In March 2020, a bill to regulate euthanasia and medically assisted suicide was submitted to the Public Health and Social Assistance Committee of the House of Representatives of the República Oriental del Uruguay (Public Health and Social Assistance Committee, Folder No. 67 of 2020. Handout No. 28, March 2020). ¹ This bill was promoted by Dr. Ope Pasquet Iribarne, who is a Uruguayan lawyer and politician, member of the Partido Colorado and current president of the House of Representatives since March 1, 2022.

Article 1 of this bill determines that a person of legal age, mentally fit, sick with a terminal, irreversible and incurable pathology or afflicted by unbearable suffering, can request death or help to kill himself. Article 1 also states that a doctor acting in accordance with the proposed law and at the express request of the person is exempt from liability.

The first reflection that arises to me is that the situation raised is very mobilizing, it is of great ethical and moral complexity for those who request it, for the family and for the members of the health team, among which are the nursing professionals.

The criticism I make is that the bill in none of its articles contemplates either implicitly or explicitly the role of nursing, since it is known that nursing care is part of all care processes for all people in any place and stage of life in our health system.

In this sense, it is interesting to share what the Bachelor of Nursing Montserrat Busquets refers to analyzing the Euthanasia Law recently approved in Spain: “Under the argument that euthanasia belongs to the medical decision at the end of life, the law does not contemplate the work of nurses”. ⁽²

In December 2021, the Public Health and Social Assistance Commission of the House of Representatives of the Oriental Republic of Uruguay presents a new bill with modifications that arise from the analysis of the first project. The first modification is that it is only entitled “Euthanasia” (Public Health and Social Assistance Commission, Folder No. 2137 of 2021. Handout No. 600, December 2021). ³

This bill in article 6 states that in the event that the doctor refuses to act for personal convictions of a philosophical and / or religious nature, he must make it known in writing and if he decides to act, he will be exempt from responsibility for providing the provision of help.

The question that arises is: is the nursing staff who refuse to perform the procedure in what legal context is it also exempt from responsibility?

Faced with this situation, we must bear in mind the validity of Law No. 18815 of 2011, which regulates the exercise of the university profession of nursing and nursing assistant in our country. In the chapter on the Rights of nursing personnel in article No. 8 literal E refers: “Make use of conscientious objection when institutional directives allow procedures that may violate respect for the life, dignity and rights of users”, ⁴ a right that we have and consider does not conflict with the obligation to respect the right of the user to make their own decisions (literal G article 9). ⁴ Again, it can be said that the role of nursing staff is not considered in this new project either.

In August 2022, the Public Health and Social Assistance Commission of the House of Representatives of the Eastern Republic of Uruguay presented another euthanasia project again. This project arises from the merger of the one presented by Deputy Ope Pasquet and the Colorado Party bench in 2020, and the one presented in 2021 by the Frente Amplio, since the two bills referred to the issue of euthanasia and modifications were made requested by organizations linked to the subject. These modifications are the subject of discussions in the Chamber of Senators and Deputies for approval before the end of the year (Public Health and Social Assistance Commission, Folder No. 2762 of 2022. Handout No. 691, August 2022).⁵

Article 7 of this new bill states that the physician and the other members of the healthcare team whose services are required for the exercise of the right may validly object conscientiously. On this occasion they decide to include conscientious objection, a subject that I consider fundamental for the practice of our profession, but once again a great doubt arises in my mind... are we part of "the other members of the health care team", who are they referring to, the psychologist, the nutritionist, the physiotherapist, who participate in the procedure, with what function?

In Uruguay, as of 2021, according to data provided by DEMPESA (División de Evaluación y Monitoreo del Personal de la Salud del Ministerio de Salud Pública), there are 7670 Registered Nurses, 30790 Nursing Assistants and 20215 physicians. ⁶

Nurses must carry out medical prescriptions and sometimes doubts arise, due to the indicated doses of medications, the ways of administering or other procedures related to care, we have to be convinced that we do the right thing and that there are no ethical issues to reconsider.

Lucía Lozano in her degree dissertation at the University of Alicante “Analysis on the role of nursing in the law of euthanasia in Spain” refers:

Scientific evidence concludes that nursing participates actively in the process of euthanasia, covering the basic needs of terminal patients. Even so, it should be pointed out what is the true function of nursing in euthanasia since it is not defined in the Law.

The results obtained show that nurses are involved in the entire process of care for euthanasia, from the request to the subsequent care of the family. ⁷

The nurse cares in the process of dying. At the end of life the person has a great fragility and greater degree of dependence and it may be the time when he makes big decisions and the request for euthanasia can become present and in these circumstances our duty is to continue caring.

In August 2022, the Faculty of Nursing of the Universidad de la República asked to be received in Parliament to discuss the euthanasia bill; presented the Council of the faculty supported “the current regulatory framework” and asked that the norm guarantee “the universalization of palliative care”, as well as requested a hearing the College of Nursing, both institutions were not received. ⁸

Who was received in the Commission of Public Health and Social Assistance and appears in the shorthand version of the meeting held on July 6, 2022, was the dean of the Faculty of Health Sciences of the Universidad Católica del Uruguay. In his exposition he refers:

With all due respect, I feel in the two projects as a biologicist reduction. I say this because when one reads them, they seem to lack a more holistic vision of the person. They focus a lot on the biological, on pathology, on terminal pathology, although they talk about the loss of some capabilities. Above all, they focus a lot on the participation of the physician as the one who receives the request of the person who asks for the act of euthanasia. The truth is that one sees the physician in the project a bit alone. I believe that in both projects the health care team is not taken into account. In fact, in the legislation or in the projects of other countries, with a few exceptions, it is not taken into account and I understand that Uruguay should not for that reason fail to pay attention to this aspect. It is not taken into account that the physician could be accompanied by nursing graduates, nursing assistants, depending on the type of drug, by pharmaceutical chemists, by pharmacy assistants, by qualified pharmacists. This means that there is a whole context in which this type of situation could occur and, depending on the place where this type of event could take place, there is a team that accompanies the physician; this is something I would like to emphasize. ⁹

believe that the concepts expressed are substantial, it is a bill that ignores the multidisciplinary work that is carried out daily in health services, it is a bill where the role of nursing is not visible.

At the time of culminating this reflection in September 2022, the Health and Social Assistance Commission of the Chamber of Deputies voted in favor of the Euthanasia bill.

It seems to me that the balance is uneven, we cannot talk about euthanasia in a country where 35 % of people subject to palliative care do not have access to it. Let's give those who need the option of having a multidisciplinary team that allows the correct control of symptoms and active listening, from the psychological approach, giving space to spiritual and religious care, looking for the corresponding support networks, a function that fulfills a palliative care team.

From palliative care, needs are met, through the management and control of symptoms, seeking to cover daily needs through emotional support to the patient and his family, accompanying the patient and his family in the dying process, in palliative sedation to the patient, to the family and then in the grieving process. It should be clear that euthanasia is not part of palliative care, it is not complementary. The discussion is badly posed, it is not euthanasia vs palliative care, in any case it should be palliative sedation vs euthanasia and we can start arguing.

We must fight for a National Palliative Care Law in Uruguay to universalize care for children and adults.

I do not agree with euthanasia because of my philosophical and ethical convictions, but beyond this I must be realistic, whether or not we agree the situation is raised and if the law is approved, we must make decisions and leave determined:

The CIE (Consejo Internacional de Enfermeras - International College of Nursing) code of ethics in the suggestions item indicates that it is a guide for value-based action and makes sense if applied to the realities of nursing. ¹⁰

Our reality indicates that ethical debates related to the health care process arise daily and the issue of euthanasia shows us. It is evident that, as a collective, nurses in Uruguay are indebted to not have their own code of ethics that protects our profession, it is necessary from these situations to deepen the discussion.