Perceptions and attitudes of medical students and doctors on Euthanasia

Introduction

Euthanasia, a contentious issue spanning medicine, philosophy, sociology, law, and theology, involves intentionally ending a life to relieve intractable suffering. It includes active euthanasia (administering lethal medication), assisted suicide (providing means for self-administered death), passive euthanasia (withholding or withdrawing treatment), dysthanasia (prolonging life through aggressive interventions despite poor prognosis), and orthothanasia (allowing natural death without undue prolongation or hastening).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/doctors 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. A semi-structured questionnaire, developed through literature review, included two sections: Section A (demographics and awareness) and Section B (Attitudes Toward Euthanasia [ATE] Scale,⁸ and perceptions). 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. Majority of the respondents were in the 18-24 age group. 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 Doctors.

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, indicating a preference for autonomy and gaps in detailed knowledge (see Table 1).

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, showing diverse ethical perspectives (see Table 2).

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, suggesting information source influences attitudes more than demographics (see Table 3).

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, emphasizing the role of external narratives in shaping autonomy preferences (see Table 4).

Discussion

Our study showed that 86.3% of the participants were aware about euthanasia but with limited knowledge about its types (47.2%), legalities (44.3%), and guidelines (30.2%). These findings mirror a 2013 study done in New Delhi where, while 80% of healthcare professionals were aware of euthanasia, ethical concerns like misuse and religious objections showed polarised attitudes with only 50% of the participants supporting it’s legalization under strict conditions.¹ However in our study 66% of the study participants were in support of euthanasia which likely suggests a regional shift. This change of thought could be driven by media exposure (29.2%) which was reported to be the most common first source of knowledge of euthanasia. The significant association between information source and attitudes (p = 0.012) indicates personal research fosters support, while hearsay and news align with patient autonomy preferences (p = 0.008),⁹ highlighting media’s role in shaping ethical perspectives.

Passive Euthanasia is legal in India since the Aruna Shanbaug case⁵ in 2011, with Active euthanasia being prohibited as clarified in the in the 1996 Gian Kaur ruling, which embedded the “right to die with dignity” in Article 21 but excluded assisted suicide.⁶ This legal take on euthanasia paired with the religious diversity in India and collectivist family norms possibly contributes to the opposition (34%), citing misuse (38) or medical ethics (23).⁴ These concerns reflect the global scenario as where in a 2012 UK review religious beliefs drove opposition to euthanasia.¹⁰ However contrary to a study done in Sri Lanka where only 47.1% of medical students supported euthanasia¹¹ our study found a higher support of 66%. Our study findings do align with the 2011 South Indian study’s 69.3%,⁹ suggesting evolving regional attitudes post-Shanbaug.

The study being done in a single institution and use of convenience sampling limits the generalizability of the study. The results of the study may overrepresent urban educated view of euthanasia. Multi-institutional studies with stratified sampling and qualitative methods could reduce bias and explore media’s influence further. The lack of demographic influence (gender, year of study) suggests medical curricula should integrate evidence-based euthanasia education to counter media-driven narratives. Unlike the New Delhi study’s focus on ethical dilemmas,¹ this study’s emphasis on autonomy (71.7% favor patient consent) aligns with global trends in the Netherlands, where patient-driven euthanasia is legalized.² As India navigates its euthanasia discourse, these findings underscore the need for informed policy reflecting healthcare providers’ perspectives, balancing autonomy with sociocultural and ethical constraints. Future research should investigate rural perspectives and longitudinal trends to deepen understanding.

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.