Perceptions and attitudes of medical students and physicians on Euthanasia

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In India, passive euthanasia has been permitted since the 2011 Aruna Shanbaug case, but active euthanasia remains prohibited. Healthcare providers’ perspectives are critical in shaping discourse, given their close involvement in patient care. This study aimed to assess the perceptions and attitudes of medical students and physicians toward euthanasia. Methods A cross-sectional study, conducted with ethical clearance, involved 212 medical students and doctors at a private medical college in South India between March and June 2022. A self-developed semi-structured questionnaire, including the Attitudes Toward Euthanasia (ATE) scale, was used. Data were analyzed using descriptive statistics and chi-square tests to examine associations between demographic variables, sources of information, and attitudes. Results Awareness of euthanasia was high (86.3%), but knowledge of its types (47.2%), legal status (44.3%), and guidelines (30.2%) was limited. Overall, 66% supported euthanasia, with relief of suffering (78.6%) and patient autonomy (65%) cited as key reasons. Opposition (34%) was mainly due to concerns about misuse (52.8%) and the belief that medicine should preserve life (45.8%). Most respondents (71.7%) believed patient consent should be the final authority in euthanasia decisions. Information source significantly influenced attitudes (p = 0.012), with personal research fostering stronger support compared to hearsay or news. Conclusion The study highlights evolving attitudes toward euthanasia among medical professionals in India, with growing emphasis on patient autonomy. Media and information sources significantly shape perceptions, underscoring the need for structured education on end-of-life care within medical curricula. Broader multi-center studies are warranted to capture diverse perspectives and guide future policy. 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F1000Research 2025, 13 :1009 ( https://doi.org/10.12688/f1000research.153956.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] Previously titled: Perceptions and attitudes of medical students and doctors on Euthanasia Rohith Motappa https://orcid.org/0000-0002-8939-2850 1 , Ajay Mallya https://orcid.org/0000-0002-2280-3176 2 , Meghna Guleria 3 , [...] Aditi Singhal 3 , Pallavi Nambiar 3 , Vaibhavi Gaiha 3 , Himani Kotian https://orcid.org/0000-0002-1252-507X 2 Rohith Motappa https://orcid.org/0000-0002-8939-2850 1 , Ajay Mallya https://orcid.org/0000-0002-2280-3176 2 , [...] Meghna Guleria 3 , Aditi Singhal 3 , Pallavi Nambiar 3 , Vaibhavi Gaiha 3 , Himani Kotian https://orcid.org/0000-0002-1252-507X 2 PUBLISHED 05 Sep 2025 Author details Author details 1 Department of Community Medicine, Rajajinagar, ESIC Medical College & PGIMSR and Model Hospital, Bangalore, Karnataka, 560010, India 2 Community Medicine, Kasturba Medical College, Mangalore, Karnataka, 575001, India 3 Kasturba Medical College, Mangalore, Karnataka, 575001, India Rohith Motappa Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ajay Mallya Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Meghna Guleria Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Aditi Singhal Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Supervision, Validation Pallavi Nambiar Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Vaibhavi Gaiha Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Himani Kotian Roles: Data Curation, Formal Analysis, Validation, Visualization OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. Abstract Background Euthanasia remains a contentious ethical and legal issue worldwide. In India, passive euthanasia has been permitted since the 2011 Aruna Shanbaug case, but active euthanasia remains prohibited. Healthcare providers’ perspectives are critical in shaping discourse, given their close involvement in patient care. This study aimed to assess the perceptions and attitudes of medical students and physicians toward euthanasia. Methods A cross-sectional study, conducted with ethical clearance, involved 212 medical students and doctors at a private medical college in South India between March and June 2022. A self-developed semi-structured questionnaire, including the Attitudes Toward Euthanasia (ATE) scale, was used. Data were analyzed using descriptive statistics and chi-square tests to examine associations between demographic variables, sources of information, and attitudes. Results Awareness of euthanasia was high (86.3%), but knowledge of its types (47.2%), legal status (44.3%), and guidelines (30.2%) was limited. Overall, 66% supported euthanasia, with relief of suffering (78.6%) and patient autonomy (65%) cited as key reasons. Opposition (34%) was mainly due to concerns about misuse (52.8%) and the belief that medicine should preserve life (45.8%). Most respondents (71.7%) believed patient consent should be the final authority in euthanasia decisions. Information source significantly influenced attitudes (p = 0.012), with personal research fostering stronger support compared to hearsay or news. Conclusion The study highlights evolving attitudes toward euthanasia among medical professionals in India, with growing emphasis on patient autonomy. Media and information sources significantly shape perceptions, underscoring the need for structured education on end-of-life care within medical curricula. Broader multi-center studies are warranted to capture diverse perspectives and guide future policy. READ ALL READ LESS Keywords Euthanasia, legalization, healthcare providers Corresponding Author(s) Ajay Mallya ( [email protected] ) Close Corresponding author: Ajay Mallya Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Motappa R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Motappa R, Mallya A, Guleria M et al. Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.12688/f1000research.153956.3 ) First published: 05 Sep 2024, 13 :1009 ( https://doi.org/10.12688/f1000research.153956.1 ) Latest published: 31 Mar 2026, 13 :1009 ( https://doi.org/10.12688/f1000research.153956.4 ) Revised Amendments from Version 2 Terminology updated: All instances of “doctor” changed to “physician” to clarify participants were MDs. Definitions updated: Introduction revised with current definitions of euthanasia and physician-assisted suicide, reflecting medical assistance in dying. Abstract revised: Colloquial or opinion-based statements removed; aim, methodology, ethics approval, and participants clarified. Methods/results clarified: Use of ATE scale explicitly reported; percentages for age groups added; no interpretations presented in the results section. Discussion expanded: Media influence, religious diversity, collectivist norms, and curriculum implications elaborated with supporting literature. Terminology updated: All instances of “doctor” changed to “physician” to clarify participants were MDs. Definitions updated: Introduction revised with current definitions of euthanasia and physician-assisted suicide, reflecting medical assistance in dying. Abstract revised: Colloquial or opinion-based statements removed; aim, methodology, ethics approval, and participants clarified. Methods/results clarified: Use of ATE scale explicitly reported; percentages for age groups added; no interpretations presented in the results section. Discussion expanded: Media influence, religious diversity, collectivist norms, and curriculum implications elaborated with supporting literature. See the authors' detailed response to the review by Dennis Demedts See the authors' detailed response to the review by Yelson Alejandro Picón Jaimes See the authors' detailed response to the review by Toni Buterin READ REVIEWER RESPONSES  There is a newer version of this article available. Suppress this message for one day. Introduction Euthanasia and physician-assisted suicide (PAS) are complex and ethically charged practices involving the intentional termination of life to alleviate suffering. Euthanasia entails the deliberate ending of a patient’s life by a healthcare professional, typically through lethal medication, at the patient’s explicit request. PAS, on the other hand, involves a physician providing a patient with the means to end their own life, such as a prescription for lethal substances, again at the patient’s explicit request. Collectively, these practices are often referred to as medical assistance in dying (MAiD). 1 Globally, regulatory approaches differ significantly. The Netherlands legalized euthanasia and assisted suicide in 2002, requiring unbearable suffering and voluntary patient consent. 2 Canada introduced Medical Assistance in Dying (MAiD) in 2016, covering euthanasia and assisted suicide for terminal and select non-terminal conditions. 3 Belgium and Luxembourg permit euthanasia under stringent criteria, while many countries, including India, prohibit active euthanasia and assisted suicide. 4 These variations reflect diverse cultural, ethical, and legal perspectives, essential for contextualizing attitudes toward euthanasia. In India, euthanasia remains illegal, but judicial rulings have shaped its discourse. The 2011 Aruna Shanbaug case permitted passive euthanasia, allowing withdrawal of life support for patients in persistent vegetative states. 5 The 1996 Gian Kaur v. State of Punjab ruling recognized the “right to die with dignity” under Article 21 of the Indian Constitution, limited to passive euthanasia and excluding active euthanasia or assisted suicide. 6 This judgment established a constitutional framework for dignified death, balancing patient autonomy with ethical and legal constraints. Advancements in medical technology have extended life expectancy, intensifying debates about quality of life. Healthcare providers, particularly those managing terminal illnesses, play a critical role in these discussions. Their attitudes toward euthanasia, influenced by global trends and local legal frameworks, are vital for informing policy and practice. This study examines the perceptions and attitudes of medical students and doctors at Kasturba Medical College, Mangalore, toward euthanasia and its potential legalization, situating their views within global and Indian contexts. Methods This cross-sectional analytical study, conducted at Kasturba Medical College, Mangalore, Karnataka, India, from March 10 to June 13, 2022, assessed attitudes and perceptions toward euthanasia among 220 medical undergraduates, interns, and post-graduates/physicians who provided informed consent. The sample size was calculated using the formula: N = Z 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. Data were collected using a semi-structured questionnaire developed through literature review, which included demographic details, awareness questions, and the validated Attitudes Toward Euthanasia (ATE) Scale. 8 The ATE Scale used a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). The questionnaire was distributed via Google Forms through WhatsApp, email, and Telegram, accessible only after online informed consent. Data were analyzed using SPSS version 25.0, with descriptive statistics (means, standard deviations, proportions) summarizing responses and chi-square tests, t-tests, and linear regression assessing associations between variables and attitudes. The study was approved by the Institutional Ethics Committee of Kasturba Medical College (EC/NEW/INST/2020/742, March 17, 2022). Participation was voluntary, with no risk to participants, and data were kept confidential for research purposes. Participants could withdraw without explanation, and consent was obtained via Google Forms, allowing only consenting participants to proceed, as approved by the ethics committee. Results Out of the 212 people who responded 128(60.4%) were female and 84(39.6%) were males. Of the respondents, 127 (61.1%) were in the 18–24 years age group, 13 (6.3%) were in the 25–30 years age group, and 68 (32.7%) were above 30 years. There were 41(19.3%) 1st year students, 60(28.3%) 2nd year students, 5(2.4%) 3rd year students, 9(4.2%) 4th year students and 97(45.8%) interns, PG and physicians. Among 212 medical students and doctors, 86.3% were aware of euthanasia, but only 47.2% knew its types, 44.3% understood its legal status in India, and 30.2% were familiar with guidelines. News (29.2%) and hearsay/work (25.9% each) were primary information sources, reflecting media influence. Most (71.7%) favored patient consent for euthanasia decisions, with 66% supporting its practice (see Table 1 ). 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 Responses to the Attitudes Toward Euthanasia (ATE) Scale showed distinct patterns across the 208 participants. Items related to withdrawal of life support at the request of a patient received comparatively higher endorsement, with 47.6% agreeing or strongly agreeing that a doctor should remove life support when requested by a dying patient, while 38.4% disagreed or strongly disagreed. When withdrawal of life support was framed around the doctor’s judgment that recovery was unlikely, agreement was lower (23.6% agreed or strongly agreed) and disagreement higher (59.1%). Prescribing or administering medication to intentionally end life received lower levels of support. For example, at the request of a dying patient, 45.7% agreed or strongly agreed that a doctor should prescribe sufficient medication to end life, while 27.9% disagreed or strongly disagreed. When the same option was presented in the context of severe pain, only 14.5% agreed or strongly agreed, and 65.4% disagreed or strongly disagreed. Items framed as moral prohibitions received stronger agreement, with 56.7% endorsing that it would be wrong to end the life of a patient in severe, uncontrollable pain and 46.6% agreeing it would be wrong if the doctor judged the patient would not recover ( Table 2 ). Table 2. Distribution of participants’ responses to the Attitudes Toward Euthanasia (ATE) Scale statements. ATE Scale Strongly Disagree n (%) Disagree n (%) Neutral n (%) Agree n (%) Strongly Agree n (%) If a patient in severe pain requests it, a doctor should remove life support and allow that patient to die. 30 (14.4%) 50 (24.0%) 52 (25.0%) 57 (27.4%) 19 (9.1%) It is okay for a doctor to administer enough medicine to end a patient’s life if the doctor does not believe that they will recover. 49 (23.6%) 54 (26.0%) 54 (26.0%) 36 (17.3%) 15 (7.2%) If a patient in severe pain requests it, a doctor should prescribe that patient enough medicine to end their life. 72 (34.6%) 64 (30.8%) 42 (20.2%) 23 (11.1%) 7 (3.4%) It is okay for a doctor to remove life-support and let a patient die if the doctor does not believe the patient will recover. 65 (31.2%) 58 (27.9%) 36 (17.3%) 39 (18.8%) 10 (4.8%) It is okay for a doctor to administer enough medicine to a suffering patient to end that patient’s life if the doctor thinks that the patient’s pain is too severe. 57 (27.4%) 68 (32.7%) 46 (22.1%) 26 (12.5%) 11 (5.3%) Even if a doctor does not think that a patient will recover, it would be wrong for the doctor to end the life of a patient. 50 (24.0%) 68 (32.7%) 52 (25.0%) 30 (14.4%) 8 (3.8%) It is okay for a doctor to remove a patient’s life-support and let them die if the doctor thinks that the patient’s pain is too severe. 36 (17.3%) 36 (17.3%) 61 (29.3%) 54 (26.0%) 21 (10.1%) If a dying patient requests it, a doctor should prescribe enough medicine to end their life. 28 (13.5%) 30 (14.4%) 55 (26.4%) 69 (33.2%) 26 (12.5%) Even if a doctor knows that a patient is in severe, uncontrollable pain, it would be wrong for the doctor to end the life of that patient. 9 (4.3%) 33 (15.9%) 48 (23.1%) 71 (34.1%) 47 (22.6%) If a dying patient requests it, a doctor should remove their life support and allow them to die. 12 (5.8%) 42 (20.2%) 55 (26.4%) 61 (29.3%) 38 (18.3%) Of 140 supporters of euthanasia legalization, relief of suffering (110) and patient autonomy (91) were the main reasons, highlighting humanitarian priorities. Among 72 opponents, concerns about misuse (38) and the belief that medicine should preserve life (33) were predominant, alongside ethical and palliative care considerations (see Table 3 ). Table 3. Distribution of participants for and against euthanasia based on their justification for their opinion. * 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 (see Table 4 ). Table 4. 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 (see Table 5 ). Table 5. 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 found that 86.3% of participants were aware of euthanasia, but only 47.2% knew its types, 44.3% were aware of legal status, and 30.2% understood the relevant guidelines. These findings are similar to a study in New Delhi, where 80% of healthcare professionals were aware of euthanasia, but only 50% supported legalization under strict conditions. 9 In our study, 66% of participants expressed overall support for euthanasia, indicating higher acceptance compared to prior studies in India. 10 , 11 The Attitudes Toward Euthanasia (ATE) Scale revealed more detailed insights: 47.6% of participants agreed or strongly agreed that doctors should remove life support at a patient’s request, while only 14.5% supported prescribing medication to actively end life. Meanwhile, 56.7% agreed or strongly agreed that it would be wrong for a doctor to actively end a patient’s life in severe, uncontrollable pain. 8 This suggests that while general support for euthanasia is high, participants favor passive forms over active euthanasia, consistent with patterns observed in other Indian studies. 7 , 10 Media was reported as the most common initial source of knowledge (29.2%), and attitudes significantly differed according to information source (p = 0.012) and exposure to patient autonomy narratives (p = 0.008). Previous research highlights the influential role of media in shaping public and professional perceptions of euthanasia. 12 Religious diversity and collectivist family norms in India also appear to influence opposition: 34% of participants opposed euthanasia, often citing potential misuse (n = 38) or ethical concerns (n = 23). 13 These findings align with evidence that religious and cultural values are major determinants of euthanasia attitudes worldwide. 4 , 13 Legally, passive euthanasia is permitted in India since the Aruna Shanbaug case in 2011, while active euthanasia remains prohibited under Indian law. 5 , 6 Comparatively, countries such as the Netherlands and Canada have legislation allowing euthanasia or physician-assisted suicide under strict criteria. 2 , 3 Regional differences were observed: only 47.1% of Sri Lankan medical students supported euthanasia, 11 while support in South India was higher at 69.3%, 10 suggesting evolving regional perspectives post- Shanbaug . The absence of significant demographic influences (gender, year of study) indicates that formal training rather than personal traits drives attitudes. Evidence shows that integrating euthanasia education in medical and nursing curricula improves understanding and ethical decision-making. 14 , 15 In our study, 71.7% of participants emphasized patient consent, reflecting global trends where patient autonomy is central to legalized euthanasia frameworks. 2 , 16 Limitations include single-institution sampling and potential urban bias. Multi-institutional studies with stratified sampling and qualitative approaches could provide a more representative understanding of attitudes and explore the influence of media further. Future research should also examine longitudinal trends and rural perspectives to inform ethically sound and culturally sensitive policy. Conclusion Our study reveals evolving attitudes toward euthanasia among medical students and doctors, reflecting a growing acceptance within India’s constrained legal framework, which permits only passive euthanasia. The findings underscore the tension between ethical principles like autonomy and cultural factors such as religious diversity, shaping diverse perspectives among healthcare providers. Limited by a single-institution sample, the study may not capture broader Indian views, necessitating multi-center research with diverse sampling to explore these dynamics further. Integrating euthanasia education into medical curricula could foster informed ethical discussions, addressing gaps in understanding. These insights contribute to India’s ongoing euthanasia debate, highlighting the need for policies that balance patient rights with societal and ethical considerations, paving the way for nuanced healthcare practices. 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 . 17 This project contains the following underlying data: 1. 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 18 This project contains the following underlying data: 1. 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 1. Grove G, Lovell M, Hughes I, et al. : Voluntary-assisted dying, euthanasia and physician-assisted suicide: global perspectives—systematic review. BMJ Support. Palliat. Care. 2022; 12 : 423–433. 2. 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 3. 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 4. 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. PubMed Abstract | Publisher Full Text 5. Mudur G: Indian court says it may sanction euthanasia in the future. BMJ. 2011 [cited 2022 Jul 3]; 342 (mar11 2): d1628. PubMed Abstract | Publisher Full Text Reference Source 6. Bandewar SV, Chaudhuri L, Duggal L, et al. : The Supreme Court of India on euthanasia: Too little, too late. Indian J. Med. Ethics. 2018 Apr-Jun; 3 (2): 91–94. PubMed Abstract | Publisher Full Text 7. Subba SH, Khullar V, Latafat Y, et al. : Doctors’ Attitude Towards Euthanasia: A Cross-sectional Study Experience. J. Assoc. Physicians India. 2016; 63. Reference Source 8. Wasserman J, Clair JM, Ritchey FJ: A scale to assess attitudes toward euthanasia. Omega (Westport). 2005; 51 (3): 229–237. PubMed Abstract | Publisher Full Text Reference Source 9. Sinha VK, Basu S, Sarkhel S: Euthanasia: An Indian perspective. Indian J. Psychiatry. 2012; 54 (2): 177–183. PubMed Abstract | Publisher Full Text | Free Full Text 10. Kamath S, Bhate P, Mathew G, et al. : 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. PubMed Abstract | Publisher Full Text | Free Full Text Reference Source 11. Herath HMMTB, Wijayawardhana KWSM, Wickramarachchi UI, et al. : Attitudes on euthanasia among medical students and doctors in Sri Lanka: a cross sectional study. BMC Med. Ethics. 2021 Dec 7; 22 (1): 162. PubMed Abstract | Publisher Full Text | Free Full Text Reference Source 12. Cohen J, Van Landeghem P, Carpentier N, et al. : Public acceptance of euthanasia in Europe: a survey study in 47 countries. Int. J. Public Health. 2014; 59 (1): 143–156. PubMed Abstract | Publisher Full Text 13. Koodamara NK, Prabhu N, Thomas B, et al. : Euthanasia: India’s major religious points of views. Indian J. Public Health Res. Dev. 2018; 9 (10): 962–965. Publisher Full Text 14. Verpoort C, Gastmans C, De Bal N, et al. : Nurses’ attitudes to euthanasia: a review of the literature. Nurs. Ethics. 2004; 11 (6): 349–365. Publisher Full Text 15. Khatony A, Fallahi M, Rezaei M, et al. : Comparison of attitude of nurses and nursing students toward euthanasia. Nurs. Ethics. 2022; 29 (1): 208–216. Publisher Full Text 16. 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. PubMed Abstract | Publisher Full Text Reference Source 17. Mallya A, Motappa R: Data - Perceptions and Attitudes of Medical Students and Doctors on Euthanasia.xlsx. figshare. 2024 [cited 2024 Aug 20]. Publisher Full Text Reference Source 18. Mallya A, Motappa R: Questionnaire - Perceptions and Attitudes of Medical Students and Doctors on Euthanasia. figshare. 2024 [cited 2024 Aug 20]. Publisher Full Text Reference Source Comments on this article Comments (0) Version 4 VERSION 4 PUBLISHED 05 Sep 2024 ADD YOUR COMMENT Comment Author details Author details 1 Department of Community Medicine, Rajajinagar, ESIC Medical College & PGIMSR and Model Hospital, Bangalore, Karnataka, 560010, India 2 Community Medicine, Kasturba Medical College, Mangalore, Karnataka, 575001, India 3 Kasturba Medical College, Mangalore, Karnataka, 575001, India Rohith Motappa Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ajay Mallya Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Meghna Guleria Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Aditi Singhal Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Supervision, Validation Pallavi Nambiar Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Vaibhavi Gaiha Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Himani Kotian Roles: Data Curation, Formal Analysis, Validation, Visualization Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (4) version 4 Revised Published: 31 Mar 2026, 13:1009 https://doi.org/10.12688/f1000research.153956.4 version 3 Revised Published: 05 Sep 2025, 13:1009 https://doi.org/10.12688/f1000research.153956.3 version 2 Revised Published: 30 Jul 2025, 13:1009 https://doi.org/10.12688/f1000research.153956.2 version 1 Published: 05 Sep 2024, 13:1009 https://doi.org/10.12688/f1000research.153956.1 Copyright © 2025 Motappa R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Motappa R, Mallya A, Guleria M et al. Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.12688/f1000research.153956.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 3 VERSION 3 PUBLISHED 05 Sep 2025 Revised Views 0 Cite How to cite this report: Salas S. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r438853 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-438853 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Dec 2025 Sofia Salas , Universidad del Desarrollo, Santiago, Chile Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.187552.r438853 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 ... Continue reading READ ALL 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. At least from the abstract, there is no data to support this: “The study highlights evolving attitudes toward euthanasia”. Please clarify. Introduction: the authors mention that, worldwide, there are diverse cultural, ethical, and legal perspectives towards euthanasia. Considering this, it should be interesting to give the rationale of exploring the views of medical students and medical doctors at Kasturba Medical College, Mangalore, Karnataka, India. Does this region represent a particular view or cultural context or a particular region within India? Why they choose to do the study at this hospital and not in another one? Or it was for convenience (they work there)? Please clarify. Methods : how was validated the semi-structured questionnaire developed through literature review? Please clarify. Was there any intention to have adequate sampling of participants in different years? It is surprising that there were only 5 and 9 students from years 3 & 4, respectively. Maybe it could be more interesting to have medical students, interns and medical doctors (assuming that residents already are graduated from medical school) as three categories. 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). There are some minor inconsistencies regarding the number of participants: in methods they say “110 students, 110 doctors/interns/post-graduates”; in results section, there are 115 students and 97 participants in the other categories. Likewise, they say “out of the 212 people…”, but “Responses to the Attitudes Toward Euthanasia (ATE) Scale showed distinct patterns across the 208 participants”. I assume that there are missing responses, but that should be clear. Table 1 shows the distribution of participants opinions regarding euthanasia. However, if they asked questions to be answered with “aware”, “not aware”, it is very difficult to verify that knowledge. For example: “Legalities concerning the practice of euthanasia in India”, they could answer “fully aware”, but their actual knowledge be wrong. Please clarify. With respect to Table 4, it is rather confusing the way data is presented. I am particularly concerned with the analysis done when there are so few cases (for example, only 5 students in 3 rd year). Please review with an expert if the way you are presenting the data is correct. For example, in table 4, 65% of female participants (84 out of 128) and 66% of males (56 out of 84) favor euthanasia; in other words, there is no gender difference. But the authors calculated the % in the other way. 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. Conclusion: Data presented in the study do not support that there is “a growing acceptance” of euthanasia in India. Results should not be generalized to a whole country. References: if possible, please include more updated studies. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Salas S. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r438853 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-438853 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Iddrisu M. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r430565 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-430565 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Dec 2025 Merri Iddrisu , University of Ghana, Accra, Ghana Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.187552.r430565 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 ... Continue reading READ ALL 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 Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Iddrisu M. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r430565 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-430565 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Winters JP. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r430867 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-430867 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Dec 2025 Janine Penfield Winters , University of Otago, Dunedin, New Zealand Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.187552.r430867 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 ... Continue reading READ ALL 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Winters JP. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r430867 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-430867 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Espericueta L. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r428352 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-428352 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 Nov 2025 Luis Espericueta , Universidad de Granada, Granada, Spain Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.187552.r428352 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. ... Continue reading READ ALL 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? No Competing Interests: No competing interests were disclosed. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Espericueta L. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r428352 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-428352 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 2 VERSION 2 PUBLISHED 30 Jul 2025 Revised Views 0 Cite How to cite this report: Demedts D. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.184704.r404173 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v2#referee-response-404173 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 18 Aug 2025 Dennis Demedts , Vrije Universiteit Brussel, Brussels, Brussels, Belgium Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.184704.r404173 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: ... Continue reading READ ALL 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 Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? No References 1. Demedts D, Magerman J, Goossens E, Tricas-Sauras S, et al.: Using simulation to teach nursing students how to deal with a euthanasia request. PLOS ONE . 2024; 19 (3). Publisher Full Text 2. Demedts D, Fobelets M, Tricas-Sauras S, Bilsen J: 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 . Publisher Full Text 3. Radulović D: Euthanasia – A Legal or Medical Issue: A Narrative Review. Iranian Journal of Public Health . 2025. Publisher Full Text 4. 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. 5. Grove G, Lovell M, Hughes I, Maehler E, et al.: Voluntary-assisted dying, euthanasia and physician-assisted suicide: global perspectives—systematic review. BMJ Supportive & Palliative Care . 2025; 15 (4): 423-435 Publisher Full Text Competing Interests: No competing interests were disclosed. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Demedts D. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.184704.r404173 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v2#referee-response-404173 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 11 Sep 2025 Ajay Mallya , Community Medicine, Kasturba Medical College, Mangalore, 575001, India 11 Sep 2025 Author Response 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 ... Continue reading 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 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 Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 11 Sep 2025 Ajay Mallya , Community Medicine, Kasturba Medical College, Mangalore, 575001, India 11 Sep 2025 Author Response 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 ... Continue reading 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 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 Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 05 Sep 2024 Views 0 Cite How to cite this report: Buterin T. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.168923.r363347 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v1#referee-response-363347 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 19 Feb 2025 Toni Buterin , University of Rijeka, Rijeka, Croatia; University of Rijeka Faculty of Health Studies (Ringgold ID: 611977), Rijeka, Primorje-Gorski Kotar County, Croatia Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.168923.r363347 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 ... Continue reading READ ALL 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? No Competing Interests: No competing interests were disclosed. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Buterin T. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.168923.r363347 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v1#referee-response-363347 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 09 Aug 2025 Ajay Mallya , Community Medicine, Kasturba Medical College, Mangalore, 575001, India 09 Aug 2025 Author Response Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 09 Aug 2025 Ajay Mallya , Community Medicine, Kasturba Medical College, Mangalore, 575001, India 09 Aug 2025 Author Response Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Picón Jaimes YA. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.168923.r360955 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v1#referee-response-360955 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Jan 2025 Yelson Alejandro Picón Jaimes , Univ Ramon Llul, Barcelona, Spain Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.168923.r360955 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, ... Continue reading READ ALL 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? No 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 Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Picón Jaimes YA. Reviewer Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.168923.r360955 ) The direct URL for this report is: https://f1000research.com/articles/13-1009/v1#referee-response-360955 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 09 Aug 2025 Ajay Mallya , Community Medicine, Kasturba Medical College, Mangalore, 575001, India 09 Aug 2025 Author Response Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 09 Aug 2025 Ajay Mallya , Community Medicine, Kasturba Medical College, Mangalore, 575001, India 09 Aug 2025 Author Response Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 4 VERSION 4 PUBLISHED 05 Sep 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 4 5 6 7 Version 4 (revision) 31 Mar 26 Version 3 (revision) 05 Sep 25 read read read read Version 2 (revision) 30 Jul 25 read Version 1 05 Sep 24 read read Yelson Alejandro Picón Jaimes , Univ Ramon Llul, Barcelona, Spain Toni Buterin , University of Rijeka, Rijeka, Croatia; University of Rijeka Faculty of Health Studies (Ringgold ID: 611977), Rijeka, Croatia Dennis Demedts , Vrije Universiteit Brussel, Brussels, Belgium Luis Espericueta , Universidad de Granada, Granada, Spain Janine Penfield Winters , University of Otago, Dunedin, New Zealand Merri Iddrisu , University of Ghana, Accra, Ghana Sofia Salas , Universidad del Desarrollo, Santiago, Chile Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Salas S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Dec 2025 | for Version 3 Sofia Salas , Universidad del Desarrollo, Santiago, Chile 0 Views copyright © 2026 Salas S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 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. At least from the abstract, there is no data to support this: “The study highlights evolving attitudes toward euthanasia”. Please clarify. Introduction: the authors mention that, worldwide, there are diverse cultural, ethical, and legal perspectives towards euthanasia. Considering this, it should be interesting to give the rationale of exploring the views of medical students and medical doctors at Kasturba Medical College, Mangalore, Karnataka, India. Does this region represent a particular view or cultural context or a particular region within India? Why they choose to do the study at this hospital and not in another one? Or it was for convenience (they work there)? Please clarify. Methods : how was validated the semi-structured questionnaire developed through literature review? Please clarify. Was there any intention to have adequate sampling of participants in different years? It is surprising that there were only 5 and 9 students from years 3 & 4, respectively. Maybe it could be more interesting to have medical students, interns and medical doctors (assuming that residents already are graduated from medical school) as three categories. 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). There are some minor inconsistencies regarding the number of participants: in methods they say “110 students, 110 doctors/interns/post-graduates”; in results section, there are 115 students and 97 participants in the other categories. Likewise, they say “out of the 212 people…”, but “Responses to the Attitudes Toward Euthanasia (ATE) Scale showed distinct patterns across the 208 participants”. I assume that there are missing responses, but that should be clear. Table 1 shows the distribution of participants opinions regarding euthanasia. However, if they asked questions to be answered with “aware”, “not aware”, it is very difficult to verify that knowledge. For example: “Legalities concerning the practice of euthanasia in India”, they could answer “fully aware”, but their actual knowledge be wrong. Please clarify. With respect to Table 4, it is rather confusing the way data is presented. I am particularly concerned with the analysis done when there are so few cases (for example, only 5 students in 3 rd year). Please review with an expert if the way you are presenting the data is correct. For example, in table 4, 65% of female participants (84 out of 128) and 66% of males (56 out of 84) favor euthanasia; in other words, there is no gender difference. But the authors calculated the % in the other way. 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. Conclusion: Data presented in the study do not support that there is “a growing acceptance” of euthanasia in India. Results should not be generalized to a whole country. References: if possible, please include more updated studies. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. 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. reply Respond to this report Responses (0) Salas S. Peer Review Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r438853) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-438853 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Iddrisu M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Dec 2025 | for Version 3 Merri Iddrisu , University of Ghana, Accra, Ghana 0 Views copyright © 2025 Iddrisu M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 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 Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. 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. reply Respond to this report Responses (0) Iddrisu M. Peer Review Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r430565) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-430565 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Winters J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 24 Dec 2025 | for Version 3 Janine Penfield Winters , University of Otago, Dunedin, New Zealand 0 Views copyright © 2025 Winters J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. 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. reply Respond to this report Responses (0) Winters JP. Peer Review Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r430867) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-430867 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Espericueta L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 12 Nov 2025 | for Version 3 Luis Espericueta , Universidad de Granada, Granada, Spain 0 Views copyright © 2025 Espericueta L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? No Competing Interests No competing interests were disclosed. 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. reply Respond to this report Responses (0) Espericueta L. Peer Review Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.187552.r428352) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1009/v3#referee-response-428352 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Demedts D. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 18 Aug 2025 | for Version 2 Dennis Demedts , Vrije Universiteit Brussel, Brussels, Brussels, Belgium 0 Views copyright © 2025 Demedts D. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 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 Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? No References 1. Demedts D, Magerman J, Goossens E, Tricas-Sauras S, et al.: Using simulation to teach nursing students how to deal with a euthanasia request. PLOS ONE . 2024; 19 (3). Publisher Full Text 2. Demedts D, Fobelets M, Tricas-Sauras S, Bilsen J: 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 . Publisher Full Text 3. Radulović D: Euthanasia – A Legal or Medical Issue: A Narrative Review. Iranian Journal of Public Health . 2025. Publisher Full Text 4. 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. 5. Grove G, Lovell M, Hughes I, Maehler E, et al.: Voluntary-assisted dying, euthanasia and physician-assisted suicide: global perspectives—systematic review. BMJ Supportive & Palliative Care . 2025; 15 (4): 423-435 Publisher Full Text Competing Interests No competing interests were disclosed. 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. reply Respond to this report Responses (1) Author Response 11 Sep 2025 Ajay Mallya, Community Medicine, Kasturba Medical College, Mangalore, 575001, India 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 View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Demedts D. Peer Review Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.184704.r404173) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1009/v2#referee-response-404173 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Buterin T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 19 Feb 2025 | for Version 1 Toni Buterin , University of Rijeka, Rijeka, Croatia; University of Rijeka Faculty of Health Studies (Ringgold ID: 611977), Rijeka, Primorje-Gorski Kotar County, Croatia 0 Views copyright © 2025 Buterin T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? 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 Are the conclusions drawn adequately supported by the results? No Competing Interests No competing interests were disclosed. 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. reply Respond to this report Responses (1) Author Response 09 Aug 2025 Ajay Mallya, Community Medicine, Kasturba Medical College, Mangalore, 575001, India Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Buterin T. Peer Review Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.168923.r363347) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1009/v1#referee-response-363347 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Picón Jaimes Y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Jan 2025 | for Version 1 Yelson Alejandro Picón Jaimes , Univ Ramon Llul, Barcelona, Spain 0 Views copyright © 2025 Picón Jaimes Y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 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 Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? No 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 Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. 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. reply Respond to this report Responses (1) Author Response 09 Aug 2025 Ajay Mallya, Community Medicine, Kasturba Medical College, Mangalore, 575001, India Dear Reviewer Thank you for your insightful feedback. We’ve revised the manuscript to address your comments, improving clarity. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Picón Jaimes YA. Peer Review Report For: Perceptions and attitudes of medical students and physicians on Euthanasia [version 3; peer review: 2 approved with reservations, 5 not approved] . F1000Research 2025, 13 :1009 ( https://doi.org/10.5256/f1000research.168923.r360955) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1009/v1#referee-response-360955 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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