A Concept Analysis of Voluntary Active Euthanasia

Written By: Sam Savage

Published Date: December 6, 2006 Last Edited: December 6, 2006

By Guo, Fenglin

TOPIC. Euthanasia has a wide range of classifications. Confusion exists in the application of specific concepts to various studies.

PURPOSE. To analyze the concept of voluntary active euthanasia using Walker and Avant’s concept analysis method.

SOURCES OF INFORMATION. A comprehensive literature review from various published literature and bibliographies.

CONCLUSIONS. Clinical, ethical, and policy differences and similarities of euthanasia need to be debated openly, both within the medical profession and publicly. Awareness of the classifications about euthanasia may help nurses dealing with “end of life issues” properly.

Search terms: Concept analysis, end of life issues, voluntary active euthanasia, terminally ill patients

Introduction

Euthanasia is a very sensitive topic, and the debate surrounding it has intensified since its practice in the Netherlands in the 1980s. Much euthanasia-related articles have been published, but it is often not clear which kinds of euthanasia were being discussed. Debates regarding the right to die issues may be completely different according to voluntary euthanasia, nonvoluntary or involuntary euthanasia, passive euthanasia (PE), active euthanasia (AE), and assisted suicide.

McInerney and Seibold (1995) found that the majority of nurses could distinguish between active and passive euthanasia, but it was only in terms of active euthanasia that the debate was seen as significant. It was considered that the term passive euthanasia, particularly in relation to withdrawal of treatment, has served to confuse the real debate centering on active euthanasia.

The lack of specificity in these terms represents a continuing source of difficulty for understanding and study in this area. Research highlighting these concepts can give impetus to the development of social policy, and raise ethical awareness surrounding right to die issues among nurses and other health professionals.

For the purpose of clarifying the concept of voluntary active euthanasia (VAE), a concept analysis of VAE was performed using the systematic procedure suggested by Walker and Avant (1995). The suggested steps are as follows:

1. select a concept

2. determine the aims or purpose of the analysis

3. identify all uses of the concept that you can discover

4. determine all defining attributes

5. construct a model case

6. construct borderline, related, and contrary cases

7. identify antecedents and consequences

8. define empirical referents

Aims of the Analysis

The aims of the analysis are, first, to develop an operational definition of the theoretical concept of VAE. Second is to define the meaning of VAE in order to clarify the concept and its relevance and use in nursing practice and nursing education. Specific sub- aims were to:

* Determine the definition and critical attributes of VAE

* Identify the antecedents and consequences of VAE

* Identify the empirical referents for the critical attributes of VAE

Definitions of VAE

Euthanasia is a composite term derived from two Greek words-eu, meaning “well,” and thantos, meaning “death”-and means “good death” or “painless, happy death” (Begley, 1998). The Oxford dictionary definition of euthanasia is “the painless killing of a patient suffering from an incurable and painful disease” (Thompson, 1995, p. 465). However, it is classified in various forms, including voluntary, nonvoluntary and involuntary (Thompson et al., 2001). It may be voluntary at the request of the patient. This indicates that it must be carried out at the request of a competent patient. This implies adherence to another prima facie principle, that of respect for autonomy. Euthanasia may also be involuntary, where the views of the patient are disregarded.

It may also be described as active or passive euthanasia. “Passive” describes the withholding of treatment that would be necessary for the continuation of the patient’s life. “Active” implies that something is done or given with the intention of hastening death (Begley, 1998).

VAE is usually the administration of a lethal drug or other methods to terminate the life of a patient who is in a state of constant suffering (Oosthuizen, 2003). In other words, it is active assistance in dying. For example, if the patient cannot act by himself or herself because of his or her terminal illness, the physician or the nurse’s actions directly cause the patient’s death.

Defining Critical Attributes

Walker and Avant (1995) described the “critical attributes” of the concept being analyzed as the characteristics of the concept that appear repeatedly during the literature review. These characteristics help to name the occurrence of a specific phenomenon as differentiated from another similar or related one. Five critical attributes occurring in all cases of VAE have been identified as follows:

* The patient is in intolerable suffering

* The patient asks for a peaceful and painless death to retain dignity in life

* The patient is willing to end his or her life

* The physician or nurse’s actions directly cause the patient’s death

* The patient gives fully informed consent

Constructing a Model case

Walker and Avant (1995) recommended using a model case as the next step of concept analysis, and they described it as a “real- life” example of the use of the concept. The model case should include all the critical attributes and be a pure case example of the concept. Wilson (1963) refers to the model case as an instance in which there is absolute certainty that the model is the concept, “well, if that isn’t an example of so and so, then nothing is” (p. 28).

Patient A was a 95-year-old, very fragile, malnourished woman. She was admitted to hospital with severe abdominal pain under a diagnosis of liver cancer. She was fully dependent. She felt intolerable pain and had a very low quality of life. She told her physician, her daughter, and her niece that she did not want to live and want to die in peace. Why did she have to spend her last few days in pain and misery? She asked the junior doctor on duty, Jane, to give her a lethal morphine injection to die in peace. Jane had witnessed A.’s intolerable suffering many times, and strongly sympathized with her. After she got the consent of A., her family, and the senior doctors, she injected A. with a lethal dose of morphine. A. died shortly afterwards.

All five of the defining attributes of VAE are included in this model case. That is voluntary active euthanasia. Patient A was terminally ill, and was in severe pain. She made a request of dying with dignity and wanted to die in peace. The junior doctor’s action directly resulted in unrecoverable death of patient A.

Constructing Borderline, Related, and Contrary Cases

Borderline, related, and contrary cases are developed to provide examples of “clearly not the concept.” They are very useful to further clarify the analyzing concept and help with understanding (Walker & Avant, 1995).

Borderline Case

The borderline case may have only a few of the defining attributes, or may contain additional attributes. According to Walker and Avant (1995), it is used to promote further understanding of the concept under study. A borderline case of VAE is constructed as follows:

Patient B. was an 89-year-old woman. She had surgery for bowel cancer 2 years ago. She was admitted to hospital under “chest infection.” She was terminally ill, very fragile, malnourished, and fully dependent. She did not want to live in misery. She discussed “to die with dignity” with her daughter, son, and her physician Joe. They could not help her although they understood her feelings, but they said that they would not take any active part in bringing about her death. B. asked for a lethal dose of morphine. Joe gave it to her. B. injected herself with the lethal morphine and soon died.

Most attributes of VAE are presented in this case. For example, the patient was in intolerable suffering; she asked for a peaceful and painless death to maintain the dignity of life, and was willing to end her life. But it was she herself who injected the morphine.

Thus, this must be viewed as physician-assisted suicide (PAS) and a borderline case of the concept of VAE. Physician assisted suicide means allowing a doctor or other person to assist a person who has an invincible and understandable desire to commit suicide (Thompson et al., 2001). The doctor or nurse provided the drug or injection and the patient carried out the act herself.

Related Cases

Related cases are instances that represent a different but similar concept (Walker & Avant, 1995). Generally a different word is used, but the experiences have several features in common. They may involve several attributes (but not all) of the concept under study. These terms are discussed here as related cases. They demonstrate ideas that are very similar to the concept of VAE, but differ from it when examined closely.

Nonvoluntary euthanasia refers to the case of a patient who is not in a position to have, or express, views regarding the continuance of his or her life. For example, a patient in a vegetative state. Another example is the recent American case, the removal of severely brain-damaged Terri Schiavo’s feeding tube.

Voluntary passive euthanasia (VPE) is a concept used to d\escribe the withholding of treatment that would be necessary for the continuation of the patient’s life (Thompson et al., 2001). It is letting a patient die naturally rather than using extraordinary artificial methods (transplant, life-sustaining drugs) or machines (heart-lung machines, respirators) to keep him or her alive in a constant state of suffering or unconsciousness. In this case the patient voluntarily chooses to die “naturally” of whatever ills affecting him or her. Stopping life-sustaining therapies is typically considered passive assistance in dying. Death is more a result of the patient’s will and resolve than an inevitable consequence of the disease.

Another related case is involuntary euthanasia. This is equated with “murder,” although the patient may be in intolerable suffering. The Dr. Shipman’s case in the UK was typically “involuntary euthanasia.” Thus, although the patient may be willing to die, his (or her) informed consent is essential in all cases.

Contrary Case

Contrary cases can often be helpful in an analysis, since it may be easier to say what something is not than what it is. Contrary cases are those which are clear examples of “not-the-concept” (Walker & Avant, 1995). A contrary case of VAE is presented below:

Patient C. is a 35-year-old woman. Because of renal failure, she has to attend dialysis every day. She is independent in activities of daily living. She is optimistic and has never given up her right to live. Her family supported and assisted her to the hospital every day and encouraged the doctors to try every possible treatment for her. The health professionals carried out active treatments, and C. is still alive.

This situation presents the contrary case of VAE. Patient C. is not in intolerable suffering. She did not ask for a peaceful and painless death. She wants to live. Her family also wants her to live, and the health professionals carried out active treatments. The defining attributes of voluntary active euthanasia are completely absent from this case.

Identifying Antecedents and Consequences

Walker and Avant (1995) stated that identifying antecedents and consequences focuses on the social contexts of the analyzing concept, and helps to further refine the critical attributes.

Antecedents of VAE

Antecedents are situations or phenomena that precede the concept (Rodgers, 1993). Walker and Avant stated that it can be identified from the previous presentation of material, and identity incidents that must occur prior to the occurrence of the concept (Walker and Avant, 1995). Therefore, the proposed antecedents of VAE are

* The individual suffers from a disease

* Two or more individuals are involved

* The patient expresses intolerable pain

* The patient is mentally competent and autonomous

* The patient has a poor quality of life or meaningless life

* The patient has the desire to end life

Consequences of VAE

Consequences, on the other hand, are those events or incidents which occur as a result of the occurrence of the concept (Walker & Avant, 1995). Rodgers (1993) refers to situations, events, or phenomena that follow the analyzed concept. Therefore, the proposed consequence of VAE is the patient’s unrecoverable death.

Empirical Referents

The empirical referents are measures of the defining attributes of the concept, and are specific behavioral signs which indicate that the concept has occurred. In many cases the critical attributes and the empirical referents are identical (Walker & Avant, 1995).

However, in the concept of VAE with its abstract defining attributes, the empirical referents indicating the presence of VAE proceed from communication to discussion, to solemn expression, to positive action. Following this action, the individual’s heartbeat stops. Vital signs disappear (no response, no pulse, and no respiration) and pupils are dilated.

Conclusions and Implications to Nursing Practice

Among health professionals, nurses have the most contact with and are often involved in caring for terminally ill patients. They intimately witness the devastation of life-threatening illness and struggle to provide humane care. Professional conduct and respect for patient’s autonomy sometimes are contradictory, which places the nurse in an ethical dilemma.

Schwarz (2004) pointed out that “even nurses with many years experience in providing end-of-life care may be uncertain about identifying and doing the ‘right thing’ for dying patients” (p. 233).

As the largest group of healthcare professionals, nurses must learn to deal with the ethical, legal, and social consequences of euthanasia practices. Clinical, ethical, and policy differences and similarities of VAE need to be debated openly, both publicly and within the medical profession. However, failure to acknowledge the risks of accepted practices may also undermine the quality of terminal care and put patients at unwarranted risk. Hidden, ambiguous practices and inconsistent justifications should be avoided.

Therefore, the analysis of the concept of VAE indicates the importance of achieving conceptual clarity prior to joining any debates. Awareness of the classifications about euthanasia may help nurses dealing with “end of life issues” properly, and may also provide valuable references for nurses who continue to be asked for assisting in dying.

Research highlighting these concepts can give impetus to the development of social policy, and raise ethical awareness surrounding right to die issues among nurses and other health professionals.

References

Begley, A.M. (1998). Beneficent voluntary active euthanasia: A challenge to professionals caring for terminally ill patients. Nursing Ethics: An International Journal for Health Care Professionals. 5(4), 294-306.

Mclnerney, F., & Seibold, C. (1995). Nurses’ definitions of and attitudes towards euthanasia. Journal of Advanced Nursing, 22(1), 171-82.

Oosthuizen, H. (2003). Doctors can kill-Active euthanasia in South Africa. Medicine and Law, 22, 551-560.

Rodgers, B.L. (1993). Concept analysis: An evolutionary view. In Rodgers, B.L., & Kanfl, K.A. (Eds.), Concept development in nursing: Foundations, techniques, and application (pp. 73-92). Philadelphia: WB Saunders.

Schwarz, J.K. (2004). Responding to persistent requests for assistance in dying: A phenomenological inquiry. International Journal of Palliative Nursing, 10(5), 225-235.

Thompson, D. (Ed.) (1995). The concise Oxford dictionary (9th ed.). Oxford: Oxford University Press.

Thompson, I.E., Melia, K.M., & Boyd, K.M. (2001). Nursing ethics (4th ed.). Edinburgh: Churchill Livingstone.

Walker, L., & Avant, K. (1995). Strategy for theory construction in nursing (3rd ed.). Norwalk, CT: Appleton & Lange.

Wilson, J. (1963). Thinking with concepts. New York: Cambridge University Press.

Fenglin Guo, PhD, MSc, BSc, RGN

Fenglin Gou, PhD, MSc, BSc, RGN, is a Fellow at De Montfort University, Leicester, UK.

Author contact: [email protected], with a copy to the Editor: [email protected]

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