Legal and Ethical Issues of Euthanasia: Argumentative Essay

(

Bilal S. H. Badr Naga Majd T. Mrayyan (1) Bilal S. H. Badr Naga., MSN, RN, Prince Sultan Cardiac Center in Qassim, Saudi Arabia (2) Majd T. Mrayyan., Prof, RN, The Hashemite University, Jordan Correspondence: Bilal S. H. Badr Naga., MSN, RN, Prince Sultan Cardiac Center in Qassim, Jordan Email: Bilal_badrnaga@yahoo.com

Abstract Euthanasia is one of the issues that has been the subject of intense debate over time. It has been a pertinent issue in human rights discourse as it also affects ethical and legal issues pertaining to patients and health care providers. This paper discusses the legal and ethical debates concerning both types of euthanasia. It focuses on both the supporter of euthanasia and the opponent of euthanasia. Several statements for the Euthanasia argument arediscussed: a merciful response that alleviates the suffering of patients which is sometimes wrongly perceived to be otherwise unrelievable; the autonomy in which the patient has the right to make his own choices; the regulation and legislation of existing practices of euthanasia to protect health care providers and patients. In this heated debate religious, political, ethical, legal and personal views are also included. Among all these, those who desperately want to end their lives because they simply cannot go on in any way, are the ones who suffer. Every individual or group has a different viewpoint regarding euthanasia. Euthanasia is considered a practical, emotional, and religious debate. Key words: euthanasia, palliative care, type of euthanasia.

Case scenario
A 56 year old female patient, divorced 5 years ago, a mother of one daughter, lives with her 20 year old daughter. She was working as a maths teacher, was well and very active until six months ago; she started to complain of generalized pain and weight loss, severe headache, multiple seizure episodes. She was diagnosed as having a metastasis brain tumor stage IV. She received two cycles of chemotherapy and refused radiotherapy. She developed hypoxic damage to her brain cells which left her paralyzed, and blind.She has been lying in her bed, depressed, with no contact with the outside world. She is religiously and sincerely fed by her daughter. She is suffering from intolerable pain. She asks her doctor to die in peace and signed an agreement consent form with the witness of her daughter. Her doctor gave her a high dose of morphine and terminated her life immediately.

This case was used to discuss the different opinions and answer the following questions in order to understand the concept of euthanasia. Is euthanasia a legal behavior? Does the patient have the right to request death peacefully? Despite the patient's agreement and consent, is participating in the killing of a patient considered ethical behavior and professional? Is there a long term impact and a sense of guilt by family and health care providers? Finally, why are some supporting a peaceful death and why some are against it, with opinion support?

Introduction
Euthanasia is a concept used in the medical field which means easy death or gentle death, and is defined as the deliberate speeding up of the death of an individual based on terminal medical conditions (Jonsen, Siegler, and Winsdale, 2002). Euthanasia reflects one of the current debatable issues and raises many questions that need to be answered.

Health care professionals, including oncology nurses, frequently encounter ethical issues when caring for end of life patients and have to make a decision and choose between difficult or unacceptable options and are frequently obligated to use their own moral reasoning to solve these ethical issues (Elis & Hartley, 2007).

In today's world, in spite of technological and scientific progress, especially in the field of laws and regulations related to human health there is still ambiguity and controversy over the concept of peaceful death (euthanasia). Thus, this ethical dilemma may impose health care providers to legal and ethical risk.

The ethical and legal aspects of the concept of euthanasia are still widely debated in many countries of the world. There are several opinions based on the principles of personal morality and religious beliefs. Thus, scientists and researchers are still looking to reach a general consensus on this ethical dilemma.

In Islamic countries there are discussions and debates about withholding or withdrawing the life support therapies or allowing a patient at the end of the life to choose peaceful death. Based on Islamic law, health care providers are not protected and have no immunity in case of deciding to help patients to die. Thus, according to the Islamic point of view; it is not recognized for a patient to have the right to die voluntarily because life is a divine trust and an opportunity to refine the spirit. Then, no one has the right to quit human life through any form of interference with active assistance.

Some Muslim Clerics scholars emphasized that life-saving equipment cannot be stopped unless physicians are confident of the inevitability of death and no hope (Zahedi, Ali Larijani, & Draper, 2007).

Therefore withholding or withdrawing treatment of any patient is never easy and cannot be generalized without taking into consideration the cultural, social, and religious factors when making decisions. The incidence of death as a result of euthanasia has been found to differ between countries (Onwuteaka-Philipsen, Fisher, Cartwright, Deliens, Miccinesi, Norup, et al. 2006; Ganz, Benbenishty, Hersch, Fischer, Gurman, &Sprung, 2006).

In the Netherlands as an example of a western country it is seen that nine percent of all deaths in 1990 were a result of euthanasia (Remmelink, et al. 1991). Unfortunately, there is a lack of statistics on the incidence of direct terminating of life by physicians in the Kingdom of Jordan and no clear policy about euthanasia for patients at the end of life stage whether that is secondary to cancer, or to any other end stage illness.

The advancement in medical technology is bringing deaths into hospitals where life, may be prolonged for a long time. For example, in Britain at any one time there are about two thousand people who have spent more than six months in a persistent vegetative state from which they will never recover. Many dread the endless indignity of such a fate. Worldwide there is a need to address the issue of euthanasia in order to manage and support clients and staff who are in a situation where a request of death is in place. In Jordan, yet, there are no studies that discuss euthanasia, or end-of-life decisions in any clinical setting.

This paper aims to discuss euthanasia among different western countries and Islamic countries and focus on the legal, religious, and social perspectives regarding this controversial issue.

This argument essay is attempted to decrease and limit the argument among health care professionals regarding euthanasia in order to enhance clear decisions, communication and accountability. This paper is organized to discuss and show viewpoints from both sides of the arguments and is concluded with the writer's opinion. A case scenario was selected and discussed for better understanding of this issue of euthanasia.

Definition and Background of Euthanasia
The definitions of euthanasia are not enough to find a clear society consensus. In order to increase public support we need to keep clear definitions so we know what we're talking about. Euthanasia is taken from the Greek ward euthanos, which means "good death." Death with dignity and without suffering, but the question is, how do we go about achieving this?

Euthanasia is the active killing of a patient by a physician, on the patient's request and in the patient's interest (Tom and Arnold, 1979). There are two types of euthanasia - passive and active. Passive euthanasia is defined as allowing a patient to die by withholding treatment, whereas active euthanasia is defined as taking measures to directly cause a patient's death. Another division of euthanasia is that it is voluntary, involuntary, and non voluntary. Voluntary euthanasia is when a patient gives his agreement whereas non voluntary is when the agreement is unavailable because of a patient's coma (Singer, 2011). Involuntary euthanasia occurs when euthanasia is performed on a person who is able to provide informed consent, but does not, either because they do not choose to die, or because they were not asked. Nurses may encounter many questions from patients and their families when counselling them about hastening the death of a patient (Gorman, 1999; Lewis, 2007). There are some statistics regarding medical practitioners who support or oppose euthanasia (Appendix A).

Physician Assisted Suicide (PAS) is defined as: 'The situation where a doctor intentionally helps a person to commit suicide by providing drugs for self-administration, at that person's voluntary and competent request' (Best, 2010). According to Best, in PAS the doctor is not doing the action but morally he is involved as the motive intention and the outcome are the same. Thus, euthanasia and PAS are used interchangeably in this paper.

Euthanasia Worldwide
Euthanasia is a controversial issue in Australia. Although there are different laws in Australia related to euthanasia, the legislations in most States consider it as illegal. At first, it was legal by Rights of the Terminally Ill Act 1995, and then it was overridden by the Australian government. But an Australian Dr. Philip Nitschke helped three patients to achieve euthanasia (Alexander, 2010). In 2002 in Belgium the Belgian parliament passed legislation for euthanasia (Adams & Nys, 2003).

Smets and his colleagues (2010) conducted a survey and found that most deaths by euthanasia compared with other deaths were more often younger, male, cancer patients and more often died in their homes. In almost all cases, unbearable physical suffering from uncontrolled pain, poor wound healing, and poor social interactions were reported.

Canadian laws on living wills and passive euthanasia are a legal dilemma. It is illegal to 'aid and abet suicide' under Section 241(b) of the Criminal Code of Canada, which states that this is an indictable offence with a potential fourteen-year sentence if the appellant is found guilty (Ministry of Attorney General, 2010). Also the British law has the same attitude toward euthanasia by considering it as illegal by all means.

In Indian laws, passive euthanasia is legal supported by the Supreme Court for brain death patients, but any actions whatsoever to end the life of a patient (active euthanasia) is illegal (Magnier, 2011). The same case applies to Ireland. Active euthanasia is considered illegal while passive euthanasia is legal. The Israeli and Jewish laws consider euthanasia as illegal, but in some cases it can be accepted under the Israeli law (Butcher, 2005; Brody, 2009).

Active euthanasia is illegal in most of the United States. While voluntary, passive euthanasia is considered legal; the patients have the right to reject medical treatment. Italy witnesses a social and legal crisis about a woman who had a car accident and she has been unconscious since 1992.

The Prime Minister Perleskony refused to endorse euthanasia for this woman claiming that nobody has the right to end the life of any human being. The Supreme Court in Italy decided to end this woman's life by euthanasia and they stopped giving her food or drink. And so the decision taken by the Italian government breaks the sentence taken by the Supreme Court according to the Italian law. It is obviously noticed that in the countries which allow euthanasia, such as Holland, there has been poor palliative and hospice care whereas in the countries where euthanasia is forbidden, they have developed hospice care for the patients who are suffering badly.

The issue of euthanasia has been raised in recent years in Islamic countries due to the debate over specific cases in which specific patients or their families have asked health care professionals, judges and religious people for a patient's right to die with dignity in a number of different ways (Bernard, 2000). In reality the issue did not enter into open public debate as it has in the USA and European countries. Despite this, the concept of euthanasia has mainly concentrated on physicians due to the nature of their roles.

Turkey, as an Islamic country forbids euthanasia strictly and considers such actions as a crime by the Criminal Law of Turkey (Karadeniz, Yanikkerem, Pirincci, Erdem, Esen, and Kitapcioglu, 2008). In Jordan euthanasia is illegal even if informed consent is taken from the patient or his family, thus it is considered a crime against human life and the one who commits euthanasia whether actively or passively will be punished by the law as being an intentional act.

Discussion
Regarding Patient Suffering
Many patients experience pain and suffering when they are dying, that is true, and during my clinical experience I have seen many dying patients who at their end stage illness were in pain, and they may be treated without dignity, or experiencing spiritual disorders.

But, we think this is an individual experience.This is supposed not to happen, but it is still happening and people are using this factor to convince people for the legalization of euthanasia. We must do better and look for better solutions. There is another option, which explains why euthanasia is increasingly unnecessary.

In the Greek Orthodox Church euthanasia is not accepted in every type, and there is no legal legislation or any action that helps patients to be allowed euthanasia (Voultsos, Njau, and Vlachou, 2010). Keown, (2005) reported Buddhists' point of view and found that there are many different opinions about euthanasia and they justify it as to end the sufferings of a patient. However, there is no justification whatsoever to end the life of a human being under any circumstances.

Moreover, in the teachings of the Catholic Roman Church euthanasia is a crime against life and God. On the other hand, Evangelical churches and the Roman Catholics have the same attitudes towards euthanasia which says that life is sacred. According to the Hindu views, there are two points of view. One considers euthanasia as a good action; the other considers it as disturbing the cycle of death and rebirth. Also, why are churches that established the first hospices in the 19thcentury and medical and nursing students now receiving training in pain control, because they believe that different types of pain respond to different treatments and this will help in caring of the dying.

In general, suffering is not only a medical problem but also an existential problem that extends beyond physical pain. It is influenced by many factors such as psychological, cultural and spiritual factors and we can deal with physical symptoms but the suffering may remain.
Islam forbids all forms of self-killing whatever the reason is for life and death is in the hands of Allah and nobody has the right to end this life bestowed by Allah and it is considered as a suicide. This means that Islam is totally against euthanasia whether active or passive and considers it a type of killing if it is committed by a different person and a suicide if it is committed by the same person and both of them should be punished and sent to hell in the other life. Thus Islam has a clear cut attitude towards euthanasia which is strictly forbidden by all means because Islam and the prophet (the messenger of Allah) said that life belongs to Allah and He is the only One who has the right to give or take it away without any exceptions. Accordingly, all the Fatwa Councils in all the Arab and Islamic countries do not pass any law (Fatwa) considering it as legal under any circumstances.

In addition, the Islamic Code of Medical Ethics, 1986 mentions that the concept of a life not worthy of living does not exist in Islam. Justification of taking life to escape suffering is not acceptable in Islam. Prophet Mohammad taught: "There was a man in older times that had an infliction that taxed his patience, so he took a knife, cut his wrist and bled to death. Upon this God said: My subject hastened his end, I deny him paradise." (Translation of Sahih Muslim, Book 35). Yusuf al-Qaradawi, the chairman of the International Union for Muslim Scholars (IUMS) mentioned that we can say that the Islamic perspective is that life belongs to Allah. It is He who gives and takes away life. No human can give or take it. Muslims are against euthanasia. They believe that all human life is sacred because it is given by Allah, and that Allah chooses how long each person will live (Fatwah Bank. 1996).

Moreover, the religious community in Islamic countries has discussed some sensitive medical issues such as definition of death, withholding and withdrawing life sustaining measures, and its legality as early as 1983. The Permanent Committee for Research and Fatwa issued a statement (Riyadh No. 6619; 1983) that advanced life support measures can be stopped if the medical team affirms that brain function has irreversibly ceased (Albar, 2004). The Islamic FIqh (comprehension) Academy; 3rd session, 1986, Amman, Jordan, Resolution No. 5 concluded that a person can be declared dead in one of two conditions: (1) complete and irreversible cardiopulmonary arrest affirmed by physicians. (2) Cessation of brain activity and affirmation by physicians that this cessation is irreversible and that the brain has entered the state of decomposition (OIC, 2003; Albar, 2004).

Physician and Protection of Life
One aspect of the euthanasia debate that is often ignored is that it expects doctors to perform euthanasia. One of the main roles of physicians is to gain a patient's trust and therapeutic relationship, and how does one maintain this goal if the patient's perception will change toward the physician who participates in killing patients (murder) instead of being a protector of life! Euthanasia violates codes of medical ethics which prohibits doctors from helping their patients die.

Perspectives of those who Oppose Euthanasia
There are people who are against euthanasia because they consider it a murder. Those who rejected euthanasia fear it may become a means of health care cost containment, and become non-voluntary and against the rights and value of human life. Those people defend their opinions through emphasizing the respect of human dignity through searching for solutions for cost containment, not through killing patients because of their suffering, and should identify the reasons that make a patient's request for euthanasia and find solutions to enhance their quality of life (Voultsos, Njau, and Vlachou, 2010). This means that it is not the choice of the physician to decide about killing patients even if they have signed an agreement and this is not a violation of their human rights.

Euthanasia is a social, legal, and ethical dilemma although many feel euthanasia is an unethical practice, one of the biggest arguments against this process is belief about the casual nature with which it will be approached in the future.

If euthanasia is permitted without the necessity to abide by government regulations and laws, people will use it as a means to get out of even simpler troubles.

Moreover, there may be ways in which pressure may be put on individuals to die or end their lives because they may seem as 'burdens' to the family. They may also use it as a method of avoiding heavy medical expenditures that may be needed in cases that are complicated. Religious views suggest that only God has the right to take life, and it is something human beings should not meddle with. Furthermore, they believe that life is a precious gift that has been bestowed upon us by the Almighty, and giving it up due to some pain is no way to value it. Political views suggest that euthanasia will have an effect on society, no matter how personal a decision it is. As a society that survives on following the footsteps of others, deciding to request death will cause other individuals (in less deplorable situations) to follow these methods too.

These are simply some thoughts on the ongoing debate that is a cause for concern all over the world. From the humanitarian point of view, the right to die with dignity, respect, comfort, and peace belongs to every individual, and this cannot be ignored no matter how many arguments are put forth against this practice.

Though several facts may be presented to you to persuade or dissuade you about this practice, it is ultimately your belief that will allow you to think whether or not such a practice should be legalized. It is a good idea to remember that death and dying is inevitable and an ultimate eventuality. In effect, the legalization of euthanasia under the strict governing of laws and regulations will allow those who wish to avail of this right, to do so with dignity. It is a process that will take a while, while the pros and cons of euthanasia are considered, and till all human beings are convinced that it may be a boon from Allah when viewed from the perspective of the right to life.

Human rights give everyone the right to take the best medical management to face different diseases and their signs and symptoms that affect all quality of life domains; therefore, from the British physicians' point of view, the majority of them do not support legalizing assisted dying, neither in the form of euthanasia nor physician-assisted dying. (Seale, 2009)

Euthanasia is complex, and there are ethical, legal, social, and moral arguments. The fear of euthanasia is that it will become a broad area for cost saving for health care institutions and toward health care providers in order to allow euthanasia to terminate life of patients under many circumstances; and that condoning voluntary euthanasia is a slippery slope towards allowing involuntary assisted killing (Rietjens et al. 2009).

The perspective of university students about euthanasia was studied in Pakistan. Students who opposed legalization (74.4%) cited impediments to future medical research as the most common reason, followed by the risk of misuse by physicians or family members. Only 8.9% of students cited religious beliefs as a reason against legalization of euthanasia. (Shaikhand & Kamal, 2011)

Perspectives of those who Support Euthanasia
This is one of the broad arguments for euthanasia. Supporters of euthanasia should know there is a social, ethical and legal impact on society, patients, and their families. Socrates, an ancient philosopher of Greece chose to kill himself instead of being exiled. The debate concerns one question: is euthanasia ethical? The case rests on one main fundamental moral principle: mercy. There are many even within the medical field who believe that euthanasia is far more ethical to those who have suffered terribly in terminal illnesses.

There are a many good reasons to accept euthanasia as the best option; it helps the patient, the patient's family, and the family's economy. It is a choice and alternative for a patient's decision which should be respected in order to alleviate suffering. There are many countries where euthanasia is allowed in order to give the right for everybody to end his life and help in health care cost containment. Patients in chronic prognosis do not have a choice to live. They can request euthanasia to stop suffering.

Patients in terminal stages of disease and suffering from uncontrolled severe pain, poor wound healing, poor social interaction, and poor emotional and economic status tend to request euthanasia. Euthanasia allows patients to terminate their perpetual state of suffering and die with dignity, respect, comfort, peace, and free of pain, when the patients cannot perform physical, emotional, and social tasks.

Advocates and supporters for euthanasia ask about why such a person should continue to live in suffering. There will be guilt, anger, frustration, and sadness associated with the decision of choosing euthanasia. In this way, it is considered improper to demand death, when feeling weak. Also, it is believed that the person in question has an obligation towards society, where she/he simply cannot choose to die because the life and death is given from God only.

In Greece euthanasia is applicable under legal documentation without giving attention to ethical, or social aspects of euthanasia (Voultsos, Njau, and Vlachou, 2010). Also, in Flemish hospitals all health policies contain euthanasia procedures; that involve caregivers, patients, and relatives. Euthanasia policies go beyond summarizing the euthanasia law by addressing the importance of the euthanasia care process; to give the patients and their families the rights to die in dignity as well as when the patients arrive at a critical prognosis which cannot be controlled by medical management (Lemiengre, Casterle , Denier, Schotsmans,& Gastmans, 2008).

There is a substantial majority of nurses supporting the practice of euthanasia for patients with a terminal illness with extreme uncontrollable pain or other distress and for their own involvement in consultancy about euthanasia requests. There is, however, uncertainty about their proper role in the performance of euthanasia. Older nurses were more likely than younger nurses to support life-ending without the patient's request (Inghelbrecht, Bilsen, Mortier, & Deliens, 2009).

Some of the arguments favoring the practice found in other studies included the need to relieve severe and incurable pain in the context of terminal illness or extremely poor quality of life, allowing patients to exercise freedom of choice and freeing up medical resources to help others (Roubaix, 2008).

Pakistani student perspective toward euthanasia was to relieve patient's suffering but only when a committee of physicians agreed to commit it. Only 25.6% of students agreed that euthanasia should be legalized in Pakistan to put an end to the sufferings of the patients. (Shaikhand & Kamal, 2011)

Perspectives of the Researcher
Death is considered the inevitable end of a human's life; it is the Creator who gives and takes away the human's life. We believe that euthanasia is not legal, ethical, and religious in all forms or names. It is strange in the twenty-first century to find supporters for euthanasia not exploiting the scientific, medical and technological advances in finding new medical methods to prevent or relieve the disease or its symptoms. The second reason we understand that euthanasia is opposed to palliative care, supposed to be encouraged not neglected. In Jordan, for example, palliative care is started at King Hussein Cancer Center (KHCC) and does not appear in other health care institutions. Moreover, Catholic hospitals have rigidity in using the concept of euthanasia and give support and availability of palliative care and a multidisciplinary team to introduce the best health management to terminally ill patients to improve quality of life for patients and their families (Lemiengre, Casterle, Denie, Schotsmans, & Gastmans, 2008). Also, the major fear held by the dying is not physical pain, but is also the fear of being abandoned by family, society, or both.

The World Health Organisation (WHO) recommends that governments devote more attention to pain relief and palliative care before considering laws to allow euthanasia. Most patients who request euthanasia change their minds once satisfactory pain control is established.

The third reason is the religious sense toward caring of patients in order to prevent euthanasia by providing dignity, respect, and freedom from suffering in the end of the patients' life. Catholic nurses also agreed more often than non-religious nurses to prevent euthanasia requests by comprehensive palliative care and to overcome signs and symptoms that make patients request euthanasia (Inghelbrecht, Bilsen, Mortier, & Deliens, 2009). On the other hand, palliative care is not only limited to patients but also to their families. Family members are an important part of a patients care, to give patients more rapport, support, and security.

It is common for family members to become overwhelmed by the additional responsibilities placed upon them when they find one of their members suffers from chronic disease such as cancer. Palliative care can help patients, families, and friends to cope with this disease and give them the support they need. It gives holistic care that consists of physical, spiritual, emotional, and coping care.

We consider euthanasia as an act of murder. Our Quran emphasizes this "He who created death and life that he might try you as to which of you is better dead, he is the mightiest, the most forgiving" (Qur'an- 67:2). Also taking one's life in Islam is only required for the sake of abolishing crime, ensuring peace, tranquility and security in the human society. Also, Islam does not believe in prolonging life as everyone has been created for a life span. Scientists are to assist but not replace Allah in the creation of death " Allah gives life and death and Allah sees well all that you do" (Qur'an 3:156).

There is no doubt that the financial cost of maintaining critical illness is a factor. However the question is when the human becomes ill and cost becomes a financial burden on the society, should allow death naturally and the cost is the responsibility of the society and they should change their priorities and divert funds from administrative and recreational areas to compensate the financial burden.

The suffering which one undergoes as a result of illness does not takeover one's dignity rather in fact benefits him spirituality by removing his/her sins as described by Prophet Mohammad."Any Muslim is affected with harm because of sickness or some inconvenience, Allah will remove his sins for him as a tree sheds its leaves" (Sahih Al-bukhari: Kitab Ultibb, 153). Thus, our responsibility is to seek treatment rather than mercy killing or suicide. Prophet Mohammad emphasized this when he said "O Muslims, seek cure, since
Allah has not created any illness without creating a cure" (Ibne Majah, Abu Daw'od) thus, if we do not know the cure, it is now our responsibility to search for the cure not instead to start killing patients to end their sufferings.

Statement of Argumentation
The first statement for euthanasia argument is a merciful response that alleviates the suffering of patients which ia sometimes wrongly perceived to be otherwise unbearable. The second statement for euthanasia debate is the autonomy in which the patient has the right to make his own choices. The third statement for euthanasia argument is legal, social, ethical, and religious aspects of euthanasia. The last statement is the regulation and legislation of existing practices of euthanasia to protect health care providers and patients.

Recommendations
Relieving pain, restoring dignity, improving quality of life and giving people back control over their lives is far better than fatal injections. Most people are visibly relieved when they are told euthanasia is not an option.

When symptoms are properly controlled, fears dealt with, appropriate practical, emotional and spiritual help is provided and people feel safe, it is very rare for people to ask again for death by euthanasia.

Euthanasia is a complex issue from a global perspective. Different cultures, traditions, religions and laws make the issue too simple for quick explanation. Therefore the recommendation for euthanasia is stated in four axes that consist of legal, governmental, social, and education axes. Legally, there must be strict laws preventing euthanasia and even those helping to do it. There should also be legislation against this act and punishment of those who do it or even help to do it. Socially, local governmental and non-governmental institutions should also be against euthanasia and they should do their best to prevent it by all means and to establish groups and charities to help patients and their families socially, spiritually and financially.

Educationally, all academic institutions (universities and colleges) teaching medical programs should teach medical ethics courses as part of their programs to enable the students to understand the ethical bases to deal with patients and their families based on ethical backgrounds.

Furthermore, governmental and private health sector should pay more attention to establishing a palliative care unit in hospital to cover all chronic diseases. In Jordan since 2004 when the Palliative Care Jordanian Society was established to give the right for the patients not to feel pain, loneliness and suffering in various stages of their illness is considered a duty of health care providers and the medical institutions to take into consideration the psychological, social and spiritual aspects when dealing with patients who complain of chronic diseases, and allow the patients to die with respect, dignify, peace, comfort, and without any social isolation.

Summary and Conclusion
Euthanasia has been a hot topic of debate for a while now. While some believe it is only humane to enable a human being to end his suffering by means of assisted suicide, others believe that all pain and suffering endured by human beings is God's will, and should be accepted as it has been given by God. In this heated debate religious, political, ethical, legal and personal views are also included. Among all these, those who desperately want to end their lives because they simply cannot go on in any way are the ones who suffer. Every individual or group has a different viewpoint regarding euthanasia.

Euthanasia is considered a practical, emotional, and religious debate. There is also a deep and broad history of euthanasia, which cannot be ignored when having a debate regarding this subject. Based on this history, beliefs, and viewpoints, certain arguments for and against euthanasia have been put forward.

Appendix A

source: Gallup Poll, Angelfire, Nightingale Alliance. Date Verified: 7.23.2012
Retrieved from: http://www.statisticbrain.com/euthanasia-statistics/

References
Akashi, M. Yano, E and Aruga, E. (2012). Under-diagnosis of pain by primary physicians and late referral to a palliative care team. BMC Palliative Care journal, (11), 7, 2-9.
Ameringer, S. (2010). Barriers to Pain Management among Adolescents with Cancer. Journal of Pain Management Nursing, (11), 4, 224-233.
Alexopoulos, E.C., Koutsogiannou, P., Moratis, E., Mestousi, A., & Jelastopulu, E. (2011).
Pain in cancer patients: The Greek experience. European Journal of Oncology
Nursing, 15, 442-446.
Adams, M., & Nys, H. (2003). Comparative reflections on the Belgian Euthanasia Act. Medical Law Review, 11(3), 353-376. Doi: 10.1093/medlaw/11.3.353.PMID 16733879.
Alexander, Cathy (2010). "Pro-euthanasia TV ad ban 'a violation of free speech'". The Age (Melbourne), 23(3). Doi:10.1529/medlaw/21.3.353.PMID 45735579.
Bagcivan, G., Tosun, N., Komurcu, S., Akbayrak, N., & Ozet, A. (2009). Analysis of patient-related barriers in cancer pain management in Turkish Patients. Journal of Pain and Symptom Management, 38(5), 727-737. doi: 10.1016/j.jpainsymman
Beuhler, J., Malone, M., Majerus-Wegerhoff, J. (2006). Patterns of responses to symptoms in
rural residents: The symptom-action-time-line process. In H. Lee, Winters, C. (Ed.),
Rural Nursing: Concepts, Theory, and Practice (2nd ed., pp. 129-137). New York:
Springer.
Brennan, F., Carr, D., Cousins, M. (2007). Pain management: A fundamental human right Anesthesia & Analgesia, 105(1), 205-221.
Brody, Shlomo (2009). "Ask the Rabbi: 'Passive euthanasia'". Jerusalem Post. Retrieved 6 January 2012.
Butcher, Tim (8 December 2005). "Israelis to be allowed euthanasia by machine". Daily Telegraph. Retrieved 6 January 2012.
Bernard , L. (2000). Resolving Ethical Dilemmas, A Guide for Clinicians New York: Lippincott Williams andWilkins, page 156.
Fatwah Bank on IslamOnline.net on Mar. 22, 2005. "Euthanasia and Physician-Assisted Suicide," submitted to the Institute of Medicine Committee on Care at the End of Life on May 13, 1996.
Gordijn, B and Janssens, R. (2000). The prevention of euthanasia through palliative care: new developments in the Netherlands. patient education and counseling journal, (1)41, 35 46.
Gorman, D. (1999). Active and passive euthanasia: the cases of Drs. Claudio Alberto de la Rocha and Nancy Morrison. Canadian medical association journal, 1999; 160:857-60.
India's Supreme Court lays out euthanasia guidelines. Mark Magnier, Los Angeles Times. 8 March 2011. Retrieved 8 March 2011
Inghelbrecht, E., Bilsen, J., Mortier, F., Deliens, L. (2009). Attitudes of nurses towards euthanasia and towards their role in euthanasia: A nationwide study in Flanders, Belgium. International Journal of Nursing Studies, (9)46, 1209-1218. doi: 10.1016/j.ijnurstu.2009.02.009
Islamic Code of Medical Ethics endorsed by the First International Conference on Islamic Medicine. Islamic Organization of Medical Sciences, Kuwait, 1981, p.65. Retrieved from http://www.rewi.unijena.de/rewimedia/Downloads/LS_Ruffert/Ethical+Codes/Islami +Code of+ Medical+ Ethics. Pdf
Karadeniz G., Yanikkerem E., Pirinçci E., Erdem R., Esen A., Kitapçioglu G.(2008). Turkish health professional's attitude toward euthanasia. Omega Journal of Death and Dying; 57(1), 93-112.
Keown, D. (2005). End of life: the Buddhist View. The Lancet Journal, (366)9489, 952-955. Doi:10.1016/S0140-6736(05)67323-0
Lemiengre, J.Casterle, B. Denier, Y. Schotsmans, P and Gastmans, C. (2008). How do hospitals deal with euthanasia requests in Flanders (Belgium)? Patient Education and Counselling Journal, 71, 293-301. doi: 10.1016/j.pec.
Lewis, P. 2007. The empirical slippery slope from voluntary to non-voluntary euthanasia. Journal of Law Medicine Ethics, (1)35, 197-210.
Lemiengre, J.Casterle, B. Denier, Y. Schotsmans, P and Gastmans, C. (2008). How do hospitals deal with euthanasia requests in Flanders (Belgium)? Patient Education and Counselling Journal, 71, 293-301
Ministry of Attorney General, 2010. Retrieved from http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm
Rietjens, J. Paul J. Maas, P. Onwuteaka-Philipsen, B. Delden, J and Heide, A. (2009). Two decades of research on euthanasia from the Netherlands: what have we learnt and what questions remain? Journal of Bioethical Inquiry, 2009, 6:271-283
Roubaix, D. M. (2008). Are there limits to respect for autonomy in bioethics? Journal of Medicine and Law, 27, 365-399
Rietjens, J. Paul J. Maas, P. Onwuteaka-Philipsen, B. Delden, J and Heide, A. (2009). Two decades of research on euthanasia from the Netherlands: what have we learnt and what questions remain? Journal of Bioethical Inquiry, 2009, 6:271-283. Retrieved from http://eutanasia.ws/hemeroteca/t300.pdf
Remmelink, J. et al. (1991). Medical Decisions About the End of Life, I. Report of the Committee to Study the Medical Practice Concerning Euthanasia. II. The Study for the Committee on Medical Practice Concerning Euthanasia (2)19, 199
Smets, T., Bilsen, J., Cohen, J., Rurup, M. L. & Deliens, L. (2010). Legal euthanasia in Belgium: characteristics of all reported euthanasia cases. Medical Care Journal, 48 (2), 187-192. Doi: 10.1097/MLR.0b013e3181bd4dde.
Seale, C. (2009). Legalisation of euthanasia or physician-assisted suicide: survey of doctors' attitudes. Jounal of Palliative Medicine, 00, 1-8. doi: 10.1016/j.jflm.2009.01.014.
Shaikh, M and Kamal, A. (2011). Beliefs about euthanasia among university students: perspectives from Pakistan, Eastern?Mediterranean?Health?Journal, (17) 10, 794 797. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22256415
Singer, P. (2011). Practical Ethics. New York: Cambridge University Press.
Inghelbrecht, E. Bilsen, J. Mortier, F , and Deliens, L. (2009). Attitudes of nurses towards euthanasia and towards their role in euthanasia: A nationwide study in Flanders, Belgium, International Journal of Nursing Studies, 46, 1209-1218. doi: 10.1016/j.ijnurstu.2009.02.009
Jonsen, A., Siegler, M., Winsdale, W.J. (2002). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. New York: McGraw Hill.
Tom, L. B and Arnold, I. D. (1979). The Definition of Euthanasia. Journal of Medicine and Philosophy, (3)4, 294 312.
Translation of Sahih Muslim, Book 35. University of Southern California. Hadith 35.6480. Retrieved from http://arthursclassicnovels.com/islam/sahih-muslim10.html
Voultsos, P., Njau. S. N., and Vlachou, M. (2010). The issue of euthanasia in Greece from a legal viewpoint, Journal of Forensic and Legal Medicine, (17)3, 131-136. doi: 10.1016/j.jflm.2009.01.014.
Voultsos, P. Njau, S and Vlachou, M. (2010). The issue of euthanasia in Greece from a legal viewpoint, Journal of Forensic and Legal Medicine, (17) 3, 131-136
Voultsos, P. Njau, S and Vlachou, M. (2010). The issue of euthanasia in Greece from a legal viewpoint, Journal of Forensic and Legal Medicine, (17) 3, 131-136