Comments to the authors:

Thanks to the authors for giving me the opportunity to review their study that explores the perceptions and attitudes of medical students and physicians from a private medical college in South India toward euthanasia. I agree with them that euthanasia has profound ethical and legal issues. 

I have some observations and need clarification on some paragraphs.

Abstract:

Sample size was 212, distributed among medical students and doctors. Please provide more information in this section regarding how many students and doctors participated in the study, and a little more information related to how they were recruited and which year were the students, and the specialty of the doctors.

Methods:

how was validated the semi-structured questionnaire developed through literature review? Please clarify.

Results:

In India, “interns” are already medical doctors, or are still students? If interns are not yet doctors, maybe it should be better to have a different category (medical students, interns, and doctors). This is important, since they mention that only 39% of the participants are older than 25 y (6.3% were in the 25–30 years age group, and 32.7% were above 30 years).

Discussion:

Regarding the data provided in this study, it is not clear how they can suggest that there is an evolving regional perspectives post- Shanbaug. There is a huge time lapse between references 10 & 11, so differences cannot be attributed to regional perspectives after a particular case.

References: if possible, please include more updated studies.

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?

Yes

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?

Partly

Reviewer Expertise:

MD, with expertise in medical education and bioethics.

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.

Reviewer Comments

Abstract

Clarity -There is a need for more clarity of purpose and methodology in the abstract. It should indicate what was measured in the study.

Introduction

Context: The legal context of euthanasia is well discussed in the introduction (covering many nations), but some broader discussion of attitudes to and laws on euthanasia worldwide would be beneficial.

Definition: Definitions of euthanasia and physician-assisted suicide (PAS) could be clearer,  specifically distinguishing between active and passive euthanasia.

Literature References: Add such references on modern literature discussing world views of euthanasia and possible consequences.

Methods

Design: It is essential to clarify the design of the study (cross-sectional and analytical). Consistency in wording should be used throughout the paper.

Sample Size Calculation: Please state the rationale for selecting a convenience sampling and clearly indicate its limitations in the methods section.

Validation of the questionnaire: A more extensive description of how the questionnaire was developed and validated would strengthen the methodological quality.

Results

Presentation of Data: The authors should ensure that all tables are clear and presentable. The numbers in Table 2 do not appear to sum correctly; confirm the accuracy of the data.

Descriptive vs. Analytical: Both descriptive and analytical statistics are used to meet study objectives.

Discussion

Role of media: The media's role in influencing public perceptions of euthanasia could be explained with examples and references.

Culture: A more nuanced exploration of cultural and religious considerations would have deepened the analysis of perceptions about euthanasia.

Comparative analysis: Discussion and comparison of the outcomes qualitatively and quantitatively with other studies conducted in diverse settings.

Conclusion

Guesswork:  Desist from anything that reads like conjecture. Keep conclusions to those that are based purely on the data collected.

Implications:  Discuss broader policy and practice implications for medical education regarding euthanasia.

General Comments

Limitations: The authors should clearly present the study's limitations and future research directions.

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

Yes

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?

Partly

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

Partly

Reviewer Expertise:

Psychosocial oncology, women's health, palliative care, and  spiritual and ethical issues in healthcare

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.

A nice idea for a study but the execution is unsophisticated and cluncky.  Two areas are particularly concerning. 

The PAS scale is quite an old instrument, and strong arguments can be made that as language has shifted in this field, the work to standardize this as a metric is no longer valid. 

Terms:

I am an expert in this area (terms about end-of-life decisions, palliative care, life-prolonging care, withholding and withdrawing no longer helpful technology, euthanasia, and assisted dying). 

This field is very difficult in that the meaning of terms is disputed and inconsistent.  Because the participants in this study are medical pre-professionals, I strongly recommend using 21 ^st century medical terminology for euthanasia and assisted dying (EAD).

The authors use the term “euthanasia” inconsistently.  Particularly noticeable, is the use of the term (incorrectly) in the abstract in variance with the better accepted definition in sentence 2 of the introduction.   The term euthanasia has come to mean, as the authors report "Euthanasia entails the deliberate ending of a patient’s life by a healthcare professional, typically through lethal medication, at the patient’s explicit request."

While the term "passive euthanasia", was used in the Indian court decision of 2011 is medically outdated and no longer used by medical professionals working with patients and families about the use of technology during the death process.  Particularly, the term “passive euthanasia” is avoided by end-of-life specialists and intensive care staff due to confusion with involuntary active euthanasia. Use of the term passive euthanasia signals a philosophy or social sciences perspective rather than the vocabulary used by medical professionals working with patients in settings equipped with advanced life-prolonging technology.   In countries with access to modern ICU care, the withdrawal of life-prolonging treatment that does not meet the patients goals of care is described as “forgoing no longer helpful intervention”.  Well-known examples of this vocabulary are in the American Academy of Pediatrics statements on forgoing medically provided nutrition and hydration (Diekema Foregoing mediclly provided nutrition and hydration in children, 2009 https://doi-org.ezproxy.otago.ac.nz/10.1542/peds.2009-1299)  

Consider the terms "withholding and withdrawing life-sustaining treatment" and consideration of the modern term "managed withdrawal of life-sustaining medical therapy (MWLSMT)".   I recommend considering this term (or citing literature about this term) Because most deaths of young people in modern, well-funded Intensive Care Units occur after withdrawal of life-prolonging technology, medical literature considering paediatric ICU death uses the term ​​​"​​​​managed withdrawal of life-sustaining medical therapy (MWLSMT)" This usually done because the goal of care cannot be met.  I recommend these two articles that document this:  Sands et al. “Characteristics of deaths in paediatric intensive care: a 10 year study. (2009)

Methodology-

Please describe how you got 212 respondants out of 220.  This is so incredible a response rate that it could appear falsified to some without explanation of how you did this.

I am not an expert in methadology so I cannot peer review  the remaining parts of this section.

Other: I am  unsure why the word euthanasia is capitalized in the title. Suggest updating terms.

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?

No

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:

Bioethics and Palliative Medicine.  Specific research foci: euthanasia, assisted dying, palliative medicine, paediatric palliative care, withholding life-prolonging treatments.

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.

Introduction

In the definition of euthanasia, the authors state: “typically through lethal medication.” I question the pertinence of typically. What other legally recognized means of performing euthanasia exist? This point should also be reviewed in the definition of PAS.

The authors write that “Globally, regulatory approaches differ significantly” and mention the Netherlands, Canada, Belgium, and Luxembourg. However, it is not clear in what sense these frameworks differ significantly. On the contrary, the Benelux countries share many regulatory characteristics concerning assisted dying, and Canada’s legislation is not far from these models. If the goal is to illustrate broader diversity, it would be useful to include Colombia—where euthanasia was decriminalized judicially despite the absence of a specific law—or certain U.S. jurisdictions where only PAS is legal and restricted to terminal illness.

Throughout the article, the terms euthanasia and active euthanasia are used. As another reviewer has noted, the most recent literature no longer distinguishes between active and passive euthanasia. 

Results

In the Results section, the authors write: “Of 140 supporters of euthanasia legalization, relief of suffering (110) and patient autonomy (91) were the main reasons, highlighting humanitarian priorities.” Labeling these motivations as humanitarian seems inadequate, as the term is ambiguous. A more precise alternative would be to refer to the bioethical principles of beneficence and respect for autonomy. In any case, this interpretation seems more appropriate for the Discussion section.

Discussion

In this section, the authors state: “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.” However, unless I am mistaken, the cited study does not include such findings. The authors should verify their source.

The manuscript also reads: “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.” Yet, the data presented do not clearly support that religious diversity influenced opposition, given that religion appeared only eight times in Table 3. Nor is the connection with family norms evident when the two main reasons for opposing euthanasia were its potential misuse and its contradiction with

medical deontology.

The authors further claim: “These findings align with evidence that religious and cultural values are major determinants of euthanasia attitudes worldwide.” However, neither of the two sources cited identifies religious or cultural values as major determinants worldwide. In fact, one of those studies focuses exclusively on India. While these papers discuss religion and cultural aspects, they are not empirical studies capable of substantiating such a broad claim.

A similar issue arises with the statement: “In our study, 71.7% of participants emphasized patient consent, reflecting global trends where patient autonomy is central to legalized euthanasia frameworks.” The cited references—Dutch legislation and a UK-based study—do not justify framing this as a global trend.

Overall, the discussion would benefit from deeper engagement with specialized bioethical literature and a more detailed analysis of the study’s results and variables.

Conclusions

The conclusions are brief—most of the section focuses on limitations. Furthermore, the statement “The findings underscore the tension between ethical principles like autonomy and cultural factors such as religious diversity, shaping diverse perspectives among healthcare providers” is not entirely supported by the data, since, as mentioned above, the results do not indicate religion as a predominant factor.

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

No

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:

Healthcare policy, bioethics, medical ethics.

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.

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.

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.

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.