Perceptions and attitudes of medical students and physicians on Euthanasia

Introduction

Euthanasia remains among the most debated topics in modern medicine. Discussions on euthanasia often includes ethical principles such as patient autonomy, beneficence, non-maleficence and also the societal interpretation of dignity of life. Globally, the perception and attitude towards euthanasia has evolved over the decades, and longitudinal studies show that opinions of the professionals and public on the topic vary widely across cultural, legal, economic contexts.¹

Advances in critical care and life-sustaining technologies have altered the way people experience the end of life within modern healthcare system. Conditions that were once fatal can now be prolonger through various life-sustaining interventions. While these advances may have improved survival, they have complicated the decisions surrounding the limits of these life-sustaining treatments. The focus has shifted from whether life can be prolonged to whether it should be prolonged. As a result ethical debates around end-of-life decision-making have become more intense.²

Legal frameworks governing euthanasia differ across countries. While some countries permit involvement of a physician in life-ending decisions under regulated conditions others strictly prohibit this.³ In India, the judiciary has recognized passive euthanasia and advance directives under defined safeguards, while active euthanasia continues to remain unlawful.^4,5

Evolving legal and medical landscapes places doctors at the centre of end-of-life decision-making. Medical practitioners are often required to handle complex situations that involve communicating end-of-life decisions to patients and their families, understanding patient wishes them and decide whether to withhold life-sustaining treatment. Studies conducted in various countries have shown that physicians and medical students vary in their views on these issues, influences by years of experience, personal beliefs and medical speciality.^3,6

Medical students represent future healthcare providers and are in formative stage of developing their ethical frameworks. The exposure to ethics and palliative care training received at this stage may shape their views and how they handle end-of-life decisions in their practice. Prior research suggests that attitudes towards euthanasia and end-of-life care may shift during medical training, highlighting the importance of understand perceptions at different stages of professional development.⁷

Despite increasing international literature on euthanasia, literature exploring the perception of both medical students and practicing physicians remains limited within several regions, including India. Furthermore , differences in sociocultural context, religious diversity and healthcare infrastructure may influence how euthanasia is perceived within Indian setting. Given the evolving judicial landscape and growing emphasis on patient-centred care, assessing the attitude is relevant for informing medical education, ethical discourse and health policy discussions. Therefore this study aims to assess the perception and attitudes of medical students and physicians towards euthanasia and to explore factors associated with their views.

Methods

This cross-sectional analytical study, conducted at Kasturba Medical College, Mangalore, Karnataka, India, from March 10 to June 13, 2022. The study population comprised medical undergraduates, interns, and post-graduate trainees/physicians enrolled or working at the institution during the study period. Those willing to participant and provide an informed consent were included in the study. Incomplete responses were excluded from the analysis. Ethical approval was obtained from the Institutional Ethics Committee of Kasturba Medical College (EC/NEW/INST/2020/742; March 17, 2022).

The sample size was calculated using the formula: N = Zα2pq/d2, where Zα2 = 1.96 (95% confidence), p = 0.468 (prevalence from Subba et al.),⁸ q = 1−p = 0.532, and d = 0.0468 representing 10% relative precision. The calculated sample size was 200, which was increased to 220 to account for a 10% non-response rate. A total of 220 participants were included, comprising 110 students and 110 interns/post-graduates/physicians. Convenience sampling was employed owing to the voluntary nature of participation and accessibility of eligible participants during the study period.

Data were collected using a semi-structured questionnaire developed through literature review. The instrument comprised two sections: Section A included demographic and awareness-related questions, and Section B consisted of the validated Attitudes Toward Euthanasia (ATE) Scale.⁸ The ATE Scale utilized a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) and is designed to assess individuals’ attitudes toward euthanasia across various ethical and clinical dimensions. The questionnaire underwent content validity assessment by experts in community medicine and medical ethics and was pilot-tested to assess feasibility and comprehensibility. Pilot data were excluded from the final analysis.

The questionnaire was distributed via Google Forms through WhatsApp, email, and Telegram. The first page of the google form contained the participant information sheet and a consent from. The participants could only access the questionnaire after agreeing to participate in the study. The data collected were stored in a password-protected electronic database accessible only to the investigators.

Data were analysed using SPSS version 25.0. Descriptive statistics, including frequencies and percentages, were used to summarize the data. Responses to the ATE Scale were analysed item-wise and presented as proportions. The chi-square test was applied to assess associations between demographic variables, source of information, and attitudes toward euthanasia. A p-value < 0.05 was considered statistically significant.

Results

Out of the 212 people who responded 128(60.4%) were female and 84(39.6%) were males. Of the respondents, 127 (61.1%) were in the 18–24 years age group, 13 (6.3%) were in the 25–30 years age group, and 68 (32.7%) were above 30 years. There were 41(19.3%) 1st year students, 60(28.3%) 2nd year students, 5(2.4%) 3rd year students, 9(4.2%) 4th year students and 97(45.8%) interns, PG and physicians.

Among 212 medical students and doctors, 86.3% were aware of euthanasia, but only 47.2% knew its types, 44.3% understood its legal status in India, and 30.2% were familiar with guidelines. News (29.2%) and hearsay/work (25.9% each) were primary information sources, reflecting media influence. Most (71.7%) favored patient consent for euthanasia decisions, with 66% supporting its practice (see Table 1).

Responses to the Attitudes Toward Euthanasia (ATE) Scale showed distinct patterns across the 208 participants. Items related to withdrawal of life support at the request of a patient received comparatively higher endorsement, with 47.6% agreeing or strongly agreeing that a doctor should remove life support when requested by a dying patient, while 38.4% disagreed or strongly disagreed. When withdrawal of life support was framed around the doctor’s judgment that recovery was unlikely, agreement was lower (23.6% agreed or strongly agreed) and disagreement higher (59.1%).

Prescribing or administering medication to intentionally end life received lower levels of support. For example, at the request of a dying patient, 45.7% agreed or strongly agreed that a doctor should prescribe sufficient medication to end life, while 27.9% disagreed or strongly disagreed. When the same option was presented in the context of severe pain, only 14.5% agreed or strongly agreed, and 65.4% disagreed or strongly disagreed. Items framed as moral prohibitions received stronger agreement, with 56.7% endorsing that it would be wrong to end the life of a patient in severe, uncontrollable pain and 46.6% agreeing it would be wrong if the doctor judged the patient would not recover (Table 2).

Of 140 supporters of euthanasia legalization, relief of suffering (110) and patient autonomy (91) were the main reasons, highlighting humanitarian priorities. Among 72 opponents, concerns about misuse (38) and the belief that medicine should preserve life (33) were predominant, alongside ethical and palliative care considerations (see Table 3).

Associations between demographics (gender, age, year of study) and information source with euthanasia attitudes (For/Against) showed no significant links for gender (p = 0.876) or year of study (p = 0.513). Information source was significant (χ² = 10.875, p = 0.012), with personal research linked to greater support (see Table 4).

A significant association was observed between the source of first information about euthanasia and the preferred final decision-maker for euthanasia (χ² = 22.287, p = 0.008), with respondents informed by hearsay or news strongly favoring patient consent (see Table 5).

Discussion

Our study revealed varying levels of awareness and acceptance of euthanasia among medical students and physicians, reflecting the complexity of the ethical decision making in end-of-life care.

In the present study about 86% of the participants reported that they were aware of euthanasia, indicating that the concept is widely recognised among medical students and physicians. However deeper knowledge on the topic seems limited as only 47.2% were aware about its types, 44.3 were aware of its legal status in India and only 30.2% were familiar with existing guidelines. These findings suggest that while euthanasia is widely recognised, knowledge regarding the legal and ethical frameworks remains limited among healthcare professionals. Such gaps affect clinical decision-making in end-of-life care, and can lead to uncertainty in responding to patients requests, and inadequate guidance for patients and patient attenders during terminal illness.

Media exposure emerged as the most common source of information about euthanasia among participants followed by hearsay and workplace exposure. This pattern suggests that awareness about euthanasia often develops through informal channels rather than through strong academic training. This may partly explain the limited knowledge gap among the participants regarding the legal and ethical frameworks.

Sixty six percent of the study participants supported euthanasia while 34% opposed it. A cross sectional study done by Subba et al. reported that 46.8% of physicians regarded euthanasia justifiable under certain circumstances, indicating a lower acceptance compared to the present study.⁹ Differences in reporting may reflect the variation in study population, professional experience and the sociocultural contexts.

Among the participants who supported euthanasia the most common reason cited for support were relied of suffering (110 participants) followed by respect for patient autonomy (91 participants). These two reflect the major ethical principles that frequently arise in debates about euthanasia and have been reported by previous studies where alleviation of intractable suffering and honouring patients’ wishes were identified as key motivations for supporting euthanasia.⁶ Consistent with this emphasis on patient autonomy, a strong preference for patient-led decision making was observed in our study, with 71.7% of participants indicating that the final decision regarding euthanasia should lie with the patient.

Participants’ preference for relieving suffering was also reflected in responses to the ATE scale, where a relatively higher proportion supported withdrawal of life-support in situations involving severe suffering or terminal illness, whereas fewer participants supported administering medication to intentionally end a patient’s life. Similar trends were observed in previous studies where healthcare professionals were more likely to support withdrawal of life-sustaining treatment than direct life-ending interventions reflecting the ethical concerns regarding the direct involvement of a physician in ending a patient’s life.⁹

Support for euthanasia remained relatively consistent across different demographic groups, suggesting limited influence of demographic factors on attitudes toward euthanasia in this population. In contrast, the source of first information about euthanasia demonstrated a significant association with the participants’ attitude. A significant relationship was also seen between source of first information about euthanasia and participants’ views regarding the final decision-maker for euthanasia. Participants who learned about euthanasia from news and hearsay were more likely to favour patient consent as final authority. This reflects how source and nature of information may influence perceptions patient autonomy and end-of-life decision making.

The use of structured questionnaire, incorporating the ATE scale allowed standardised measurement of attitude towards euthanasia of all participants. Including participants from different stages of medical carrier provided insights across medical education continuum. However these findings are based on data from a single institution, which may limit the generalisability of the results and may reflect an urban institutional context. Additionally cross-sectional study design limits the ability to make causal relationship between variables. Further studies should examine rural perspectives to inform ethically sound and culturally sensitive policy.

Conclusion

The present study highlights varied attitudes toward euthanasia among medical students and physicians, with a considerable proportion expressing support for euthanasia. Knowledge regarding the legal frameworks and ethical guidelines remains limited. The source of information may influence attitudes toward euthanasia and decision-making authority. These findings highlight the need for inclusion of education on end-of-life decision-making, ethical and legal aspects of euthanasia in the medical curriculum.