situational vignettes in which a patient requests PAD, followed by a choice of four responses requiring various levels of nurse involvement with PAD (Young et al., 1993) (Table 1). A Hebrew translation of the questionnaire was used. Content validity and readability of the NARPAD questionnaire have been established (Young et al., 1993).
To ascertain test-retest reliability, 13 students completed the questionnaire twice within 2 weeks. Because the measure is nominal, the Kappa measure was used to assess stability over time for each of the vignettes. According to Anthony (1999), the Kappa values for three of the vignettes indicated substantial to almost perfect agreement (vignette #1: k = .76, p = 0; vignette #2: k = .83, p = 0; vignette #3: k = .79, p = .007). However, the Kappa value for the fourth vignette indicated only fair agreement and was not statistically significant (k = .27, p = .07). In this vignette, the patient has a long history of suffering. The lack of stability may be due, in part, to the ambivalence the nursing students experienced while considering PAD in this situation. In another study of Israeli public health nurses' attitudes toward PAD, the stability of the same measure was moderate to almost perfect (vignette #1: k = .75, p = 0; vignette #2: k = .87, p = 0; vignette #3: k = .59, p = .001; vignette #4: k = .64, p = .004) (Goldschmidt, Musgrave, & Margalith, 2000).
Religious Beliefs. Students' religious beliefs were measured by their religious affiliation and degree of religiosity. Students' religious affiliation was defined as students' report of the religion to which they belong. Degree of religiosity was defined as students' perception of their level of religiosity.
Two standard questions offered in Israeli questionnaires were used to measure students' religious affiliation and degree of religiosity. The question used to measure religious affiliation was, "What is your religion?," followed by "Judaism," "Islam," "Christianity," and "Other" as possible responses. The question used to measure degree of religiosity was, "How would you define yourself in relation to the religion?," which was followed by "Very religious," "Religious," "Moderately religious," and "Secular."
Relevant Educational Background. Relevant educational background was defined as students' past participation in an oncology clinical experience and theoretical exposure in an ethics course that addressed euthanasia. The yes or no questions related to the students' educational background included:
* "Have you had a clinical experience on the oncology, hematology, or bone transplant wards?"
* "Have you ever participated in a course that addressed the issue of euthanasia?"
Attitudes Toward Legalization of PAD. Students' attitudes toward the legalization of PAD in Israel was defined as their willingness to support a legal proposal! related to the issue and was measured by the yes or no question, "Would you support a legal act that would allow physicians to facilitate death for a competent, terminally ill adult who requests it?"
Demographic Data. In addition to the above measurements, the students completed a demographic data sheet that included gender, age, marital status, and level of education, which was defined as the year of study in the school of nursing (i.e., first year or final year).
Students' ages ranged from 19 to 45, with a mean of 22.7 (SD = 4.03). One hundred sixty students (84.2%) were women and 30 students (15.8%) were men. In this study, 57.4% (n = 109) were first-year students, and 38.9% (n = 74) were final-year students. The remainder of students gave no response.
Students were predominantly Jewish (n = 155, 81.6%); 20 (10.5%) were Muslim, and 8 (4.2%) were Christian. Seventy-four of the students (38.9%) did not consider themselves religious (i.e., secular), 34 (17.9%) reported being moderately religious, and 79 (41.6%) reported being religious or very religious. The remainder of students gave no response.
Regarding the students' relevant educational background, only 59 (31.1%) reported having clinical experience in the oncology field, whereas 125 students (65.8%) did not have such clinical experience. The remainder of the students gave no response. Seventy-six students (40%) reported attending a theoretical course that included the issue of euthanasia, whereas 87 students (45.8%) did not take much a course. The remainder of the students gave no response.
Frequencies of Students' Responses to the Vignettes on the Nurses' Attitudes Regarding PAD Questionnaire
Seventy-seven students (40.5%) supported legalization of PAD, whereas 96 students (50.5%) were against legalization of PAD. Seventeen students (8.9%) did not reply to this question.
There was no significant relationship between responses to the PAD items and students' age or marital status, and there was only one significant relationship between responses to PAD items and gender (vignette #1: χp 2(3) = 8.46, p < .05). In rignette #1 (i.e., a nurse with a long-term relationship with the patient), the male students were more likely to agree with PAD than the female students, but female students who disagreed with PAD were more likely to stay with the patient during PAD than the male students. In addition, only one significant relationship between responses to PAD items and students' level of study was found (vignette #2: χp 2(3) = 7.55, p = .05). In vignette #2 (i.e., a nurse with no prior relationship with the patient), students in their final year of study were more likely to stay with the patient even if they disagreed with PAD.
Three of the vignettes examined the students' attitudes toward passive involvement with PAD (i.e., #1, #2, #4). The students' responses to each of the vignettes were almost equally distributed among the response alternatives (Table 1). However, combination of responses according to two dimensions (i.e., agreed with PAD and would be present) revealed that in three of the vignettes (i.e., #1, #2, #3), most of the students disagreed with PAD. Only when suffering was involved did this tendency to disagree with PAD change into equivalence between agreement and disagreement.
The students' willingness to comply with the patient's request and be present in the room during PAD differs according to the vignettes. Most students refused to stay if they had no prior relationship with the patient. In vignette #3 (i.e., the nurse administers the lethal medication), most students did not agree with PAD (n = 106, 55.8%) and did not want to perform it (n = 169, 88.9%). In addition, although a large minority of students agreed with PAD (n = 81, 42.6%), they would not personally administer the medication (n = 66, 34.7%).
The relationship between religious affiliation and the vignettes in which the students were passively involved were significant (vignette #1: χp 2(9) = 16.6, p < .01; vignette #2: χp 2(9) = 14.5, p < .05; vignette #4: χp 2(9) = 17.09, p < .05). In these vignettes, Jewish students were more supportive of PAD than non-Jewish students. In vignette #1 and vignette #2, non-Jewish students who disagreed with PAD were less likely than Jewish students to stay with the patient. In vignette #4 (i.e., the effect of patient suffering), non-Jewish students were more supportive of PAD than they were in vignettes #1 and #2. In addition, non-Jewish students who disagreed with PAD in vignette #4 were more likely to stay with the patient than Jewish students.
Vignette #3 violated chi square assumptions. Therefore, only frequencies are reported. However, the vignette's results showed a similar trend among the Jewish and non-Jewish student populations. Although both Jewish and nonJewish nursing students were unwilling to administer the medication, Jewish students were more willing to administer it than non-Jewish students.
Degree of Religiosity and Students' Attitudes Toward Physician-Assisted Dying
The relationship between students' degree of religiosity and attitudes toward PAD was statistically significant in vignettes #1, #2, and #4 (Table 2). In these vignettes, the students who considered themselves religious or very religious consistently did not support PAD, although a large minority consistently agreed to a patient's request for the nurse to be present when the lethal drug was administered. On the other hand, the majority of students who considered themselves secular supported PAD and would agree to a patient's request for them to be present during PAD (vignette #1: χp 2(90) = 40.52, p = .000; vignette #2: χp 2(9) = 49.53, p = .000; vignette #4: χp 2(9) = 43.09, p = .000). The data on vignette #3 violated chi square assumptions. Therefore, only frequencies are reported. The students' responses to vignette #3 demonstrated a different trend than the other vignettes. The majority of the secular students (53.4%) would refuse to administer a lethal drug to a patient, although they supported PAD. However, similar to the previous vignettes, the religious and very religious students were against PAD, and most (89.5%) would not agree to fulfill a patient's request for the nurse to administer the lethal drug.
No statistically significant relationship was found between the students' theoretical or clinical backgrounds and their attitudes toward PAD. However, for vignette #3, a trend was identified. Students who did not attend a theoretical course on euthanasia were more likely to agree with PAD in this vignette.
The results of this study demonstrate that exposure to theoretical knowledge regarding euthanasia or having a clinical experience in oncology played a small role in shaping Israeli student nurses' attitudes toward PAD. A greater determinant of their attitudes were their religious beliefs. Less than half of the nursing students in this study (40.5% to 47.9%) supported PAD. However, a study of American nursing students in 1985 found even less support for PAD (14% to 34%) (Thrush et al., 1985), so PAD may be gaining increasing acceptance among students with the passage of time.
In a 1992 study conducted at a liberal arts college, 55% of the students support ed PAD (Weiss, 1996). A 1991-1992 survey of Norwegian nursing students' attitudes toward PAD similarly found that 55% of the students supported PAD (Sorbye et al., 1995). The growing trend of students accepting PAD may be reflective of the escalating international acceptance of PAD. It will be important to determine whether there will be a corresponding shift in Israeli nursing students' attitudes toward PAD due to increasing pressure to liberalize attitudes toward PAD.
Of the four vignettes, vignette #2 received the least support. More than half of the students (54.2%) disagreed with PAD and were unwilling to administer the lethal drug. An additional more than one third of students, although supportive of PAD, would not administer the lethal drug. Studies examining the attitudes of oncology nurses (Young et al., 1993), nurses in Nevada (Kowalski, 1993) regarding active euthanasia demonstrated a similar trend. This could be indicated of a perception that actual asdministration of a lethal drug is a more decisive step in the termination of a dying patient's life than nursing students and other health professionals are willing to take.
The lack of a relationship between relevant educational background and student's attitudes toward PAD is surprising because many students are exposed to patients with advanced cancer during oncology clinical experiences and rare of dying patients ha; been identified by nursing students as one of the major catsgories of stressful episodes in nursing Kleehammer, Hart, & Keck, 1990). In addition, a significant relationship between ethical behavior scores and personal experience in the clinical field also has been demonstrated (Dierckx de Casterle et al., 1996). The lack of relationship between having an oncology clinical experience and students' attitudes toward PAD in this study may be due to short length of exposure to dying patients. A short clinical experience may not be sufficient to influence students' attitudes toward PAD.
Theoretical knowledge on euthanasia also did not appear to affect students' attitudes toward PAD. In addition, no significant relationship was found between firstyear and final-year students' responses to PAD. These findings may be contrasted with those of other studies. A study on senior nursing students indicated the most important factor in the development of ethical decision making was the ethical concent taught in the nursing course (Cassells & Redinan, 1989). An American Association of Colleges of Nursing study found that 14% of senior students in a baccalaureate program indicated their nursing ethics course was a major source for developing ethical decision-making abilities (Gaul, 1989). In addition, higher levels of nursing education have been significantly related to increased reasoning (Dienckx de Casterle et al., 1996; Duckett et al., 1992).
Considering these studies, why did theoretical knowledge have little effect on students' responses to PAD in this study? A possible explanation may be that most Israeli nursing students are required to complete only one ethics course. However, it has been shown that participation in one ethics course is significantly related to moral choices and actions among nursing students (Gaul, 1987) and attitudes toward PAD among Israeli nurses (Musgrave, Margalith, & Goldschmidt, 2001). Therefore, a more likely explanation is that attitudes toward PAD are related to basic moral values that are more likely to be determined by family and community than by college education (Hunt, 1997). This idea is supported in this study by the significant relationship between religious beliefs and attitudes toward PAD because religious beliefs often are shaped by family and community during childhood.
Degree of religiosity among the nursing students was a significant determinant of attitudes toward PAD. The more religious students were, the less likely they were to support PAD. A similar trend has been demonstrated in previous studies. Being actively religious has been strongly associated with negative attitudes toward PAD among oncologists, oncology patients, the general public (Emanuel, Fairclough, Daniels, & Clarridge, 1996), college students (Weiss, 1996), and nursing students (Sorbye et al., 1995). Interestingly, a large minority of the religious nursing students who disagreed with PAD said they would stay with a patient while a lethal drug was being administered. Because the majority of the students were women, this may reflect the emphasis on care, which is considered to be more prevalent among women than men.
Gilligan's (1982) theory on women's moral development maintains that women are more concerned with relational aspects of the context, rather than principles, in moral decision making. Peter and Gallop (1994) found that female medical students favored a caring, moral orientation. In a study conducted among Australian medical students, a similar trend was reported (Price, Price, Williams, & Hoffenberg, 1998). Female medical students in that study were more likely to incorporate caring in their decision making (Price et al., 1998). This may be supported further by the significant gender difference found in this study in responses to the vignette concerned with a long-term relationship with a patient. Male students who disagreed with PAD were less likely than female students to stay with the patient while a lethal drug was administered.
The Jewish nursing students generally were more supportive of PAD than the non-Jewish students. Jewish health professionals in other studies have shown a greater support for PAD. In Young et al.'s (1993) study, Jewish oncology nurses were more supportive of PAD than Protestant or Roman Catholic nurses. In Kinsella and Verhoef s (1993) study, Jewish Canadian physicians also demonstrated greater support for PAD. The explanation for nonJewish students' attitudes toward PAD in the vignette concerned with suffering (#4) is difficult. The sample of non-Jewish nursing students was small and consisted of both Muslim and Christian nursing students. Further research involving larger samples of Israeli, Arab, Christian, and Muslim nursing students would need to be conducted to determine whether this attitude persisted.
This study has several limitations. A nonrandom sample was used, which limits the ability to generalize the results. In addition, the sample consisted primarily of nursing students of one religious group. Taking into consideration the sensitivity and special characteristics surrounding PAD and active euthanasia, the possible differences that exist between theoretical courses that address these issues cannot be ignored. However, despite these limitations, this exploratory study revealed a positive relationship between nursing students' religious beliefs and their attitudes toward PAD. However, no relationship was found between their attitudes toward PAD and relevant nursing education.
Further research must be conducted among nursing students from other religious groups in Israel and among nursing students from other countries to determine more clearly what part religious beliefs and education play in influencing nursing students' attitudes toward PAD. Finally, research should be conducted that not only surveys nursing students' attitudes toward PAD but also compares nursing students' attitudes toward these issues with those of other caregivers.
- Anthony, D. (1999). Understanding advanced statistics. Edinburgh: Churchill Livingstone.
- Cassells, J.M., & Redman, B.K. (1989). Preparing students to be moral agents in clinical nursing practice. Nursing Clinics of North America, 24, 463-473.
- Davis, A.J., Davidson, B., Hirschfield, M., Lauri, S., Lin, J.Y., Norberg, A., et al. (1993). An international perspective of active euthanasia: Attitudes of nurses in seven countries. International Journal of Nursing Studies, 30, 301-310.
- Dierckx de Cesterie, B., Janssen, RJ., & Grypdonck, M. (1996). The relationship between education and ethical behavior of nursing students. Western Journal of Nursing Research, 18, 330-350.
- Duckett, L., Rowan-Boyer, M., Ryden, M. B., Crisham, P., Savik, K., & Rest, J.R. (1992). Challenging misperceptions about nurses' moral reasoning. Nursing Research, 41, 324-331.
- Emanuel, E.J., Pairclough, D.L., Daniels, ER., & Clarridge, B.R. (1996). Euthanasia and physician assisted suicide: Attitudes and experiences of oncology patients, oncologists, and the public. Lancet, 347, 1805-1810.
- Gaul, A.L. (1987). The effect of a course in nursing ethics on the relationship between ethical choice and ethical action in baccalaureate nursing students. Journal of Nursing Education, 26, 113-117.
- Gaul, A.L. (1989). Ethics content in baccalaureate degree curricula: Clarifying the issues. Nursing Clinics of North America, 24, 475-483.
- Gilligan, C. (1982). In a different voice. Psychological theory and women's development. Cambridge: Harvard University Press.
- Goldschmidt, L., Musgrave, C, & Margalith, I. (2000). Public health nurses' attitudes towards physician assisted dying: The role of religiosity and education. Unpublished manuscript.
- Hunt, G. (1997). Moral crisis, professionals and ethical education. Nursing Ethics, 4, 29-38.
- Kinsella, T.D., & Verhoef, M. J. (1993). Alberta euthanasia survey: 1. Physicians' opinions about the morality and legalization of active euthanasia. Canadian Medical Association Journal, 148, 1921-1926.
- Kleehammer, J., Hart, A.L., & Keck, J. (1990). Nursing students' perceptions of anxiety-producing situations in the clinical setting. Journal of Nursing Education, 29, 183-187.
- Kowalski, S.D. (1997). Nevada nurses' attitudes regarding physician-assisted suicide. Clinical Nurse Specialist, 11, 109-115.
- Musgrave, CR, Margalith, I., & Goldschmidt, L. (2001). Israeli oncology and nononcology nurses' attitudes toward physician assisted dying: A comparison study. Oncology Nursing Forum, 28, 50-57.
- Pederson, C. (1992). Effects of structured controversy on students' perceptions of their skills in discussing controversial issues. Journal of Nursing Education, 31, 101-106.
- Peter, E., & Gallop, R. (1994). The ethic of care: A comparison of nursing and medical students attitudes, Image, 26, 47-49.
- Price, J., Price, D., Williams, G., & Hoffenberg, R., ( 1998). Changes in medical student attitude as they progress through a medical course Journal of Medical Ethics, 24, 110-117.
- Sorbye, L.W., Sorbye, S., & Sorbye, S.W. (1995) Nursing students' attitudes towards assisted suicide and euthanasia: A study from four different schools of nursing. Scandinavian Journal of Caring Science, 9, 119-122.
- Sumodi, V. (1995). Legalization of physician assisted suicide: Point/counterpoint. Nursing Forum, 30, 11-17.
- Thrush, J.C., Stewart, CS., & Paulus, G.S (1985). Effect of parental socialization on student nurses' attitudes toward euthanasia. Death Studies, 9, 395-415.
- Weiss, GL. (1996). Attitudes of college students about physician-assisted suicide: The influenee of life experiences, religiosity, and belief in autonomy. Death Studies, 20, 587-599.
- Young, A., Volker, D., Rieger, PT, & Thorpe, D.M (1993). Oncology nurses' attitudes regarding voluntary, physician-assisted dying for competent, terminally ill patients. Oncology Nursing Forum, 20, 445-451.
Frequencies of Students' Responses to the Vignettes on the Nurses' Attitudes Regarding PAD Questionnaire
Degree of Religiosity and Students' Attitudes Toward Physician-Assisted Dying