Healthcare Professionals’ Perspectives on Euthanasia Legalization in Malaysia

 Victor Isaacs, Lukman Z. M. & Norshahira O.

Faculty of Applied Social Sciences, Universiti Sultan Zainal Abidin, Malaysia

DOI: https://doi.org/10.51244/IJRSI.2024.1103027

Received: 07 February 2024; Revised: 01 March 2024; Accepted: 06 March 2024; Published: 09 April 2024

ABSTRACT

Euthanasia remains a contentious and emotionally charged subject, drawing considerable public debate and scrutiny in research compared to less controversial topics. Its involvement in deliberately ending human lives, albeit with compassionate intentions and the individual’s voluntary consent, has sparked widespread discussions among various stakeholders including academics, religious scholars, politicians, doctors, lawyers, and nurses. The present study seeks to investigate doctors’ and nurses’ attitudes towards euthanasia and its potential legalization in Malaysia. Employing a survey methodology adhering to established quantitative research protocols, participants were administered questionnaires to gather their viewpoints on euthanasia. The research enlisted 481 respondents who completed the 21-item Euthanasia Attitude Scale (EAS) questionnaire. Analysis of the data was conducted using SPSS version 29.0, employing measures such as mean, median, and standard deviation. The study revealed a strong level of reliability among the variables, with Cronbach’s Alpha values of 0.857 for EAS and 0.952 for reasons pertaining to euthanasia legalization. Pearson’s correlation coefficients ranged from 0.570 to 0.642, indicating a moderate and positive association between independent variables and the dependent variable. Furthermore, the study highlights that 81.3% of respondents held opposing views on euthanasia legalization, while 18.7% supported its legalization. Primary reasons for opposing legalization included religious beliefs (85.6%), the sanctity of human life and the belief that it should not be subject to individual authority for termination (80.2%), concerns about potential exploitation for personal gain (76.1%), and perceptions of public corruption (72.3%). These findings underscore the ongoing relevance and necessity for comprehensive examination, reflecting the multifaceted nature of the euthanasia discourse. Despite the prevailing opposition to legalization, the study underscores the enduring complexity of the euthanasia debate and the imperative of embracing diverse perspectives for effective navigation.

Keyword: Euthanasia, Doctors, Nurses, Legalization, Malaysia.

INTRODUCTION

Euthanasia has emerged as one of the most complex and contentious issues of the 21st century, following closely behind debates on cloning and genetic engineering. It has been the focal point of extensive discussions encompassing moral, religious, philosophical, legal, and human rights perspectives ([1], [2]). Central to the discourse on euthanasia is the fundamental right to life, which has served as an enduring principle throughout human history [3]. While international human rights treaties do not explicitly recognize a ‘right to die,’ many contain provisions safeguarding the ‘right to life’ [4]. The stance of international human rights law regarding voluntary euthanasia remains ambiguous and lacks clear definition[6]. Proponents argue that euthanasia can be viewed as a means of upholding the ‘right to life’ by allowing individuals to die with dignity[6].Conversely, there are concerns that legal frameworks facilitating access to medically assisted dying, particularly for those with disabilities or in old age, could perpetuate ableism and contravene Article 10 of the UN Convention on the Rights of Persons with Disabilities [7].

The notion of ‘euthanasia,’ deriving from the ancient Greek ‘euthanatos,’ meaning ‘good,’ embodies a profound contradiction [8].It encapsulates the juxtaposition between the serene idea of a death ‘good death’ and humanity’s innate instinct to cling to life fervently[9]. Death, a universal experience, is often perceived as a poignant loss, leaving an indelible void [10]. Thisdeeply rooted perspective makes the acceptance of euthanasia a morally intricate and ethically nuanced decision, subject to intense debate and contention [11].Euthanasia, involving the deliberate transition from life to death, remains a complex puzzle [12], extending beyond clinical realms into philosophy, ethics, morality, law, spirituality, medical science, economics, and cultural norms[13]. Essentially, it intertwines with the fabric of human existence, stirring the fibres of our collective consciousness [14].

Euthanasia seeks to terminate the life of a patient who has experienced prolonged, relentless, and intolerable suffering, aiming to spare them from further similar anguish [15]. In modern medicine, it is seen as an effort to relieve enduring and unjustified suffering, acknowledging the possibility that addressing pain or other symptoms may inadvertently shorten someone’s lifespan, such as by administering lethal drugs at the explicit request of the patient ([16], [4]).In practice, euthanasia is commonly categorized as either passive or active. Active euthanasia involves taking intentional steps to end the patient’s life, whereas passive euthanasia entails refraining from actions that would otherwise prolong the patient’s life[17]. Euthanasia remains illegal in the majority of countries worldwide and administering it can lead to murder charges for the responsible physician [18].However, a small but growing number of nations have enacted laws permitting euthanasia in specific extreme cases, subject to rigorous conditions. As of 2023, euthanasia has been legalized in Belgium, Canada, Colombia, Luxembourg, the Netherlands, New Zealand, Spain, and Australia [19]. The expanding legalization of euthanasia has prompted extensive debate among intellectuals, politicians, philosophers, and medical professionals [20].Several countries, particularly in Latin America, have initiated discussions on this topic within their governmental systems[3].

This article aims to explore the diverse perspectives surrounding euthanasia within the context of Malaysia, with a specific focus on understanding the attitudes of healthcare professionals. Among these professionals, doctors and nurses stand as crucial stakeholders, each bringing distinct insights and experiences to the ongoing discourse. Historically, the medical profession has maintained a notable distance from euthanasia [21].Moreover, nurses play a pivotal role in the care of patients who express a desire for euthanasia[22].It is imperative to comprehend the perspectives of experts in euthanasia, particularly given their role in providing care and support to patients during this pivotal juncture. If legalized, euthanasia would necessitate the involvement of the medical community across both public and private healthcare systems.

LITERATURE REVIEW

In the domain of medical ethics and end-of-life decision-making, it is evident that there exists a limited body of research on euthanasia within the Malaysian context[23]. Despite the increasing importance of comprehending the nuances and ramifications of euthanasia in Malaysian healthcare, there remains a noticeable scarcity of comprehensive research in this area [24]. The lack of dedicated studies and investigations on euthanasia in Malaysia underscores the necessity for a deeper exploration of this intricate and sensitive topic, one that considers the unique cultural, legal, and ethical aspects within the Malaysian context[25].

In Malaysia, all forms of euthanasia, including active, passive, voluntary, non-voluntary, and involuntary euthanasia, are explicitly prohibited, regardless of whether they are conducted with or without the individual’s consent, and regardless of their intent to alleviate suffering or pain ([26], [27]).Hehsan & Shukeri (2021)[28] underscored that during the 97th Muzakarah of the Fatwa Committee of the National Council for Islamic Religious Affairs Malaysia in December 2011, it was decreed that hastening death through euthanasia practices, whether voluntary, non-voluntary, or involuntary, or mercy killing, is unlawful according to Islamic law. Such actions are equated with killing and are considered contradictory to medical ethics in Malaysia. Additionally, during the 24th Sarawak State Fatwa Board Meeting in March 2014, it was proclaimed that euthanasia, defined as ending a person’s life before their official death, by any means or for any reason, is strictly prohibited under Islamic law. Patients expressing a desire for euthanasia, whether verbally, in writing, or through any other means, may be deemed to be exhibiting suicidal tendencies. Medical professionals deliberately ending a patient’s life in any manner may be interpreted as committing a form of homicide. Those endorsing the act of terminating a patient’s life in any way may be perceived as parties who have consented to the patient’s killing.

In Malaysia, the primary focus of euthanasia research revolves around its legal and ethical dimensions.Talib (2005) [29] highlights that euthanasia presents a significant ethical dilemma, with end-of-life decision-makers recognizing the complex interplay of medical, legal, and ethical challenges in this domain. Religious beliefs and cultural norms also wield considerable influence over end-of-life decisions. Kassim & Alias (2015) [30] note the increasing prevalence of ethical dilemmas and legal interventions in end-of-life decision-making within the medical profession. Establishing clear ethical guidelines and legal standards is paramount to guide healthcare professionals in determining appropriate courses of action for their patients. Considering the relevant ethical codes and legal provisions in Malaysia pertaining to end-of-life decision-making is crucial. However, the absence of legal precedents and limitations within the Malaysian regulatory framework pose significant challenges. Thus, there is a pressing need to develop comprehensive ethical codes and legal standards to navigate end-of-life decision-making in Malaysia effectively. Alias et al. (2015) [25] underscore the urgent need for a regulatory framework concerning end-of-life care in Malaysia. A well-structured legal framework addressing both ethical and legal considerations would provide healthcare professionals with enhanced guidance and confidence in their actions’ validity. While some non-governmental organizations and medical societies offer guidelines for practical aspects of end-of-life care, the development of a comprehensive regulatory system in this field is still evolving.

In Islamic countries like Malaysia, where euthanasia remains illegal, some scholars argue that Islam does not prohibit the use of Advance Medical Directives (AMD) as a means to honour patients’ preferences regarding their end-of-life care [31]. Essentially, in cases where a patient is suffering from a terminal illness where medical interventions would be futile, withholding or withdrawing such treatments is considered permissible, provided healthcare professionals obtain the patient’s consent beforehand [32]. However, several factors require careful consideration, including the patient’s cognitive capacity during the AMD creation process, the expert opinions of medical professionals, the involvement of family members in end-of-life care decisions, and limitations on a patient’s decision-making when establishing an AMD. According to Kamalruzaman et al. (2022) [24], euthanasia and AMD represent highly contentious issues in this specific context, requiring thorough scrutiny at every stage before any potential legalization is contemplated. The primary source of controversy stems from the lack of full societal acceptance of these practices, leading to persistent disputes rooted in differing beliefs, legal perspectives, cultural disparities, political influences, and societal norms. To pave the way for the potential legalization of euthanasia and AMD, it is crucial for healthcare professionals to adhere rigorously to their ethical standards while intensifying efforts to provide the highest quality end-of-life care for all individuals. Simultaneously, governments should establish a legal framework that considers the multifaceted factors that arise within a nation when contemplating the legalization of these practices. A core principle that must be upheld is the preservation of the intrinsic value of human life. It is essential to recognize that ethics cannot exist in isolation from morality, a principle that extends to the domain of legality as well.

In this study, a comprehensive analysis of previous quantitative research on euthanasia in Malaysia revealed consistent opposition to its legalization. Rathor et al. (2014) [18] found that a majority of Malaysian doctors and patients expressed disapproval of euthanasia or physician-assisted suicide, irrespective of circumstances. Only 15% of doctors reported instances where patients sought assistance in dying. However, both doctors (29.2%) and patients (61.5%) expressed openness to withdrawing or withholding life-sustaining treatment for patients with no chance of recovery. Notably, religious beliefs significantly influenced patient perspectives more than the severity of the illness. Similarly, Arif et al. (2002) [2] discovered that 67.91% of 399 participants, including doctors, nurses, and medical students, were opposed to euthanasia, with religion playing a crucial role in shaping this stance. Despite a good level of awareness about euthanasia, the majority were not in favor of its legalization in Malaysia. Additionally, Adchalingam et al. (2005) [33] conducted a cross-sectional survey involving 400 medical students from diverse backgrounds. Their aim was to explore students’ attitudes toward euthanasia and examine factors influencing medical decision-making and ethical reasoning concerning end-of-life issues. Results showed that a majority (52%) supported the withdrawal of active therapy for terminal and painful illnesses, while 48% opposed it. Approximately 71% of students were against active euthanasia, yet 27% believed in moral justification for assisting patients in end-of-life decisions. Regarding the legalization of euthanasia, around 32% expressed support, while 67% strongly opposed it. Notably, 61% of students indicated they would neither practice euthanasia nor opt for it themselves, even if legally permitted. A significant concern among respondents was the potential misuse of euthanasia by unethical healthcare practitioners, highlighting the need for further debate at local and international levels.

While many Malaysians oppose the legalization of euthanasia in the country, there is a pressing need for the establishment of a clear and comprehensive regulatory framework governing its legality, especially regarding passive euthanasia [25]. Passive euthanasia involves allowing a patient’s life to end naturally, without active medical intervention to prolong it([8], [34]). In this form, medical professionals or caregivers may withhold or withdraw life-sustaining treatments or interventions, such as ventilators, feeding tubes, or medications, when these are deemed no longer beneficial or are causing undue suffering to the patient [13]. Typically, passive euthanasia is carried out in accordance with the patient’s advanced directives, living will, or the decision of a legally authorized surrogate decision-maker when the patient is unable to make their own choices. It is legally and ethically distinct from active euthanasia, where deliberate actions are taken to actively end a patient’s life, such as administering a lethal dose of medication [21].

Proponents of passive euthanasia argue that it helps alleviate pain and suffering in terminally ill individuals, respects individual autonomy and self-determination, and upholds the right to make decisions about the timing and manner of one’s death [20].Additionally, they cite reasons such as reducing dependence on medical life-support systems, preserving dignity throughout the dying process, prioritizing quality of life over its duration, and eliminating legal risks for healthcare professionals, families, and loved ones [12]. Conversely, opponents of euthanasia contend that individuals in vulnerable situations should be protected from coercive actions. They argue that legalizing euthanasia would broaden the criteria for eligibility, potentially compromising the inherent sanctity of life, and advocate against altering laws to accommodate a small minority seeking euthanasia [4]. Furthermore, they believe that hastening death contradicts the fundamental purpose of medicine, which is to heal. Critics express concerns about the possibility of wrongful deaths due to diagnostic errors and assert that pain can be effectively managed through appropriate palliative care. Additionally, they argue that legalizing euthanasia could dampen motivation to invest in research and implement best-practice treatments [36].

Acknowledging the validity of all arguments and recognizing the significance of both sides of the debate, a tension arises from the delicate balance between the fundamental concept of the right to life and the deeply personal autonomy individuals possess over their own bodies. The right to life stands as an unwavering cornerstone of our societal values, contrasting with the equally profound principle of individual agency – the right for individuals to make decisions about their own lives and bodies. In the context of the euthanasia debate, we find ourselves navigating the complex terrain where these principles intersect, prompting us to grapple with questions about when and how the right to life should yield to the autonomy of individuals experiencing unbearable suffering [17].Given that only a small number of individuals have direct experience with or a desire to undergo euthanasia, it underscores the influential role that mediated sources play in shaping perceptions and providing the framework through which we understand matters related to health, illness, and end-of-life experiences [14].

RESEARCH METHOD

The objective of this research is not to explore new issues or establish causal relationships but rather to provide an overview of euthanasia and its associated legalization issues in Malaysia at the time of the study. To achieve this goal, a quantitative research approach was employed to investigate the perspectives of healthcare professionals, including doctors and nurses. The researcher conducted an extensive review of existing literature, analysing over 60 sources, to develop a self-report questionnaire tailored to the research objectives. This questionnaire includes the Euthanasia Attitude Scale (EAS) and inquiries about respondents’ backgrounds and their positions on either supporting or opposing euthanasia legalization. The EAS comprises 21 items distributed across four domains: ethical considerations (11 items), practical considerations (4 items), treasuring life (4 items), and naturalistic beliefs (2 items). Respondents provided their responses on a 5-point Likert-type scale, ranging from 5 = strongly agree to 1 = strongly disagree, with scores ranging from 21 to 105. Higher scores indicate more positive attitudes toward euthanasia.

The questionnaire’s suitability and relevance were subsequently confirmed by a panel of 13 professionals, comprising 3 doctors, 4 lawyers, 3 nurses, and 3 academicians. The internal consistency of the questionnaire was evaluated, and Cronbach’s alpha values were calculated, ranging from 0.857 to 0.952 in the pilot study involving a suitable sample of 40 respondents. This indicates substantial agreement among respondents with the statements, demonstrating good consistency among participants. Non-probabilistic sampling was utilized to recruit 481 Malaysian respondents, including 241 doctors and 240 nurses. To ensure anonymity and convenience, the questionnaire was distributed via the Internet using Google Forms, Google’s platform for creating anonymous and user-friendly surveys for both researchers and participants. The questionnaire was administered in English, as it is commonly used in the healthcare and legal professions in Malaysia, alongside the Malay language. Since the EAS was not translated or modified, internal validation was not necessary. The survey was conducted for data collection over a period of two months, from March 1st to April 30th, 2023. Ethical considerations were addressed by obtaining approval for the research and its data collection protocol from the School of Social Work Research Ethics Committee.

The collected data underwent statistical analysis using the Statistical Package for the Social Sciences (SPSS) version 29.0. Various measures such as the mean, median, standard deviation, frequencies, andpercentages were used to assess data variables. The significance level was set at p < 0.05. The normality of quantitative variables was evaluated using the Kolmogorov-Smirnov test. Confidence intervals of 95% were calculated for both means and proportions. Pearson’s correlation was utilized to examine relationships between quantitative variables. Finally, a multiple linear regression analysis was conducted for EAS total scores (dependent variables), considering independent variables that exhibited significant correlations with these scores.

FINDINGS AND DISCUSSION

1. Pearson’s correlation coefficient and descriptive analysis

Pearson’s Correlation Coefficient plays a crucial role in comprehensively exploring and quantifying intricate relationships among the variables under investigation. Noteworthy are the correlation results, consistently falling within a specific range, with values ranging from 0.570 to 0.642. These results distinctly signify the presence of a moderately robust and positively oriented relationship between the independent variables, encapsulating the multifaceted rationales for both endorsing and opposing the legalization of euthanasia, and the dependent variable, which represents the Euthanasia Attitude Scale (EAS). To gain a thorough understanding of the distribution patterns exhibited by the various components of the EAS dataset, a descriptive analysis was conducted.

This analytical procedure included computing mean values, standard deviations (SD), median values, and t-values, all contributing to unveiling the inherent characteristics residing within the dataset. The findings portrayed in Table 1 offer insightful revelations. Regarding the EAS scale, the mean score was found to be 32.3 ± 23.68, accompanied by a t-value of -6.617 and p = 0.000. Notably, the highest mean score was observed within the ethical considerations section, registering at 21.75 ± 15.28, while the associated t-value stood at -8.439 with a p-value of 0.001. In contrast, the naturalistic belief category displayed the lowest mean score, quantified at 4.34 ± 2.97, along with a corresponding t-value of -2.409 and a p-value of 0.003. Collectively, these findings substantiate the prevalent sentiment among many doctors and nurses in Malaysia who expressed strong disagreement with the notion of legalizing euthanasia.

Table 1: EAS Total Score

2. Socio-demographic characteristics of respondents in the study

Among the total respondents, 50.1% were doctors, and 49.9% were nurses, as outlined in Table 2. Female respondents constituted the majority at 60.7%, outnumbering male respondents at 39.3%. In terms of age distribution, 34.9% fell within the 25-34 age bracket, 26.8% were aged 35-44, and 23.9% were aged 45-54. Regarding marital status, 53.8% of respondents were married, with the majority (52.2%) identifying as Muslim. The educational background of respondents varied, with 44.9% holding a bachelor’s degree and 37.4% possessing a diploma.

Table 2: Socio-demographic Characteristics of Respondents in the Study(n = 481)

3. The legalization of euthanasia

Our survey results indicate that 81.3% of participants expressed opposition to euthanasia and its legalization, while 18.7% supported it. In comparison, a UK poll conducted by the Royal College of Nursing reported 49% in favour and 40% against euthanasia [17].Similarly, studies conducted in countries such as Croatia, Turkey, South Africa, and Kuwait have reported low levels of euthanasia acceptance ([9], [35]).Religion emerged as a significant factor, with 85.6% of our respondents citing religious beliefs as their reason for opposition (Table 3).This finding is consistent with prior studies indicating that religious individuals or those in religious societies tend to oppose euthanasia more than those in secular environments [36].

Most religions generally discourage the practice of euthanasia. In Malaysia, a nation recognized for its diverse array of faiths and cultures, religious beliefs significantly influence decisions concerning end-of-life matters [37]. Notably, euthanasia remains prohibited by law in Malaysia, and as of now, there are no known pro-euthanasia organizations operating within the country [18].  Our findings are consistent with similar research conducted on this subject [12].  These results provide valuable insights into the ongoing discussions surrounding euthanasia at the end of life. Further research is necessary to capture the perspectives of healthcare professionals who closely interact with chronically ill and suffering patients, as this could contribute to a more thorough understanding of the matter.

In a broader context, religion provides comprehensive guiding principles that regulate our biological behaviours and address internal conflicts triggered by external factors [38]. Moreover, it instils values into life, aiding individuals in aligning with its fundamental purpose, particularly when grappling with life’s specific objectives. The spiritual harmony advocated by religion is vital for maintaining a sense of order. This is why all major religions universally denounce both euthanasia and suicide as unethical, invalid, and inappropriate actions [39]. Given Malaysia’s racial and religious diversity, it is evident that this demographic factor warrants careful consideration. When crafting ethical guidelines and legal standards for end-of-life decisions, it is crucial to incorporate the values and perspectives of different communities, especially given the sensitive nature of the issue.

Table 3: Respondents’ Opinions on Euthanasia Legalization (n=481)

Prior research has suggested that individuals with higher levels of education are generally less inclined to oppose euthanasia compared to those with lower educational attainment ([40], [41]). However, in this survey, the majority of doctors and nurses expressed opposition to euthanasia. In addition to religious beliefs, three primary reasons for their opposition in this country include the conviction that human life is sacred and should not be subject to individual authority for termination (80.2%), concerns about potential exploitation of euthanasia for personal gain (76.1%), and the perceived prevalence of public corruption (72.3%). This finding is consistent with prior studies conducted by Demedts et al. (2023)[42] and Cayetano-Penman et al. (2021) [22]. Healthcare professionals were more reluctant to support euthanasia in countries where it was neither accepted nor legal. For instance, in Turkey, where euthanasia is illegal, approximately half of nurses do not endorse its legalization [16]. Furthermore, Green et al. (2022) [43] highlighted that their opposition to euthanasia is also associated with concerns about moral integrity and uncertainties regarding a dying patient’s capacity to make informed decisions.

The research findings are likely to fuel substantial debates among proponents and detractors of euthanasia, particularly regarding legal frameworks. As societies evolve and their beliefs and values become more nuanced, the ethical challenges associated with euthanasia are expected to become increasingly intricate. Our results reveal that a majority of survey participants harbour negative perceptions of euthanasia and oppose its legalization. Therefore, it is unsurprising that only a minority of doctors and nurses express support for euthanasia.

CONCLUSION

The euthanasia debate is a multifaceted and contentious issue that extends beyond individual perspectives to become a significant societal concern. This moral dilemma has persisted for years, generating a multitude of arguments both for and against it, making consensus challenging to achieve. Research findings play a vital role in shaping the ongoing discourse on end-of-life euthanasia, highlighting the need for continued research efforts to document the preferences of individuals enduring chronic illness and suffering, as well as healthcare professionals closely involved in their care. Globalization and changes in healthcare delivery systems are gradually influencing attitudes toward euthanasia among both the medical community and the general public. Additionally, the availability of alternative treatments, such as palliative care and hospices, provides terminally ill individuals with options for a dignified and pain-free end-of-life, reducing reliance on euthanasia. This evolving landscape poses ethical, moral, and practical challenges regarding euthanasia’s application. In the Malaysian context, there is a clear need for the development of comprehensive ethical codes and legislation to address euthanasia’s complexities. Current Malaysian statutory legislation explicitly prohibits active euthanasia, while the legal stance on passive euthanasia remains unclear, creating a legal grey area. Addressing this gap is essential to safeguard the rights and choices of individuals facing end-of-life decisions and to provide healthcare professionals with clear guidelines for making critical decisions

regarding their patients’ end-of-life care.

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