F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.153956.2 Research Article Articles Perceptions and attitudes of medical students and doctors on Euthanasia

[version 2; peer review: 1 approved with reservations, 2 not approved]

 Motappa Rohith Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-8939-2850 1 Mallya Ajay Conceptualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-2280-3176 a 2 Guleria Meghna Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 3 Singhal Aditi Conceptualization Data Curation Formal Analysis Investigation Methodology Software Supervision Validation 3 Nambiar Pallavi Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 3 Gaiha Vaibhavi Conceptualization Data Curation Formal Analysis Investigation Methodology Software Validation Writing – Original Draft Preparation Writing – Review & Editing 3 Kotian Himani Data Curation Formal Analysis Validation Visualization https://orcid.org/0000-0002-1252-507X 2 Department of Community Medicine, Rajajinagar, ESIC Medical College & PGIMSR and Model Hospital, Bangalore, Karnataka, 560010, India Community Medicine, Kasturba Medical College, Mangalore, Karnataka, 575001, India Kasturba Medical College, Mangalore, Karnataka, 575001, India ajay.mallya@manipal.edu

No competing interests were disclosed.

 30 7 2025 2024 13 1009 8 7 2025 Copyright: © 2025 Motappa R et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

The concept of euthanasia has recently come into the spotlight, and cases such as those of Aruna Shanbaug have heavily influenced people’s opinions on the topic. Whether euthanasia is performed with the intention of ending suffering that otherwise cannot be helped should truly be supported. The thoughts on this topic- especially of those who work closely with patients who suffer from terminal illnesses- healthcare providers must be analyzed. Their perception and views on legalizing the procedure and their hesitancy or lack thereof to perform such a procedure would give the rest of the world a clearer picture- a better standpoint to understand what to do. This study attempted to quantify and analyze the views of doctors and medical students regarding euthanasia.

 Methods

A cross-sectional survey of 212 doctors and medical students at a private medical college in South India was conducted to determine their attitudes toward euthanasia.

 Results

Most participants (66%) supported the practice of euthanasia. The majority of participants also believed that euthanasia should only be performed with the explicit consent of the patient (71.7%). It was also observed that those who had heard about euthanasia via hearsay mostly agreed that it must only be performed with the explicit consent of the patient. Moreover, the study showed that those who had heard about it from hearsay and news mostly stood for it.

 Conclusion

It has been noted that news and media all around us heavily influence people’s opinions. It is concluded that these opinions have changed from the past, and will likely do so depending on the environment and media around the topic.

 Euthanasia legalization healthcare providers The author(s) declared that no grants were involved in supporting this work. Amendments from Version 1

This revised article improves clarity and rigor by refining definitions, enhancing global and sociocultural context, correcting data errors, streamlining methods and results, and providing a concise conclusion focused on policy and educational implications.

 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 α 2 p q / d 2 , where Z α 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).

Distribution of participants based on opinions about various aspects of euthanasia.
Sl. No. Particulars Frequency (n) Percentage (%)
1. Awareness of people on Euthanasia
 • Aware 183 86.3
 • Not aware 29 13.7
2. Knowledge of the types of euthanasia
 • Aware 100 47.2
 • Not aware 112 52.8
3. Legalities concerning the practice of euthanasia in India
 • Aware 94 44.3
 • Not aware 118 55.7
4. Awareness of the guidelines that are used to perform euthanasia
 • Aware 64 30.2
 • Not aware 148 69.8
5. Source of information about euthanasia for the first time
 • Hearsay 55 25.9
 • News 62 29.2
 • Personal research 40 18.9
 • Work 55 25.9
6. Final proxy to administer euthanasia should lie with
 • Court of law 19 9
 • Patient themselves 152 71.7
 • Family member 25 11.8
 • Treating physician 16 7.5
7. I am for/against euthanasia
 • For 140 66
 • Against 72 34

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).

Distribution of participants for and against euthanasia based on their justification for their opinion. <xref ref-type="table-fn" rid="tfn1">*</xref>
Sl. No. Particulars Frequency (n)
1. Reason for legalisation of euthanasia in India
 • Better Utilization of resources 48
 • Minimise financial burden 63
 • Patient autonomy is valued 91
 • To relieve suffering 110
 • Others 20
2. Reasons to choose against the legalization of euthanasia in India
 • Violation of medical ethics 23
 • Might be misused for criminal reasons 38
 • Palliative care is enough 23
 • Religious beliefs 8
 • Medicine is to preserve life not end it 33
 • Others 8

Multiple responses were allowed.

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 (χ 2 = 10.875, p = 0.012), with personal research linked to greater support, suggesting information source influences attitudes more than demographics (see Table 3).

Associations between variables and attitudes toward Euthanasia.
Variable Against For Chi-Square P value
Gender Female 44 (61.1%) 84 (60.0%) 0.025 0.876
Male 28 (38.9%) 56 (40.0%)
Age >30 years 25 (34.7%) 44 (31.4%) 0.363 0.513
18-24 years 43 (59.7%) 86 (61.4%)
25-30 years 4 (5.6%) 10 (7.1%)
Year of Study 1 st year 18 (25.0%) 23 (16.4%) 3.275 0.513
2 nd year 18 (25.0%) 42 (30.0%)
3 rd year 1 (1.4%) 4 (2.9%)
4 th year 4 (5.6%) 5 (3.6%)
Intern/PG/doctor 31 (43.1%) 66 (47.1%)
I heard about Euthanasia for the first time from Hearsay 9 (12.5%) 46 (32.9%) 10.885 0.012
News 26 (36.1%) 36 (25.7%)
Personal Research 14 (19.4%) 26 (18.6%)
Work 23 (31.9%) 32 (22.9%)

The relationship between information source and preferred euthanasia decision-maker (court, patient, family, physician) was significant (χ 2 = 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).

Association between the source where the participants first heard about euthanasia and who they feel should be the final proxy of euthanasia.
I feel the final proxy of the patient should be Hearsay News Personal research Work Chi square value P value
Court of law 1 7 2 9 22.303 .008
Euthanasia should only be done with the explicit consent and will of the patient 51 43 26 32
Family member 3 7 7 8
Treating physician 0 5 5 6
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 case 5 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 euthanasia 11 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.

Ethics and consent

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.

 Data availability Underlying data

Figshare: Perceptions and Attitudes of Medical Students and Doctors on Euthanasia, https://doi.org/10.6084/m9.figshare.26200124.v2. 12

This project contains the following underlying data:

Data

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Extended data

Figshare: Perceptions and Attitudes of Medical Students and Doctors on Euthanasia. https://doi.org/10.6084/m9.figshare.26501110.v2 13

This project contains the following underlying data:

Questionnaire - Perceptions and Attitudes of Medical Students and Doctors on Euthanasia

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 References Sinha VK Basu S Sarkhel S : Euthanasia: An Indian perspective. Indian J. Psychiatry. 2012 Apr;54(2):177–183. 22988327 10.4103/0019-5545.99537 PMC3440914 Netherlands. Ministry of Health, Welfare and Sport: Termination of Life on Request and Assisted Suicide (Review Procedures) Act. The Hague: Government of the Netherlands;2002. Reference Source Canada. Parliament: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). Ottawa: Government of Canada;2016. Reference Source Fontalis A Prousali E Kulkarni K : Euthanasia and assisted dying: what is the current position and what are the key arguments? J. R. Soc. Med. 2018;111(11):407–413. 30427291 10.1177/0141076818803452 Mudur G : Indian court says it may sanction euthanasia in the future. BMJ. 2011 [cited 2022 Jul 3];342(mar11 2):d1628. 21398360 10.1136/bmj.d1628 Reference Source Bandewar SV Chaudhuri L Duggal L : The Supreme Court of India on euthanasia: Too little, too late. Indian J. Med. Ethics. 2018 Apr-Jun;3(2):91–94. 29724694 10.20529/IJME.2018.028 Subba SH Khullar V Latafat Y : Doctors’ Attitude Towards Euthanasia: A Cross-sectional Study Experience. J. Assoc. Physicians India. 2016;63. Reference Source Wasserman J Clair JM Ritchey FJ : A scale to assess attitudes toward euthanasia. Omega (Westport). 2005;51(3):229–237. 16459436 10.2190/FGHE-YXHX-QJEA-MTM0 Reference Source Kamath S Bhate P Mathew G : Attitudes Toward Euthanasia Among Doctors in a Tertiary Care Hospital in South India: A Cross Sectional study. Indian J. Palliat. Care. 2011 Sep [cited 2023 Mar 31];17(3):197–201. 22346044 10.4103/0973-1075.92336 PMC3276816 Reference Source McCormack R Clifford M Conroy M : Attitudes of UK doctors towards euthanasia and physician-assisted suicide: a systematic literature review. Palliat. Med. 2012 Jan;26(1):23–33. 22190615 10.1177/0269216310397688 Reference Source Herath HMMTB Wijayawardhana KWSM Wickramarachchi UI : Attitudes on euthanasia among medical students and doctors in Sri Lanka: a cross sectional study. BMC Med. Ethics. 2021 Dec 7;22(1):162. 34876119 10.1186/s12910-021-00731-2 PMC8650524 Reference Source Mallya A Motappa R : Data - Perceptions and Attitudes of Medical Students and Doctors on Euthanasia.xlsx. figshare. 2024 [cited 2024Aug20]. Reference Source Mallya A Motappa R : Questionnaire - Perceptions and Attitudes of Medical Students and Doctors on Euthanasia. figshare. 2024 [cited 2024Aug20]. Reference Source 10.5256/f1000research.184704.r404173 Reviewer response for version 2 Demedts Dennis 1 Referee https://orcid.org/0000-0002-6667-4855 Vrije Universiteit Brussel, Brussels, Brussels, Belgium

Competing interests: No competing interests were disclosed.

 18 8 2025 Copyright: © 2025 Demedts D 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Thank you for the opportunity to review your paper: 'Perceptions and attitudes of medical students and doctors on Euthanasia'. Euthanasia is a topic that raises many questions, not least among healthcare students and workers.

Please find my comments below:

TITLE

* Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

ABSTRACT

Background 

* The concept of euthanasia has recently come into the spotlight... Is this specific to India? Please clarify.

*  Whether euthanasia is performed with the intention of ending suffering that otherwise cannot be helped should truly be supported... This sentence is a personal statement. It is not appropriate in a scientific presentation of a study. It would be more suitable in an opinion piece.

* Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

* According to the title the aim was to research the perceptions and attitudes instead of the views.

Methods

* Please also state which questionnaire was used. Indicate the time frame, and confirm whether approval was obtained from a medical ethics committee.

Results

*  Where does the statement “explicit consent of the patient” come from? This cannot be found in the results.

Conclusion

* The conclusion cannot be derived from the results. Furthermore, it is written in colloquial language.

Keywords

* Include medical students and physicians as well.

INTRODUCTION

* These definitions are outdated. Euthanasia is the termination of life by someone other than the person concerned, carried out at their explicit request. Physician-assisted suicide involves obtaining a prescription for lethal substances from a physician with the intention of ending one's own life. Together, these constitute medical assistance in dying.

* In the Netherlands and Belgium, assisted dying is also possible for non-terminal suffering, as well as for minors (but only in cases of terminal suffering). 

METHODS

* Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

RESULTS

* Indicate the percentage of respondents in the 18-24 age group.

* Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

* Be careful not to make any interpretations in the results section. This is something for the discussion.

* The method indicates that the ATE scale was used. However, the results of this scale cannot be found anywhere.

DISCUSSION

* You state that 66% of participants support euthanasia. Wouldn't it be better to use the ATE scale, which enables you to calculate an average and indicate whether participants have a positive or negative attitude towards euthanasia?

* It is correct to state that the media can play a role. However, you should elaborate on this by explaining how the media can play a role and substantiating your argument with literature.

* Same for religious diversity in India and collectivist family norms.

* It is correct to suggest that medical curricula should integrate evidence-based euthanasia education. However, this needs to be elaborated further. There are studies on nursing students and euthanasia, as well as a study on simulation education and euthanasia.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Nursing, euthanasia, evidence-based practice, healthcare education, simulation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

References : Using simulation to teach nursing students how to deal with a euthanasia request. PLOS ONE .2024;19(3) : 10.1371/journal.pone.0299049 10.1371/journal.pone.0299049 : Nursing students’ view on their future role and skills regarding euthanasia due to unbearable mental suffering: A mixed-method Study. Nurse Education in Practice .2023;71: 10.1016/j.nepr.2023.103718 10.1016/j.nepr.2023.103718 : Euthanasia – A Legal or Medical Issue: A Narrative Review. Iranian Journal of Public Health .2025; 10.18502/ijph.v54i6.18893 10.18502/ijph.v54i6.18893 Usanos, R. A., Massé García, M. C., Lorenzo Izquierdo, D., & Esquerda Aresté, M. (2025). Euthanasia and the Media in Spain (2019-2021). Eutanasia y Medios de Comunicación en EspaÑa (2019–2021). Cuadernos de bioetica : revista oficial de la Asociacion Espanola de Bioetica y Etica Medica, 36(116), 59–68. https://doi.org/10.30444/CB.185. : Voluntary-assisted dying, euthanasia and physician-assisted suicide: global perspectives—systematic review. BMJ Supportive & Palliative Care .2025;15(4) : 10.1136/spcare-2024-005116 423-435 10.1136/spcare-2024-005116 Mallya Ajay Community Medicine, Kasturba Medical College, Mangalore, karnataka, India

Competing interests: No competing interests were disclosed.

 6 9 2025

Comment: Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

Response with Action taken: The Authors Agree with the comment and we have changed the title as per the review suggestions

Comment:  The concept of euthanasia has recently come into the spotlight... Is this specific to India? Please clarify.

Response with Action taken:  The Authors agree and the Abstract has been revised accordingly

Comment:  Whether euthanasia is performed with the intention of ending suffering that otherwise cannot be helped should truly be supported... This sentence is a personal statement. It is not appropriate in a scientific presentation of a study. It would be more suitable in an opinion piece.

Response with Action taken:  The Authors agree and the Abstract has been revised accordingly

Comment:  Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

Response with Action taken:  The Authors agree and the Abstract has been revised accordingly

Comment:  According to the title the aim was to research the perceptions and attitudes instead of the views.

Response with Action taken:  The Authors agree and the Abstract has been revised accordingly

Comment:  Please also state which questionnaire was used. Indicate the time frame, and confirm whether approval was obtained from a medical ethics committee.

Response with Action taken:  The authors agree and the abstract has been revised accordingly

Comment:  Where does the statement “explicit consent of the patient” come from? This cannot be found in the results.

Response with Action taken:  The authors agree and the abstract has been revised accordingly

Comment:  The conclusion cannot be derived from the results. Furthermore, it is written in colloquial language.

Response with Action taken:  The authors agree and the abstract has been revised accordingly

Comment: Include medical students and physicians as well.

Response with Action taken:  we have included the recommended keywords

Comment: These definitions are outdated. Euthanasia is the termination of life by someone other than the person concerned, carried out at their explicit request. Physician-assisted suicide involves obtaining a prescription for lethal substances from a physician with the intention of ending one's own life. Together, these constitute medical assistance in dying.

Response with Action taken:  The authors agree and the introduction section has been revised accordingly.

Comment: Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

Response with Action taken:  The authors agree and the manuscript has been revised accordingly

Comment: Indicate the percentage of respondents in the 18-24 age group. Done

Response with Action taken:  The authors agree and the manuscript has been revised accordingly

Comment: Please change 'doctor' to 'physician'. This clarifies that the survey was conducted with MDs, not PhDs.

Response with Action taken:  The authors agree and the manuscript has been revised accordingly

Comment: Be careful not to make any interpretations in the results section. This is something for the discussion.

Response with Action taken:  The authors agree and the manuscript has been revised accordingly

Comment: The method indicates that the ATE scale was used. However, the results of this scale cannot be found anywhere.

Response with Action taken:  The authors had missed this table whie drafting the manuscript. we now have added the same in the results section

Comment: * You state that 66% of participants support euthanasia. Wouldn't it be better to use the ATE scale, which enables you to calculate an average and indicate whether participants have a positive or negative attitude towards euthanasia?

* It is correct to state that the media can play a role. However, you should elaborate on this by explaining how the media can play a role and substantiating your argument with literature.

* Same for religious diversity in India and collectivist family norms.

* It is correct to suggest that medical curricula should integrate evidence-based euthanasia education. However, this needs to be elaborated further. There are studies on nursing students and euthanasia, as well as a study on simulation education and euthanasia.

Response with Action taken:  The authors agree and the manuscript has been revised accordingly

 10.5256/f1000research.168923.r363347 Reviewer response for version 1 Buterin Toni 1 1 Referee University of Rijeka, Rijeka, Croatia

Competing interests: No competing interests were disclosed.

 19 2 2025 Copyright: © 2025 Buterin T 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

The introduction of the paper effectively introduces the topic of euthanasia, but it contains several weaknesses that reduce its clarity and precision. In such a complex research field, euthanasia should not be narrowed to a classical definition, but instead, it should be expanded and argued as it goes beyond the scope of (only) medicine. Euthanasia involves perspectives from various fields such as philosophy, sociology, law, and theology. Before focusing on India, the introduction should provide a broader overview of global trends in the regulation (and attitudes) toward euthanasia. Many countries adopt varying approaches, from full legalization to strict prohibition, depending on the type and with different exceptions under different conditions. Understanding these variations is crucial for comparison with the Indian legal framework and the consequential attitudes – in this case, of doctors and medical students. The introduction would be clearer and stronger if the global perspective were analyzed first, followed by a more detailed discussion of the Indian case. More precise formulations and better arguments would improve the quality of the paper.

The objectives need to be formulated more precisely to be clearer and more strongly justified. The current formulations are incomplete and unclear. This is especially evident when reading the conclusion, where it is difficult to determine if the research objectives have been achieved.

The methodology requires a more detailed description. The aim and purpose of the research are unclear. The limitations of the study need to be highlighted, as the choice of participants could lead to bias and limit the representativeness of the population. Participants are from one 'pool' (Kasturba Medical College), which means the results may not be applicable to the broader population of (future) medical professionals in India.

The results are brief and need to be expanded. The first two paragraphs are duplicated. In Table 2, it is unclear how the total sample can exceed 100% for female respondents (61.1% for, 60% against). For male respondents, the total is less than 100% (38.9% for, 40% against). Is this an error, or am I misinterpreting it?

In the discussion, it is highlighted that attitudes towards euthanasia are highly diverse, but there is a lack of detailed discussion about contradictions within the results themselves (a lot of the content repeats again), as well as the influence of specific sociocultural factors in the context of India and possible causes. Additionally, the potential bias of the sample is not considered, given that the sample is limited to a single medical school. The discussion deviates from the standard academic approach. A more detailed analysis of the causes and broader implications of respondents' attitudes toward euthanasia is needed, with more concrete references to existing works, stronger argumentation, and the presentation of facts derived from research on similar topics. The discussion should also address methods for reducing bias in future research. There is no analysis of trends or a more specific comparison with previous studies.

The conclusion is based more on speculation than on the real outcomes of the objectives. In fact, it is unclear from the conclusion whether the stated objectives have been justified. The focus has shifted from assessing awareness and analyzing the attitudes of doctors and students to the influence of the media. How the media (and the way euthanasia is reported) succeeded in steering respondents toward positive attitudes and a significant correlation remains an open question. Since the role of the media in shaping views is already addressed in the discussion and conclusion, it should have been introduced earlier, particularly in relation to its influence on reporting contemporary medico-ethical controversial issues.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Medical ethics, Bioethics, Public health, History of Medicine

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Mallya Ajay Community Medicine, Kasturba Medical College, Mangalore, karnataka, India

Competing interests: No competing interests were disclosed.

 31 7 2025

Dear Reviewer

Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity.

 10.5256/f1000research.168923.r360955 Reviewer response for version 1 Picón Jaimes Yelson Alejandro 1 Referee https://orcid.org/0000-0002-7498-5346 Univ Ramon Llul, Barcelona, Spain

Competing interests: No competing interests were disclosed.

 29 1 2025 Copyright: © 2025 Picón Jaimes YA 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

Introduction

The definition of euthanasia is generally correct, but it could be made more precise by clearly differentiating between active euthanasia, assisted suicide, passive euthanasia, dysthanasia, and orthothanasia. As it stands, the current definition blends technical and common terms, which may lead to confusion.

To enhance global context, more specific data should be included, such as:

In the Netherlands, euthanasia was legalised in 2002 under strict criteria.

Canada legalised it in 2016 under the term "Medical Assistance in Dying" (MAiD).

Providing such details adds precision and context to the information.

Additionally, it would be useful to explain how the Gian Kaur judgment laid the foundation for recognising the "right to die with dignity" within the framework of Article 21 of the Indian Constitution. However, it is essential to clarify that this right does not extend to assisted suicide.

Methods

Definition of Euthanasia in Variables:

The definition of euthanasia in the "Variables" section is repetitive (already mentioned in the introduction) and overly general for the methods section.

Study Design:

The study is referred to as both cross-sectional and analytical, which creates confusion. If the study is cross-sectional, it is typically descriptive rather than analytical. This should be clarified.

The word "post-graduuates" in the inclusion criteria contains a typographical error.

Sampling Justification:

The use of convenience sampling should be justified, and its limitations acknowledged. For example:

"Convenience sampling was employed due to the accessibility of participants in an academic setting. While this method may introduce biases, it was suitable for an exploratory, single-centre study."

Additionally, if convenience sampling was used (a non-probabilistic method), it should be clarified why a probabilistic sample size calculation was performed.

Description of the Questionnaire:

The description of the data collection tool (questionnaire) is too short. It does not specify how the questionnaire was validated or whether a pilot study was conducted before its implementation.

Data Analysis:

The data analysis section is too brief and lacks clarity on the dependent and independent variables. It should also specify the measures of central tendency (e.g., mean, median) and dispersion (e.g., standard deviation) used. Moreover, it should detail which statistical tests were employed to examine associations (e.g., chi-square, t-tests).

Ethical Considerations:

The ethical considerations section should explain the data protection measures implemented, particularly since the questionnaires were administered virtually. For instance:

"All virtual questionnaires were anonymised, and responses were securely stored to ensure data confidentiality. Access to the data was restricted to authorised personnel only."

Results

The first and second paragraphs of the results section are redundant and repeat the same ideas. This should be streamlined for clarity.

The results are purely descriptive, which is inconsistent with the stated study design of an "analytical study." This discrepancy reinforces the idea that the study is descriptive rather than analytical.

The results do not adequately address the second study objective: "To analyse the attitude and perceptions of medical students and doctors on euthanasia." A more focused analysis is needed to examine attitudes and perceptions. Statistical tests (e.g., chi-square or regression analysis) could be employed to identify significant factors influencing attitudes.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

Clinical and applied bioethics in the experimental field. Research methodology. Epidemiology and public health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Mallya Ajay Community Medicine, Kasturba Medical College, Mangalore, karnataka, India

Competing interests: No competing interests were disclosed.

 31 7 2025

Dear Reviewer

Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity.