Perceptions and attitudes of medical students and physicians on Euthanasia

Introduction

Euthanasia and physician-assisted suicide (PAS) are complex and ethically charged practices involving the intentional termination of life to alleviate suffering. Euthanasia entails the deliberate ending of a patient’s life by a healthcare professional, typically through lethal medication, at the patient’s explicit request. PAS, on the other hand, involves a physician providing a patient with the means to end their own life, such as a prescription for lethal substances, again at the patient’s explicit request. Collectively, these practices are often referred to as medical assistance in dying (MAiD).¹ Globally, regulatory approaches differ significantly. The Netherlands legalized euthanasia and assisted suicide in 2002, requiring unbearable suffering and voluntary patient consent.² Canada introduced Medical Assistance in Dying (MAiD) in 2016, covering euthanasia and assisted suicide for terminal and select non-terminal conditions.³ Belgium and Luxembourg permit euthanasia under stringent criteria, while many countries, including India, prohibit active euthanasia and assisted suicide.⁴ These variations reflect diverse cultural, ethical, and legal perspectives, essential for contextualizing attitudes toward euthanasia.

In India, euthanasia remains illegal, but judicial rulings have shaped its discourse. The 2011 Aruna Shanbaug case permitted passive euthanasia, allowing withdrawal of life support for patients in persistent vegetative states.⁵ The 1996 Gian Kaur v. State of Punjab ruling recognized the “right to die with dignity” under Article 21 of the Indian Constitution, limited to passive euthanasia and excluding active euthanasia or assisted suicide.⁶ This judgment established a constitutional framework for dignified death, balancing patient autonomy with ethical and legal constraints.

Advancements in medical technology have extended life expectancy, intensifying debates about quality of life. Healthcare providers, particularly those managing terminal illnesses, play a critical role in these discussions. Their attitudes toward euthanasia, influenced by global trends and local legal frameworks, are vital for informing policy and practice. This study examines the perceptions and attitudes of medical students and doctors at Kasturba Medical College, Mangalore, toward euthanasia and its potential legalization, situating their views within global and Indian contexts.

Methods

This cross-sectional analytical study, conducted at Kasturba Medical College, Mangalore, Karnataka, India, from March 10 to June 13, 2022, assessed attitudes and perceptions toward euthanasia among 220 medical undergraduates, interns, and post-graduates/physicians who provided informed consent. The sample size was calculated using the formula: $N=Z_{\alpha }^{2}pq/d^2$ , where $Z_{\alpha }^2=1.96$ Z _α = 1.96 (95% confidence), p = 0.468 (prevalence from Subba et al.¹), q = 0.532 and d = 0.1(10% relative precision). Based on a prior study reporting 46.8% of doctors justified euthanasia,⁷ the sample size was calculated as 200, adjusted to 220 (110 students, 110 doctors/interns/post-graduates) for a 10% non-response error. Convenience sampling was employed. Data were collected using a semi-structured questionnaire developed through literature review, which included demographic details, awareness questions, and the validated Attitudes Toward Euthanasia (ATE) Scale.⁸ The ATE Scale used a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). The questionnaire was distributed via Google Forms through WhatsApp, email, and Telegram, accessible only after online informed consent. Data were analyzed using SPSS version 25.0, with descriptive statistics (means, standard deviations, proportions) summarizing responses and chi-square tests, t-tests, and linear regression assessing associations between variables and attitudes. The study was approved by the Institutional Ethics Committee of Kasturba Medical College (EC/NEW/INST/2020/742, March 17, 2022). Participation was voluntary, with no risk to participants, and data were kept confidential for research purposes. Participants could withdraw without explanation, and consent was obtained via Google Forms, allowing only consenting participants to proceed, as approved by the ethics committee.

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).

The relationship between information source and preferred euthanasia decision-maker (court, patient, family, physician) was significant (χ² = 22.287, p = 0.008), with respondents informed by hearsay or news strongly favoring patient consent (see Table 5).

Discussion

Our study found that 86.3% of participants were aware of euthanasia, but only 47.2% knew its types, 44.3% were aware of legal status, and 30.2% understood the relevant guidelines. These findings are similar to a study in New Delhi, where 80% of healthcare professionals were aware of euthanasia, but only 50% supported legalization under strict conditions.⁹ In our study, 66% of participants expressed overall support for euthanasia, indicating higher acceptance compared to prior studies in India.^10,11

The Attitudes Toward Euthanasia (ATE) Scale revealed more detailed insights: 47.6% of participants agreed or strongly agreed that doctors should remove life support at a patient’s request, while only 14.5% supported prescribing medication to actively end life. Meanwhile, 56.7% agreed or strongly agreed that it would be wrong for a doctor to actively end a patient’s life in severe, uncontrollable pain.⁸ This suggests that while general support for euthanasia is high, participants favor passive forms over active euthanasia, consistent with patterns observed in other Indian studies.^7,10

Media was reported as the most common initial source of knowledge (29.2%), and attitudes significantly differed according to information source (p = 0.012) and exposure to patient autonomy narratives (p = 0.008). Previous research highlights the influential role of media in shaping public and professional perceptions of euthanasia.¹² Religious diversity and collectivist family norms in India also appear to influence opposition: 34% of participants opposed euthanasia, often citing potential misuse (n = 38) or ethical concerns (n = 23).¹³ These findings align with evidence that religious and cultural values are major determinants of euthanasia attitudes worldwide.^4,13

Legally, passive euthanasia is permitted in India since the Aruna Shanbaug case in 2011, while active euthanasia remains prohibited under Indian law.^5,6 Comparatively, countries such as the Netherlands and Canada have legislation allowing euthanasia or physician-assisted suicide under strict criteria.^2,3 Regional differences were observed: only 47.1% of Sri Lankan medical students supported euthanasia,¹¹ while support in South India was higher at 69.3%,¹⁰ suggesting evolving regional perspectives post-Shanbaug.

The absence of significant demographic influences (gender, year of study) indicates that formal training rather than personal traits drives attitudes. Evidence shows that integrating euthanasia education in medical and nursing curricula improves understanding and ethical decision-making.^14,15 In our study, 71.7% of participants emphasized patient consent, reflecting global trends where patient autonomy is central to legalized euthanasia frameworks.^2,16

Limitations include single-institution sampling and potential urban bias. Multi-institutional studies with stratified sampling and qualitative approaches could provide a more representative understanding of attitudes and explore the influence of media further. Future research should also examine longitudinal trends and rural perspectives to inform ethically sound and culturally sensitive policy.

Conclusion

Our study reveals evolving attitudes toward euthanasia among medical students and doctors, reflecting a growing acceptance within India’s constrained legal framework, which permits only passive euthanasia. The findings underscore the tension between ethical principles like autonomy and cultural factors such as religious diversity, shaping diverse perspectives among healthcare providers. Limited by a single-institution sample, the study may not capture broader Indian views, necessitating multi-center research with diverse sampling to explore these dynamics further. Integrating euthanasia education into medical curricula could foster informed ethical discussions, addressing gaps in understanding. These insights contribute to India’s ongoing euthanasia debate, highlighting the need for policies that balance patient rights with societal and ethical considerations, paving the way for nuanced healthcare practices.