Introduction
The practice of mercy killing, also known as euthanasia or assisted suicide, has remained a contentious and morally complex issue in healthcare (Frolic & Miller, 2022; Mroz et al., 2021; Munawwar et al., 2023). It involves deliberately hastening the death of a patient who is suffering from incurable illnesses or experiencing unbearable pain (Banović et al., 2017; Richardson, 2023). Ethical considerations surrounding mercy killing have garnered significant attention in recent years, with various perspectives and debates emerging from different cultural and religious contexts (Chan et al., 2020; Gott et al., 2019; Uzelli Yilmaz et al., 2023). 
A series of studies in Iran revealed that Muslim nurses, including those in the East Azerbaijan Province, hold negative attitudes toward euthanasia (Naseh & Heidari, 2016; Naseh et al., 2015; Rahimi et al., 2015; Safarpour et al., 2019). These findings suggest a strong cultural and religious influence on the attitudes of Muslim nurses towards euthanasia. This finding is also consistent with a broader international study that found most nurses, including those in Arab countries, could not ethically justify active voluntary euthanasia (Davis et al., 1993). In particular, exploring ethical dilemmas related to mercy killing within specific religious communities can provide valuable insights into the intersection of faith, culture, and healthcare decision-making (Uzelli Yilmaz et al., 2023). 
Healthcare professionals in the intensive care units (ICUs) face the delicate task of balancing compassion, ethical principles and the individual preferences of patients and their families when addressing end-of-life care and euthanasia. These patients face severe or life-threatening medical conditions requiring intensive and continuous monitoring, specialized care and advanced medical interventions (Guttormson et al., 2022). Accordingly, nurses in the ICU often deal with individuals facing critical and life-threatening conditions, and end-of-life care decisions become crucial in high-stakes environments (Badparva et al., 2022; Wei et al., 2018). Discussions about transitioning to palliative care and the withholding or withdrawing life-sustaining treatments become integral aspects of end-of-life care in the ICU (Jin et al., 2022; Oduyale et al., 2020).
In the context of the study on the practice of mercy killing among Muslim Maranao nurses in the critical care setting, exploring the influence of religious beliefs is of utmost importance. The Maranao community, predominantly residing in the southern Philippines, holds a distinct cultural identity strongly influenced by Islamic teachings (Ali & Hassan, 2017). Within the realm of Islamic teachings, discussions surrounding end-of-life care, including mercy killing, have garnered considerable attention and debate. The understanding of Islamic principles regarding the sanctity of life and the role of human beings in preserving it is fundamental in guiding the ethical decisions and behaviors of Muslim Maranao nurses. Their interpretations of religious teachings and the moral values derived from these teachings are integral to their perspectives on mercy killing. 
This qualitative study aims to explore the practice of mercy killing among Muslim Maranao nurses in the critical care setting. Understanding the perspectives, beliefs, and experiences of Maranao Muslim nurses regarding mercy killing is crucial for addressing the ethical complexities associated with end-of-life care and ensuring culturally sensitive healthcare practices within the Maranao community. By shedding light on the lived experiences and ethical dilemmas faced by Maranao nurses, this research aims to inform healthcare professionals, policymakers and educators on the importance of culturally competent care and the development of ethical guidelines that respect Muslim communities’ religious and cultural values.
This research contributes to the existing literature on ethics in healthcare, particularly within the context of Muslim communities. It expands the knowledge base on mercy killing and its implications for healthcare practice, offering insights into the unique perspectives of Maranao Muslim nurses. Additionally, this study serves as a platform for dialogue and reflection on ethical decision-making, highlighting the need for culturally sensitive approaches to end-of-life care within diverse religious and cultural communities.

Materials and Methods

Study design
In this study, a qualitative descriptive phenomenological research design was employed to explore the practice of mercy killing among Muslim Maranao nurses in critical care settings. The purpose was to gain an in-depth understanding of the moral and ethical considerations that influence the attitudes and behaviors of Muslim Maranao nurses towards mercy killing, taking into account their personal experiences. Descriptive phenomenology is a qualitative research design that aims to explore and describe the essence of a phenomenon as experienced by individuals. This approach involves understanding the lived experiences of individuals and interpreting the meanings they attribute to these experiences (Bradfield et al., 2019).

Study participants
The study participants were selected using purposive (criterion) sampling. Muslim Maranao nurses working in critical care units in healthcare facilities located in the southern Philippines were chosen because of their direct experience and insights related to the topic of mercy killing. The nurses were selected based on the following criteria: 1) Having experience in the critical care units (ICU & CCU) for at least five years, 2) Encountering terminally ill patients (with do-not-resuscitate [DNR] order) and 3) Caring the patients in the critical care setting with palliative status.
The sample size was determined based on data saturation (n=10), which is the point at which new information and themes cease to emerge from the interviews. The participants were provided with information about the purpose and nature of the study and their voluntary participation was ensured. Confidentiality and anonymity were maintained throughout the study.

Data collection
The primary method of data collection in this study was in-depth interviews. Semi-structured interview guides were developed based on the research objectives and the relevant literature. The interview questions were designed to explore the participants’ perspectives on mercy killing, religious beliefs, cultural norms, personal experiences, and professional ethics related to end-of-life care. The first question was, “Please tell me about your experiences and observations regarding the ethical considerations in end-of-life care within the critical care setting.” Probing questions were used to encourage participants to provide detailed responses and elaborate on their views.
The interviews were conducted through face-to-face platforms, depending on the availability and preferences of the participants. With their consent, the interviews were audio-recorded to ensure accurate data capture and transcribed verbatim for further analysis.

Data analysis
Thematic analysis was employed to analyze the qualitative data obtained from the interviews. Thematic analysis is a systematic approach that involves identifying, organizing, and interpreting patterns or themes within the data. The data analysis followed Colaizzi’s seven-step method for phenomenological data analysis, presented below (Shorey & Ng, 2022).
Familiarization with the data: The transcribed interviews were read and re-read, aligning with Colaizzi’s first step to understand the data comprehensively. This step involved immersing the researcher in the rich experiences shared by the Maranao nurses.
Identifying significant statements: Meaningful and important statements were systematically extracted during the thematic analysis. These statements involved key elements of the nurses’ experiences regarding ethical dilemmas on mercy killing.
Formulating meanings: Thematic analysis involved coding the recurring and meaningful content within the data. These codes represent the formulated meanings extracted from the nurses’ statements.
Clustering themes: This step corresponds to collecting the encoded views, similar to organizing codes into potential themes during the thematic analysis. It involved grouping related concepts and patterns identified in the data.
Developing an exhaustive description: It delved into writing detailed and exhaustive descriptions based on the collected views. Thematic analysis contributed to this step by comprehensively understanding the themes that emerged from the data.
Producing the fundamental structure: It involved distinguishing similar views and sublimating theme concepts. Thematic analysis played a role in refining and defining themes by revisiting the data and comparing them against the research objectives.
Validation of the results: The final step involves returning the findings to the Maranao nurses as participants for verification, which aligns with the validation procedures undertaken in thematic analysis. This step ensures the accuracy and credibility of the identified themes and findings.
The identified themes were reviewed, refined and defined by revisiting the data and comparing them against the research objectives. Seven authors participated in checking and rechecking the step-by-step process of Colaizzi’s method of data analysis to ensure a rigorous process succeeding its approval. 

Trustworthiness and rigor
Several strategies were employed to enhance the study’s trustworthiness and rigor. Member checking was conducted, where Maranao nurses, as participants, were allowed to review and provide feedback on the analyzed data to ensure the accuracy and validity of the interpretations (Motulsky, 2021). As a comprehensive process that includes self-reflection, documentation of assumptions, suspension of judgment and continuous reflexivity, bracketing was considered in data analysis. Additionally, peer debriefing was conducted by discussing the research process, findings and interpretations with colleagues to gain different perspectives and ensure credibility. An audit trail was maintained to document the decisions made during the research process, allowing for transparency and potential future verification. Transferability of the data was established by writing an audit trail and providing a detailed description of the studied context (Sundler et al., 2019).

Dissemination of findings
The findings of this study will be circulated through academic publications in peer-reviewed journals and conference presentations. Efforts will be made to share the findings with relevant healthcare professionals, policymakers, and educators through seminars, workshops, and other knowledge dissemination platforms. The research report will be made available to the participants upon request.

Results 
This study aimed to explore the ethical dilemma of mercy killing among Muslim Maranao nurses in the critical care setting. Ten Maranao nurses with at least 5 years of working experience in the critical care settings were interviewed. Based on their descriptive characteristics in Table 1, maximum variation sampling was established. As seen in this Table, their age ranges from 28 to 45 and they are predominantly female.



They are mostly bachelor’s degree (BSN) holders, two have master’s degrees, and two have units in master’s degree with a range of experience from 5 to 20 years. Through qualitative phenomenology design and Colaizzi’s method of analysis, three themes with their respective subthemes emerged. The themes, subthemes and the related categories are presented in Table 2. 



Theme 1: Religious beliefs
Religious beliefs significantly shape individuals’ perspectives, values and ethical considerations surrounding sensitive topics such as mercy killing. Maranao nurses reflect on their understanding of Islamic principles related to end-of-life care and mercy killing. These nurses’ reflections provide invaluable insights into how their religious convictions inform their approach to ethically complex situations in healthcare. This theme emerged from various aspects of Islamic teachings, religious duties, and moral responsibility, as subthemes explored through the participants’ narratives.
Islamic teachings stand out as a prominent subtheme within religious beliefs. They delve into how Islamic teachings shape their views on intentionally hastening someone’s death and the role of Allah as the ultimate giver and taker of life. They draw upon Islamic teachings on mercy to inform their ethical judgments and decision-making processes in healthcare settings. Participants also described the role of prayer and supplication in shaping their ethical discernment and moral responsibilities, which, through prayer, they seek spiritual guidance and strength to navigate complex ethical dilemmas, including those related to end-of-life care. The interpretation of Islamic teachings and the concept of mercy in Islam guide their ethical considerations. For example, one participant (No. 7) said:
“In Islam, mercy permeates all facets of life, including healthcare. Muslim nurses embody this mercy by delivering holistic care, easing suffering and upholding the divine course of life determined by Allah.” 
Moreover, religious duties, as the second subtheme, provide valuable insights into participants’ ethical responsibilities and obligations guided by their religious beliefs. This aspect delves into their commitment to upholding the sanctity of life, navigating the delicate balance between mercy and ethical obligations and the role of spiritual guidance in informing their ethical decision-making processes. Some excerpts from the interviews with the participants are presented below.
Participant number 10 said, “As nurses, somehow it is part of our duty to seek spiritual guidance from religious leaders or scholars to deepen our understanding of Islamic teachings, especially in intricate ethical dilemmas like mercy killing.”
Participant number 1 said, “Balancing between mercy and ethical obligations is challenging, but our faith guides us.”
Furthermore, moral responsibility emerged as the third subtheme. Muslim Maranao nurses shared that their moral values have been examined. It has made them contemplate their beliefs about suffering, personal development, and the intrinsic worth of life. Their religious and cultural upbringing has influenced their moral duty, which drives them to offer assistance, solace and reverence for the organic progression of life, even when encountering suffering. Excerpts from the interviews with the participants are presented below:
Participant number 5 said, “The primary duty of a Muslim nurse is to preserve life and provide comprehensive pain management, comfort and palliative care, honoring the sanctity of life.” 
Participant number 6 said, “Guided by my moral compass, I believe in providing comprehensive and compassionate end-of-life care that upholds every individual’s inherent value and dignity.” 
Participant number 6 said, “Guided by my moral compass, I believe in providing comprehensive and compassionate end-of-life care that upholds every individual’s inherent value and dignity.” 

Theme 2: Cultural norms
Cultural norms, embedded in traditions and values, significantly influence how individuals, including healthcare professionals, perceive and navigate ethical dilemmas. This study on mercy killing among Muslim Maranao nurses highlights the critical role of cultural norms. The unique cultural identity of the Maranao community greatly impacts the attitudes and actions of Maranao Muslim nurses in their approach to ethical decisions, especially in the critical care context. This theme is explored through three subthemes: Community values, stigma and taboo and sense of identity.
As a prominent subtheme, community values highlight the importance of family and community in Maranao culture. Participants emphasized the integral role of family support networks in decision-making processes and the preservation of traditional practices. Respect for elders is deeply ingrained in Maranao society, guiding interactions within families and communities. Traditional practices, deeply rooted in cultural heritage, influence healthcare beliefs and behaviors among Maranao nurses.
Participant number 5 said, “In our Maranao culture, family and community hold a central place in decision-making, especially in critical matters like end-of-life care. The collective opinion and consensus of the family play a significant role in shaping our attitudes and actions regarding sensitive topics such as mercy killing.” 
Stigma and taboos present another critical subtheme, revealing the fear of social judgment surrounding certain healthcare decisions. Participants expressed concerns about cultural perceptions of death and dying, which might stigmatize discussions around end-of-life care and palliative interventions. The influence of cultural norms on decision-making processes underscores the need for culturally sensitive approaches to healthcare delivery.
Participant number 4 said, “There’s a fear of judgment, especially in discussing sensitive topics like death. Cultural beliefs often stigmatize such conversations, making end-of-life care challenging.” 
A sense of identity is a fundamental aspect of Maranao culture, reflecting pride in cultural heritage and traditions. Participants express a strong sense of cultural identity and the importance of upholding Maranao traditions in their professional practice. Cultural preservation and adaptation are essential considerations in healthcare delivery as Maranao nurses navigate the intersection between tradition and modernity in their roles as healthcare providers.
Participant number 8 said, “As Muslim Maranao nurses, we are committed to upholding our traditions and cultural practices in healthcare. We recognize the importance of integrating our cultural heritage into our care practices even in challenging situations like end-of-life care.” 

Theme 3: Professional ethics
Professional ethics are the cornerstone of healthcare, guiding decision-making and conduct. In the study concerning mercy killing among Muslim Maranao nurses in critical care, delving into the theme of professional ethics is essential to comprehend the ethical factors shaping these nurses’ attitudes and actions. They stress the importance of delivering holistic care, easing suffering, and upholding each person’s dignity. Their actions stem from subthemes such as duty to the patient, team collaboration, and ethical guidelines.
Duty to the patient, as the first subtheme, emphasizes the Maranao nurses’ dedication to patient care and well-being. Participants express a deep commitment to ensuring the best possible outcomes for their patients, prioritizing their health and safety above all else. Advocacy for patient autonomy emerges as another key aspect, reflecting participants’ efforts to empower patients in decision-making processes and respect their rights to self-determination. In critical care settings, nurses encounter complex ethical dilemmas that require careful consideration and navigation to uphold patient-centered care while adhering to professional standards.
Participant number 2 said, “I see my duty as a Maranao nurse who ensures the well-being of my patients. Every decision I make revolves around what is best for them, ensuring their comfort, dignity and safety throughout their care journey.” 
Team collaboration represents another significant subtheme, highlighting the importance of interdisciplinary collaboration in healthcare delivery. Maranao nurses emphasized the value of collaborative decision-making processes, where input from various healthcare professionals was sought and considered to optimize patient outcomes. Effective communication with interdisciplinary teams is essential for coordinating care plans and ensuring continuity of patient care. Participants also highlighted the importance of receiving support from colleagues and superiors, fostering a supportive work environment conducive to professional growth and development.
Participant number 6 said, “We actively engage in discussions and consult with colleagues, patients and their families to reach consensus on ethical decisions.” 
Participant number 2 said, “Having the support of colleagues and superiors is crucial in navigating complex ethical situations; Supportive environments foster ethical awareness and the provision of quality care.” 
Ethical guidelines serve as a guiding framework for Maranao nurses in navigating complex ethical dilemmas and decision-making processes. Participants demonstrated a strong familiarity with ethical codes and principles governing their practice, drawing upon these guidelines to inform their actions and decisions. Adherence to professional standards is paramount, as nurses strive to maintain the integrity and credibility of their profession while upholding ethical principles. However, participants acknowledge the inherent challenges in resolving conflicts between personal and professional ethics, underscoring the need for ongoing reflection and ethical decision-making skills development within the nursing profession.
Participant number 9 said, “Ethical guidelines serve as valuable references in our professional practice. We continuously educate ourselves on ethical codes and principles, incorporating them into our decision-making process.” 

Discussion
The perspectives of the Muslim Maranao nurses on mercy killing are deeply influenced by their religious beliefs, cultural norms, and professional ethics, particularly in critical care settings. For the participants, religious beliefs are pivotal in shaping their ethical frameworks and practices as healthcare professionals. Existing literature supports the notion that religious beliefs significantly influence the ethical decision-making processes of healthcare professionals across different cultural and religious contexts. For instance, studies conducted in Muslim-majority countries have demonstrated the central role of Islamic teachings in shaping the ethical practices of healthcare providers (Elzamzamy & Keshavarzi, 2019). Similarly, research in diverse healthcare settings has highlighted the impact of religious beliefs on healthcare professionals’ attitudes toward issues such as patient autonomy, informed consent, and end-of-life care (Bülow et al., 2012; Duivenbode et al., 2019).
Moreover, the cultural norms of Maranao nurses highlight its profound influence on the ethical perspectives and behaviors concerning the sensitive issue of mercy killing. As part of their cultural norms, community values emphasize the centrality of family and community support in Maranao culture. The reliance on family networks for decision-making aligns with findings from studies examining the influence of collectivist cultural values on healthcare practices (Hanssen & Tran, 2018; Tay et al., 2017). Also, respect for elders reflects the deep-rooted cultural norms that guide interactions within Maranao families and communities, which, on the other hand, influences their approach to patient care and decision-making. Studies on cultural influences on healthcare ethics have highlighted the significance of hierarchical structures and respect for authority figures in decision-making processes (Fernandes & Ecret, 2019; Fernandopulle, 2021). More so, some stigmas and taboos impact cultural perceptions on discussions surrounding end-of-life care and palliative interventions. Research has shown that cultural beliefs and attitudes toward death and dying can significantly influence individuals’ preferences for end-of-life care and their willingness to engage in discussions about death (Huang et al., 2021). By upholding Maranao traditions while adapting to modern healthcare practices, Maranao nurses maintain a strong sense of cultural identity, which positively influences their professional practice. Studies have demonstrated the positive impact of cultural pride and identity affirmation on healthcare providers’ job satisfaction and patient outcomes (Ali & Anwar, 2021). 
Furthermore, Maranao nurses have shown unwavering commitment to prioritizing their patient’s well-being and dignity. This dedication aligns with research findings highlighting the central role of patient-centered care in nursing practice (Ortiz, 2018). Meanwhile, it has been argued that patient-centered care, characterized by a holistic approach that addresses patients’ physical, emotional, and spiritual needs, is essential for promoting positive patient outcomes and ensuring quality healthcare delivery (Demirsoy, 2017). On the other hand, this study reflects Maranao nurses’ efforts to advocate for patient autonomy in empowering patients in decision-making processes, consistent with principles of patient rights and autonomy in healthcare ethics (Greaney & O’Mathúna, 2017). Duivenbode et al., (2019) emphasized respecting patients’ autonomy and involving them in shared decision-making, fostering trust, enhancing patient satisfaction, and promoting ethical healthcare delivery.
This study also highlights the significance of interdisciplinary collaboration in promoting effective healthcare delivery and ethical decision-making. This finding accords with a study that reported that collaborative decision-making processes involving healthcare professionals from various disciplines result in better patient outcomes and higher-quality care (Sivakumar et al., 2020). More so, ethical guidelines serve as a crucial framework for Maranao nurses navigating complex ethical dilemmas and decision-making processes. This finding aligns with research emphasizing the importance of ethical standards and procedures in guiding healthcare professionals’ conduct and ensuring ethical practice (Asare et al., 2022). This finding further emphasizes that adherence to ethical principles and guidelines is essential for maintaining trust, integrity, and professionalism in healthcare practice.
This study holds the inherent limitations of qualitative research. The findings may be specific to the Muslim Maranao critical care nurses and may not be generalized to other populations or healthcare settings. Furthermore, the subjective interpretation of the data during the analysis may introduce researcher bias. These limitations were addressed by providing a thick description of the research context, maintaining transparency in the research process, and critically reflecting on the limitations in the research report.

Conclusion
This study highlights the intricate interaction between religious beliefs, cultural norms and professional ethics in shaping the perspectives of Muslim Maranao nurses on mercy killing. The insights gained from this research have practical implications for promoting culturally sensitive and ethically sound healthcare practices in critical care settings. Healthcare professionals, policymakers, and educators should be mindful of these perspectives and engage in ongoing dialogue to ensure that end-of-life care aligns with diverse communities’ religious, cultural, and ethical values. Further research is warranted to explore additional contextual factors and to develop comprehensive guidelines and policies that address the complexities surrounding mercy killing within this specific cultural and religious context. It is also suggested that ethnographic studies be conducted to gain a deeper understanding of the concept of mercy killing in different Islamic societies.

Ethical Considerations

Compliance with ethical guidelines
The present study was approved by Ethics Committee of Mindanao State University-College of Health Sciences (MSU-CHS) (Code: CHS-REC-0717-2020). This study was conducted with careful attention to ethical considerations, ensuring the protection of participants’ rights and well-being.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization: Hamdoni K. Pangandaman, Nursidar P. Mukattil, Joy Hope C. Lambayong, Samiel P. Macalaba, Abolbashar M. Mangontawar and Norhanie A. Lininding; Supervision: Hamdoni K. Pangandaman, Nursidar P. Mukattil, Joy Hope C. Lambayong and Samiel P. Macalaba; Methodology: Hamdoni K. Pangandaman, Nursidar P. Mukattil, Joy Hope C. Lambayong, Sittie Ainah Mai-Alauya, Abolbashar M. Mangontawar and Norhanie A. Lininding; Investigation: Hamdoni K. Pangandaman, Sittie Ainah Mai-Alauya, Norhanie A. Ali, Samiel P. Macalaba, Abolbashar M. Mangontawar, Norhanie A. Lininding and Iman U. Matumadi; Data collection: Hamdoni K. Pangandaman, Sittie Ainah Mai-Alauya, Norhanie A. Ali, Samiel P. Macalaba, Abolbashar M. Mangontawar, Norhanie A. Lininding and Iman U. Matumadi; Data analysis: Hamdoni K. Pangandaman, Nursidar P. Mukattil, Joy Hope C. Lambayong and Samiel P. Macalaba; Writing the original draft: Norhanie A. Lininding: Hamdoni K. Pangandaman, Nursidar P. Mukattil, Joy Hope C. Lambayong, Samiel P. Macalaba, Abolbashar M. Mangontawar and Norhanie A. Lininding; Review and editing: Hamdoni K. Pangandaman, Nursidar P. Mukattil, Joy Hope C. Lambayong, Sittie Ainah Mai-Alauya, Mas, Abolbashar M. Mangontawar and Norhanie A. Lininding; Funding administration: All authors.

Conflict of interest
The authors declared no conflict of interest. 

Acknowledgments
The authors would like to sincerely thank all nurses participating in this study. The authors also appreciate the institutions Mindanao State University-College of Health Sciences (MSU-CHS) and Amai Pakpak Medical Center (APMC) and organizations that supported and facilitated the data collection process.




References