Nurses’ opinions on euthanasia in Spain: an evaluation using a new version of the EAS

In the bioethical field, the word euthanasia refers, based on its etymology, to “good death” [1]. In reference to the conceptual development of ethical conflicts related to the end of life, different terms have been used to focus on the bioethical debate and its implications for health care [2]. There is current bioethical consensus on the contextualization of these conflicts in two scenarios: euthanasia and assisted suicide [3, 4]. These two concepts are integrated within "medical assistance in dying" (MAID), which has been regulated in different countries [5‐8].

In the Spanish context, this regularization took place because of Organic Law 3/2021 on the regularization of euthanasia, which seeks to provide a legal response to social demands regarding ethical conflicts related to the end of life [9]. The text includes the concept of MAID, which refers to “the set of services and assistance that healthcare personnel must provide, within the scope of their competence, to patients who request the necessary aid in dying”. It also states that these benefits must be provided “in accordance with certain conditions that affect the physical situation of the person with the resulting physical or mental suffering, the possibilities of intervention to alleviate their suffering, and the moral convictions of the person regarding the preservation of their life in conditions that the person considers incompatible with their personal dignity”. In this sense, guarantees must be established to ensure that the decision to end one’s life is made with absolute freedom, autonomy and knowledge, thus protected from pressures of any kind that could come from unfavorable social, economic or family environments, or even from hasty decisions". In this context, nurses have been included in the healthcare team where in collaboration with the doctor, they will provide the necessary assistance to the patient until the moment of death. Thus, in the context of the Balearic Islands [10, 11], new roles have been introduced within nursing practice, such as for drug administration nurses, who possess competence profiles aligned with intensive care and emergencies. Furthermore, there are nurses specializing in end-of-life care, providing support in both primary and specialized settings and offering guidance to fellow professionals. The work performed by these professionals spans from the moment a euthanasia request is made to postmortem care [12].

The implementation of this law in the Spanish territory has been uneven due to the controversy it has sparked and the varying ethical and anthropological sensitivities among the different regional governments in Spain. Despite its legalization, the debate persists within the various political and social spheres of our sociocultural context. In certain regions, its enforcement has faced obstacles, as health professionals have the acknowledged right to exercise conscientious objection. According to Spanish law, this grants health professionals the individual right to refrain from participating in health actions regulated by this law if they are incompatible with their own convictions [13‐16]. Research on the attitudes of health professionals toward euthanasia using various measurement instruments has been conducted in different countries with varying regulations regarding its application, thus reflecting diverse sociocultural contexts [17‐29]. In this sense, understanding the attitudes of health professionals after the application of the law in recent years is crucial for promoting strategies that ensure its full implementation and establishing scenarios that guarantee the rights of both citizens and health professionals.

The Euthanasia Attitudes Scale (EAS) is an instrument designed to assess respondents’ attitudes toward euthanasia. Originally proposed and validated by Tordella and Neutens [30] in 1979 in the United States, it was later modified by Rogers [31] in 1996. Subsequently, the scale underwent further modifications to assess social values and ethical judgments regarding euthanasia [32]. The Euthanasia Attitudes Scale (EAS) has additionally been adapted and validated in various languages (refer to Table 1), demonstrating its applicability across different sociohealth contexts, albeit with variations in its structure [33‐36]. The initial validation of this instrument in Spanish occurred during the discussion phase of the law when euthanasia was not legal in Spain. Following this preliminary exploratory analysis and a few years after the law's enactment, it became necessary to review the questionnaire's structure and its individual items. The objective of the current study was to conduct a new validation of the EAS instrument, incorporating confirmatory analysis and readapting some of its items.

The present study aimed to validate the questionnaire in Spanish after the partial modification of items 2, 4, 7 and 15. After the adaptation of the four new items, in the new EAS-ES-R version, we found a greater internal consistency (0.892 vs. 0.878) with respect to the EAS-ES version of Onieva-Zafra et al. [32]. In the first validation of the scale in Spanish, the sample consisted only of nursing students, whereas the EAS-ES-R has a sample that includes all health professionals of the Balearic Health Service and health professionals in training. On the other hand, this consistency result is in line with the findings of the original scale [30] revised by Rogers [31], where the value obtained for the Cronbach’s α was 0.84. Furthermore, we found reliability results in line with those of the instruments validated in Greece [33] (Cronbach’s α of 0.944), in Dutch [35] (Cronbach's α of 0.822), and in the Persian version [36] (Cronbach's α of 0.88), with the Chinese version [34] (Cronbach's α of 0.77) showing lower values for this parameter.

The resulting factor structure is similar to that of the EAS-ES version, with the migration of items 2c and 2d to form part of the first factor called “ethical considerations”, while items 1b and 1 h are removed from this factor. For items 2c and 2d, this can be explained by the fact that the context in reference to the regulation of euthanasia has changed, as it is already regulated in Spain. Although the translation and validation processes in the different languages yielded disparate results in terms of the number of factor loadings and the inclusion/exclusion of items, we can see how the revision of the original Rogers questionnaire [31] yielded 9 items that met the criteria for interpreting the questionnaire. The first factor obtained, "general moral and legal acceptance", had 4 of its 5 items within the "ethical considerations" factor of our questionnaire. The missing item "God gave us life and should be the only one to end it" was not included in the EAS-ES version. As reflected in the validation of the EAS by Aghababaei [36], religious arguments are shown to be the most powerful reasons for opposition to euthanasia [37‐40]. Items 1b and 1 h move to factor 3, called "practical considerations", which is also marked by the context of the regulation of euthanasia in Spain, leaving their ethical imprint and acquiring a greater practical sense. Factor 1b is also one of the items modified in the new Spanish version and loses the religious charge of the expression "merciful reason" for "compassion", which is a more universal value and is not as affected by religious thought. The rest of the items remained grouped in the same way as in the first Spanish version in terms of the factors "appreciating life" and "naturalistic beliefs". The variations in the concepts explained have helped to improve the internal validity and reliability of the instrument and better adapt it to the new regulatory context in reference to the provision of aid in dying in Spain.

Regarding the number of loading factors, we found that the total of four obtained values are consistent with the previous Spanish version and with the work of Chong et al. [34] and Demedts et al. [35]. However, the Greek version [33] has 5 loading factors, and the revision of the original English version [31] and the Persian version [36] has 3 factors. These differences may be marked by the total number of respondents, the type of sample and the fact that some items show great variability in their explanatory power. If we look at previous validations of the instrument, we can observe that the studies with the highest number of respondents (32,34,35) are those with 4 factor loadings. However, although they present 4 factors, it is difficult to establish an exact parallelism in their configurations. This is especially visible in Chong's study (34), where despite finding 4 factors, 13 new items were introduced, for a total of 31. Furthermore, the factors have been named "General Euthanasia", "Passive Euthanasia", "Active Euthanasia" and "Non-Voluntary Euthanasia", terms that do not correspond to the bioethical conceptual content of the current debate in reference to the MAID. At present, the concepts "Passive Euthanasia" and "Active Euthanasia" are not used in bioethical language, referring only to the concept of Euthanasia or assisted suicide.

If we take into account that beliefs and attitudes about ethical dilemmas related to the end of life are not static and may vary throughout an individual's life, we can understand that the sociocultural context, undergraduate and postgraduate professional training and other sociodemographic determinants may significantly shape attitudes toward euthanasia among health professionals. Thus, the instrument shows its sensitivity to these changes in attitudes toward euthanasia in a particular context and shows how items may migrate from one factor to another because euthanasia is regulated in that particular context.

As is also shown in the bioethics literature, "religiosity" is also a factor impacting attitudes toward euthanasia [37‐41]. In the present study, we found that nonreligious people showed more favorable attitudes toward euthanasia. This is also reflected in other studies, such as that of Terkamo-Moisio et al. [27] in 2019, in which postgraduate nurses were surveyed and found that being considered religious had a negative impact on attitudes toward their caring role in the euthanasia process, which meant that they were less well prepared for the provision of care in this context. Arreciado et al. [42], in 2024, also related in their study the fact that they did not consider themselves religious to better attitudes toward euthanasia among nursing students. This predictive value of the variable "being religious" for showing different types of attitudes toward euthanasia has also been demonstrated in other previous work [43‐45].

Although Law 3/2022 on the Regulation of Euthania in Spain defines the context in which this practice can be carried out, it is true that, as Rogers [31] pointed out, the questionnaire instructions do not provide a definition of the concept of "euthanasia", which could guide the participants in the study. The fact that 68.3% of respondents acknowledged knowing little or nothing about this concept could indicate that if certain respondents were clear about this concept, they might have more favorable attitudes toward euthanasia within the health system. For this reason, it seems to be very important to develop informative and educational campaigns from the National Health System as well as in the centers where health professionals are trained.

The revised EAS-ES resulting from this study is a valid instrument for assessing attitudes toward euthanasia, with psychometric characteristics similar to those reported in the international literature. The EAS-ES-R can be used in different contexts for Spanish-speaking healthcare professionals, as it has shown significant internal consistency in a sample composed of different healthcare professions and students of healthcare professions or those studying a specialty. This makes it an important tool for detecting different attitudes toward the euthanasia and therefore for supporting the professionals who form part of the teams that provide services in the process of aid in dying and health management in the development and implementation of Law 3/2022 on the regulation of euthanasia.