Perceptions and attitudes of medical students and doctors on Euthanasia

Introduction

Medical care has advanced several times in the last century, especially in the last few decades. These advances have led to the increased longevity of multiple diseases. On an equal footing, there is an ever-increasing awareness of quality of life. People are becoming cognizant of their right to make decisions not only in their options regarding treatment, but also in their choice to end their lives. Euthanasia is defined as an easy or painless death or intentional ending of the life of a person suffering from an incurable or painful disease at his or her request.¹ It is of two types: active euthanasia, where the physician directly administers a lethal medication and ends a patient’s life, or passive euthanasia, where a patient is allowed to die by witholding life support.²

It was first legalized in the Netherlands. Subsequently, many countries followed suit, including Belgium, Luxembourg, and Canada.³ In other countries such as the US, euthanasia is legal in some states only under certain conditions. However, it is still illegal in most countries, and there have been instances in India where euthanasia has been permitted by the courts of India.^4,5 Consider, for example, Shanbaug’s case. A nurse, who was assaulted, was left with limited functionality, such as blinking and eating food placed in her mouth.^6,7 Even after extensive care was provided by the nursing staff of the hospital she remained in, her quality of life was sub-par. The Supreme Court of India permitted euthanasia to be practiced in her case to end the constant suffering her life had become. Similarly, in the case of P. Rathinam Vs. U.O.I, the Supreme Court decided that the right to life, elaborated upon in Article 21 of the Constitution, includes the right to die.⁸ In a subsequent case, Gian Kaur Vs. State of Punjab, the court held that the right to die with dignity is included in Article 21.⁴ Clearly, the Supreme Court of India has made its standpoint- in the case of absolute suffering that cannot be helped, if euthanasia helps alleviate said suffering, it may be done.

The attitude towards euthanasia has always varied over time. In recent years, there has been an increasing awareness towards the same. Understanding and analyzing the way current and future healthcare providers perceive euthanasia is important, especially in the current world, where debate about legalizing this procedure is ongoing.⁹

This study investigates the attitudes and perceptions of medical students and doctors of a private medical college in Karnataka regarding euthanasia and its legislation in India.

Methods

Variables: Euthanasia is defined as an easy or painless death or the intentional ending of life of a person suffering from an incurable or painful disease at his or her request. This is also called mercy killing.

Study design: Cross-sectional study

Study type: Analytical study

Study setting: Kasturba Medical College, Mangalore

Study population: Medical Undergraduates, Interns and Post-Graduates/Doctors of Kasturba Medical College, Mangalore

Inclusion criteria: medical undergraduates, interns, and post-graduuates/doctors who gave their consent.

Study duration: 10^th March 2022 to 13^th June 2022

Study sample: 220. 110 Students and 110 Doctors/PGs/interns.

Sample size:

N=Z_α² pq/d²

where Z_α = 1.96 for 95% confidence

p = proportion of the population which has the attribute in question

q = 1-p

d = precision

The sample size was calculated with the help of a study done by Subba et al., titled “Doctors’ Attitude Towards Euthanasia: A Cross-sectional Study,” conducted in Mangalore, March-April 2010, which found that while 46.8% of doctors justified euthanasia to alleviate suffering.¹⁰ so considering 46.8% as the prevalence of 46.8% was the prevalence of doctors who justified euthanasia and considering 10% relative precision and 95% confidence, the sample size was calculated to be 200. After adding a 10% non-responsive error, the final sample size was calculated to be 220.

Sampling strategy: Convenience sampling (non-probability sampling)

Tools for data collection: A questionnaire was prepared after extensive review of the literature. Therefore, a semi-structured questionnaire consists of two sections. Section A consists of two parts: demographic details and awareness. Section B consists of Part 1: ATE Scale and Part 2: Perceptions.

Scoring and Interpretation: Here, we used the ATE scale to interpret the attitudes of medical undergraduates, interns, and PGs/doctors towards euthanasia based on the Likert Scale.^11,12 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = Strongly Agree.

Data collection methodology: The study protocol was approved by the Institutional Ethics Committee (IEC) of Kasturba Medical College, Mangalore. After obtaining approval from the Ethics Committee, permission was obtained from the Dean of Kasturba Medical College, Mangalore, and the data were collected after obtaining informed consent from the participants. All methods were performed in accordance with the relevant guidelines and regulations. The questionnaire was sent to the students in the form of a Google link to WhatsApp, e-mail, and Telegram.

Online informed consent was obtained from all the participants. Only after consent is given can the Google link for the questionnaire be opened.

Data analysis: Data were entered and analyzed using Statistical Software Statistical Package for Social Sciences (SPSS) version 25.0. Descriptive statistics such as mean (standard deviation) and proportion were used to express the results. The various factors associated with attitudes towards euthanasia were analyzed using the chi-square, independent t-test, and linear regression analysis.

Ethical consideration: This was a questionnaire-based study of medical undergraduates, interns, and doctors of Kasturba Medical College, Mangalore. The study did not pose any risk to the participants. Interpersonal data will be kept confidential and protected. The records maintained will only be used for research purposes. Entering the research study was voluntary. The participants had the right to stop at any time and did not need to provide any reason for the same.

Ethical Approval: was taken from the institutional ethics committee of Kasturba Medical College, Mangalore. On 17-03-2022 (DHR Reg. No. EC/NEW/INST/2020/742)

Consent: Informed consent was obtained through a Google Form. The initial section of the questionnaire asked participants whether they consented to participate in the study. Those who selected ‘yes’ were allowed to proceed with the remainder of the questionnaire, while those who selected ‘no’ were not asked any further questions. This procedure was approved by the ethical committee.

Results

Our results indicated that a significant majority (86.3%) were aware of what euthanasia was, although only 47.2% possessed knowledge of the different types of euthanasia, and even fewer (44.3%) were aware of the legalities of its practice in India. Furthermore, only 30.2% of respondents were familiar with the guidelines used to perform euthanasia. Regarding the sources of their information, 29.2% first learned about euthanasia through news, followed by hearsay and work at 25.9%, and personal research at 18.9%. The majority opinion (71.7%) was that the final decision to administer euthanasia should lie with the patient themselves, while 11.8% believed it should be a family member’s decision, 9% thought it should be the court of law, and 7.5% placed this responsibility on the treating physician. Regarding the stance on euthanasia, 66% of the respondents were in favor, whereas 34% were against it (Table 1).

A significant majority (86.3%) were aware of what euthanasia was, although only 47.2% possessed knowledge of the different types of euthanasia, and even fewer (44.3%) were aware of the legalities of its practice in India. Furthermore, only 30.2% of respondents were familiar with the guidelines used to perform euthanasia. Regarding the sources of their information, 29.2% first learned about euthanasia through news, followed by hearsay and work at 25.9%, and personal research at 18.9%. The majority opinion (71.7%) was that the final decision to administer euthanasia should lie with the patient themselves, while 11.8% believed it should be a family member’s decision, 9% thought it should be the court of law, and 7.5% placed this responsibility on the treating physician. Regarding the stance on euthanasia, 66% of the respondents were in favor, whereas 34% were against it. Among the reasons for supporting the legalization of euthanasia in India, 110 respondents cited relief of suffering, 91 mentioned valuing patient autonomy, 63 highlighted minimizing financial burden, 48 emphasized better utilization of resources, and 20 had other reasons. Reasons for opposing legalization included potential misuse for criminal reasons (38 respondents), the belief that medicine is meant to preserve life (33 respondents), the view that palliative care is sufficient (23 respondents), violation of medical ethics (23 respondents), religious beliefs (8 respondents), and other reasons (8 respondents) (Table 2).

On further analysis, the source of acquiring information about euthanasia for the first time has a significant bearing on who the participants feel should be the final proxy for administering euthanasia to patients. Further statistical analysis of the variable regarding the source of euthanasia and attitude towards euthanasia was found to be significant (Table 3).

We can infer that respondents’ opinions on the legalization of euthanasia in India are highly influenced by the source of acquiring information about euthanasia for the first time, and this was found to be statistically significant (Table 4).

Discussion

This study analyzed the attitudes and perceptions of healthcare workers towards Euthanasia. The present study was conducted at Kasturba Medical College, Mangalore. The composition of the study participants varied and ranged from doctors, post-graduates, interns, to medical students, although there were more medical students and interns than doctors and post-graduates. The participants were restricted to the students and staff of Kasturba Medical College, Mangalore. Statistical Package for the Social Sciences (SPSS) was used to analyze the data.

In the present study, 86.3% of the respondents were aware of the concept of euthanasia. Similar results were obtained in a study conducted in 2013, wherein the majority of selected professionals in New Delhi were aware of the concept of euthanasia.⁷

In this study, it was found that the majority of respondents who first encountered euthanasia via news or hearsay were of the opinion that euthanasia should only be practiced with the explicit consent of the patient. 66 Of the respondents, 66% were euthanized, and 34% were against it. Moreover, the majority of people who stood for euthanasia also first encountered euthanasia via news or hearsay. Thus, this study suggests that society and mass media heavily influence controversial topics, such as euthanasia. A systematic review of studies conducted in the UK to assess the attitudes of doctors towards euthanasia was conducted in 2012. This review revealed that the doctors mostly opposed the introduction of physician-assisted suicide (PAS) and Active Voluntary Euthanasia (AVE). Religious reasons were part of why doctors opposed euthanasia.¹⁰ The present study showed majority of the people who were for euthanasia gave the reason “To relieve suffering.” A similar cross-sectional study was conducted in South India in 2011 to assess the attitudes of doctors towards euthanasia, wherein a majority of the respondents (69.3%) supported the concept of euthanasia, giving “relief from unbearable pain and suffering” as the most cited reason for the same.¹³ Another study conducted in Sri Lanka in 2021 to analyze attitudes toward euthanasia among medical students showed that 47.1% of the participants favored legalizing euthanasia, whereas 25.9% directly opposed it. 27% were undecided. Participants who came under the undecided category were more likely to have unfavorable ATE.¹¹

Thus, several studies have shown how the attitudes and perceptions of euthanasia vary among medical practitioners.

In conclusion, the attitudes and perceptions of medical practitioners towards euthanasia are varied and heavily influenced by how euthanasia is portrayed in mass media. There has been a gradual shift in people’s general opinions that seem to favor euthanasia, but concerns about its misuse continue to remain.

This study was conducted to analyze the attitudes and perceptions of healthcare practitioners towards euthanasia, and has effectively shown how the opinions and views of people shift due to mass media, society, and personal beliefs.

It is important to consider the thoughts of medical professionals towards euthanasia - those who work closely with patients - to analyze and understand the highly subjective topic of whether life must be qualitatively viewed or quantitatively.

Conclusion

In conclusion, euthanasia has been a topic of much debate since the ages and is still illegal in India; however, there is a change in the opinions of people, especially physicians and future caregivers, as is also evident in this study. Physicians’ views on this topic are also influenced by a multitude of factors such as where they first came to know about euthanasia.

In this study, we found that the majority of the respondents who first came across euthanasia via news or hearsay were of the opinion that euthanasia should only be practiced with the explicit consent of the patient.¹⁴ Furthermore majority of the people who stand for euthanasia as a practice also first encountered euthanasia via news or hearsay.

It would therefore appear that when it comes to such sensitive issues as euthanasia, the people’s opinions are influenced by the society they live in and how euthanasia is being portrayed in that society by means of mass media such as stories, news, articles, television, etc. There is indeed an evident shift in people’s opinions about euthanasia, since the majority of the respondents supported euthanasia and its legalization in this study. However, there are still lingering concerns regarding their possible misuse.