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Original Article 

Volume 13     Number 22     December 2020 
Copyright © 2020 Tehran University of Medical Sciences. 
This work is licensed under a Creative Commons Attribution-NonCommercial 
4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/).  
Non-commercial uses of the work are permitted, provided the original work is 
properly cited. 

Euthanasia and physician-assisted suicide: a systematic review of 

medical students’ attitudes in the last 10 years 

*Corresponding Author 
  
Javier Gutierrez-Castillo 

Av. Ignacio Morones Prieto, 3000 Col. 

Los Doctores. CP 64710 Monterrey, 

Nuevo León, México. 

Tel: (+52) 81 27 31 63 87 

Email: javilegtz@gmail.com 

 

Received: 25 Dec 2019 

Accepted: 1 Nov 2020 

Published: 12 Dec 2020 

 

Citation to this article:  

Gutierrez-Castillo A, Gutierrez-Castillo J, 

Guadarrama-Conzuelo F, Jimenez-Ruiz 

A, Ruiz-Sandoval JL. Euthanasia and 

physician-assisted suicide: a systematic 

review of medical students’ attitudes in 

the last 10 years. J Med Ethics Hist Med. 

2020; 13: 22. 

Alejandro Gutierrez-Castillo1, Javier Gutierrez-Castillo1*, Francisco Guadarrama-Conzuelo1, Amado 
Jimenez-Ruiz2, Jose Luis Ruiz-Sandoval 3 
 

1.Researcher, School of Medicine, Monterrey Institute of Technology and Higher Education, Nuevo León México, 
Mexico. 
2.Neurology Resident, Department of Neurology, National Institute of Medical Science and Nutrition Salvador Zubirán, 
Ciudad de México, México. 
3.Professor, Department of Neurology, Civil Hospital of Guadalajara “Fray Antonio Alcalde”, Jalisco, México. 

  

Abstract  

 This study aimed at examining the approval rate of the 
medical students’ regarding active euthanasia, passive 

euthanasia, and physician-assisted-suicide over the last ten 

years. To do so, the arguments and variables affecting 

students’ choices were examined and a systematic review was 

conducted, using PubMed and Web of Science databases, 

including articles from January 2009 to December 2018. 

From 135 identified articles, 13 met the inclusion criteria. The 

highest acceptance rates for euthanasia and physician-assisted 

suicide were from European countries. The most common 

arguments supporting euthanasia and physician-assisted 

suicide were the followings: (i) patient’s autonomy (n = 6), 

(ii) relief of suffering (n = 4), and (ii) the thought that 

terminally-ill patients are additional burden (n = 2). The most 

common arguments against euthanasia were as follows: (i) 

religious and personal beliefs (n = 4), (ii) the “slippery slope” 

argument and the risk of abuse (n = 4), and (iii) the 

physician’s role in preserving life (n = 2). Religion (n = 7), 

religiosity (n = 5), and the attributes of the medical school of 

origin (n = 3) were the most significant variables to influence 

the students’ attitude. However, age, previous academic 

experience, family income, and place of residence had no 

significant impact. 

Medical students' opinions on euthanasia and physician-

assisted suicide should be appropriately addressed and 

evaluated because their moral compass, under the influence of 

such opinions, will guide them in solving future ethical and 

therapeutic dilemmas in the medical field.  

Keywords: Euthanasia; Medical students; Medical ethics; 
Physician-assisted Suicide; Religion. 

  



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Volume 13     Number 22     December 2020 

 

  Introduction 

Death by itself is not part of an ethical 

dilemma, as all lives are bound to end since   

the moment of conception, and human 

beings confront death through their personal 

beliefs, religion, and cultural context. 

Regardless of the natural and unavoidable 

causes of death, debate over death focuses 

on how to control it as well as on who and 

how should perform the death-related 

practices in medical field. The important 

role of physicians in this debate is that they 

are often both the judge and the executor of 

such practices (1). Several physicians 

believe that the idea of promoting death is 

against Hippocratic Oath and their primary 

role as healer, while others may reject the 

idea based on their moral or religious values 

(1).  

The issues on control over death can be 

divided into two broad categories: 

euthanasia and physician-assisted suicide 

(PAS). Euthanasia is further divided into 

active euthanasia (AE) or passive euthanasia 

(PE), according to the role that the physician 

plays in the process. The term PE is no 

longer used in some countries, and the term 

Therapy Withdrawal (TW) is replaced as the 

physician’s role is limited to suspending 

treatment or stopping additional measures 

that artificially prolong life. In TW, the 

physician acts as a mere observer while the 

disease advances and ends the patient’s life. 

However, in AE, the physician operatively 

engages in ending patient's life by 

administering a toxic substance that 

accelerates death (2). In PAS, the physician 

intentionally helps the patient to commit 

suicide by providing drugs for their self-

administration at the patient’s competent and 

voluntary request (3). The differences 

among aforementioned approaches have 

implications that surpass their moral 

approval, as the medical actions involved in 

these approaches are regulated by law. 

According to the American Medical 

Association (AMA), AE and PAS are in 

conflict with physicians’ healing role. 

Furthermore, their management are quite 

challenging, if not completely impossible, 

and they entail grave risks to the society (4). 

However, PE, described as withdrawal or 

withholding life-sustaining treatment, is 

ethically acceptable for a patient capable of 

decision-making, and if an intervention is 

not expected to achieve the patients’ goals 

for care or desired quality of life (4).  

The contributions of this study are as 

follows: (i) quantitative assessment of 

medical students’ approval rate for AE, PE 

and PAS over the last ten years, (ii) analysis 

of the most common arguments validating 

such practices, and (iii) evaluation of the 

variables that can influence a personal 

position on the topic. This study aimed at 

answering the following questions: What is 

the percentage of euthanasia or PAE 

approval among medical students? What are 

the most common arguments associated with 

the approval or rejection of euthanasia or 

PAE? What are the variables affecting the 

approval or rejection of euthanasia and 

PAE?  

 



Gutierrez-Castillo A., et al. 

 

 

 

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Volume 13     Number 22     December 2020 

Method 

This study was conducted following the 

Preferred Reporting Items for Systematic 

Reviews and Meta-Analyses (PRISMA) (5) 

(Figure 1).  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1- PRISMA flowchart 

The literature searches in April 2019, 

included articles published between January 

2009 and December 2018, and focused on 

PubMed and Web of Science as the primary 

electronic databases. The databases were 

searched using the following search strings: 

S
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 Records identified through 
searching databases: 

PubMed (n= 63) 
Web of Science (n = 72) 

Records after removal of    
the duplicates  

(n = 97) 

Records screened (n 
= 97) 

Records excluded (n = 
72) 

Full-text articles 
assessed for eligibility  

(n = 25) 

Full-text articles 
excluded, with reasons 

*Language (n=2) 
*Unavailable online (n=3) 
*Wrong population (n=3) 

*Does not address 

focused question (n=4) 

Studies included in 
qualitative synthesis  

(n = 13) 

https://pubmed.ncbi.nlm.nih.gov/
https://pubmed.ncbi.nlm.nih.gov/
https://pubmed.ncbi.nlm.nih.gov/


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Volume 13     Number 22     December 2020 

(medical students) AND (euthanasia OR 

Physician-assisted suicide).  

Our review focused on original cross-

sectional descriptive studies in English 

whose main population, or part of it, was 

composed of medical students and 

quantified their personal views regarding the 

legalization or practice of PAS or 

euthanasia. 

Only original descriptive articles that 

quantitatively addressed the first focused 

question in the last ten years were included. 

The excluded cases were the followings: (i) 

Review articles, book chapters, conference 

papers, and letters to the editor; (ii) Non-

neutral reports, where the authors expressed 

their views or stated an opinion on the topic; 

(iii) Articles whose main population 

consisted of physicians, nurses, or any group 

other than undergraduate medical students; 

(iv) Articles for which the complete text 

could not be found online; and, (v) Articles 

written in languages other than English.  

Records were initially screened according to 

the titles and abstracts. Relevant abstracts 

and articles without an abstract were 

selected for full-text review. Articles 

selected in the first screening were carefully 

read and analyzed to determine whether they 

addressed the first focused question and 

whether they fulfilled the inclusion criteria. 

Further analyses were made to determine if 

they described any argument or variable that 

could persuade medical students to take a 

positive or negative side. 

 

Results 

A total of 135 articles were identified after 

the database search (63 in PubMed and 72 in 

Web of Science); 97 non-duplicate 

documents were screened by the title and 

abstract. From the 25 articles eligible for 

full-text review, 13 fulfilled the inclusion 

criteria and were selected for further analysis 

(6-18). Reasons for exclusion of 12 

remaining articles were as follows: (i) use of 

a language other than English (n = 2); (ii) 

absence of a full-text version online (n = 3); 

(iii) inclusion of a study population different 

than undergraduate medical students (n =3); 

and, (iv) failure to address the first focused 

question (n = 4). 

From the 13 selected articles, seven (6-12) 

were published between 2014 and 2018 and 

six (13-18) were published between 2009 

and 2013. Two studies were from Africa (7, 

9), four were from America (6, 8, 12, 14), 

one was from Asia (15), and six were from 

Europe (10, 11, 13, 16-18). The countries 

involved included Austria (n = 1) (18), 

Belgium (n = 1) (11), Brazil (n = 1) (12), 

Canada (n = 1) (14), Germany (n = 1) (10), 

Greece (n = 1) (18), Mexico (n = 2) (6, 14), 

Pakistan (n = 1) (15), Poland (n = 2) (13, 

16), and South Africa (n = 2) (7, 9).  

Eight articles addressed the approval rate of 

medical students regarding legalization of 

AE, PE or PAS (7-9, 11, 13, 15-17); ten 

stated a positive attitude toward AE 

exclusively (6-12, 15, 17,18); six addressed 

acceptance of PE (6, 9,10, 12, 14, 18); and, 

six addressed acceptance of PAS (7, 8, 10, 



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Volume 13     Number 22     December 2020 

14, 15, 18). Two articles addressed the 

students’ personal views on AE, PE or PAS, 

whether exclusively or conjunctively (13, 

16). The results are summarized in Table 1. 
 

Table 1- Percentage of approval for AE, PE, and PAS, as well as the legalization of euthanasia or 

PAS. 

  Percentage of approval 

Article Country N 

Legalization 

of euthanasia 

or PAS 

Active 

Euthanasia 

(AE) 

Passive 

Euthanasia 

(PE) 

Physician-

assisted 

suicide (PAS) 

Gutierrez and 

Gutierrez, 2018 (6) 
Mexico 1319 - 

44.4% 

(n=586) 

52.1% 

(n=687) 
- 

Jacobs and 

Hendricks, 2018 (7) 

South 

Africa 
277 

52.7% 

(n=146) 

41.9% 

(n=116) 
- 

35% 

(n=97) 

Bator et al, 2017 (8) Canada 405 
88% 

(n=354) 

38% 

(n=153) 
- 61% (n=246) 

Marais et al, 2017 (9) 
South 

Africa 
481 

44.6% 

(n=300) 

36.2% 

(n=243) 

67.3% 

(n=452) 
- 

Anneser et al, 2016 

(10) 
Germany 241 - 

19.2% 

(n=46) 

83.3% 

(n=200) 
51.2% (n=123) 

Roelands et al, 2015 

(11) 
Belgium 151 

97.4% 

(n=147) 

31.8% 

(n=48) 
- - 

Lucchetti et al, 2014 

(12) 
Brazil 3630 - 

41.4% 

(n=1503) 

45.7% 

(n=1659) 
- 

Leppert et al, 2013 

(13) 
Poland 401 

26% 

(n=104) 

12%* 

(n=48) 

Loria et al, 2013 (14) Mexico 99 - - 
61% 

(n=60) 

52% 

(n=51) 

Hassan et al, 2013 

(15) 
Pakistan 493 

27.2% 

(n=134) 

14.2% 

(n=70) 
- 

32.8% 

(n=162) 

Leppert et al, 2013 

(16) 
Poland 588 

29.59% 

(n=174) 

11.73%* 

(n=69) 

Stronegger et al, 

2011 (17) 
Austria 694 

30.8% 

(n=214) 

25.5%† 

(n=122) 
- - 

Kontaxakis et al, 

2009 (18) 
Greece 251 - 

52% 

(n=130) 

79.2% 

(n=199) 

69.7% 

(n=175) 

* The authors grouped the approval for either AE and PE, or PAS. 
† 

This question was addressed in a 

population of 478 students. 

 

Out of eight articles that addressed the 

positive views on legalization of the 

procedures, the lowest acceptance rate was 

26% (13) and the highest 97% (11). The 

lowest and highest acceptance rates were as 

follows: (i) 14.2% (15) and 52% (18) for 

AE, (ii) 45.7% (12) and 83.3% (10) for PE, 

and (iii) 32.8% (15) and 69.7% (18) for 



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Volume 13     Number 22     December 2020 

PAS. The highest acceptance rates in the 

four scenarios were observed among 

students in European countries (10-12, 15), 

while the lowest acceptance rates were 

related to Pakistan (15) and Brazil (12). 

Eight articles (6-8, 11, 15-18) were related 

to second main question addressing 

students’ arguments for or against the 

practice of AE, PE or PAS. The most 

common arguments supporting AE, PE or 

PAS practice were as follows: (i) patients’ 

autonomy (n = 6) (6 - 8, 11, 16, 17); (ii) 

relief of suffering or beneficence (n = 4) (7, 

11, 16, 17); and, (iii) the thought that 

terminally-ill patients are additional burden 

(n = 2) (11, 18). Less relevant arguments 

included the followings: (i) legality of the 

procedure (6); (ii) educational or clinical 

experience (8); and, (iii) quality of life or 

life expectancy (18). The most common 

arguments against AE, PE or PAS were the 

followings: (i) religious or personal beliefs 

(n = 4) (7, 8, 15, 18); and, (ii) “slippery 

slope” argument or risk of abuse (n = 4) (7, 

8, 16, 18); and, (iii) physicians’ 

responsibility to preserve life (7, 18).  The 

results are summarized in Table 2. 

 

Table 2- Students’ arguments in favor or against the practice of euthanasia or PAS 

Article Country 
Students’ arguments in favor 

of euthanasia or PAS 

Students’ arguments against 

euthanasia or PAS 

Gutierrez and 

Gutierrez, 2018 (6) 
Mexico 

Legality of the procedure 

Patient’s autonomy 
- 

Jacobs and Hendricks, 

2018 (7) 

South 

Africa 

Patient’s autonomy 

Relief of suffering 

Religion or personal beliefs 

Physicians’ role in preserving life 

“Slippery slope”/Lead to abuse 

Bator et al., 2017 (8) Canada 
Educational/clinical experience 

Patient’s autonomy 

Religion or personal beliefs 

Teachings 

“Slippery slope”/Lead to abuse 

Roelands et al., 2015 

(11) 
Belgium 

Patient’s autonomy 

Relief of suffering 

The patient is a burden 

- 

Leppert et al., 2013 

(13) 
Poland 

Patient’s autonomy 

Relief of suffering 
“Slippery slope”/Lead to abuse 

Hassan et al., 2013 

(15) 
Pakistan - Religion or personal beliefs 

Stronegger et al., 2011 

(17) 
Austria 

Patient’s autonomy 

Beneficence 
- 

Kontaxakis et al., 2009 

(18) 
Greece 

Quality of life 

Length of expected life 

Financial burden 

Physician’s role of preserving life 

“Slippery slope”/Lead to abuse 

Religion or personal beliefs 

 

Regarding the third focused question, 11 

articles (6-9, 11, 12, 14-18) highlighted 

variables that could cause the medical 

students to approve or disapprove AE, PE or 

PAS practices. Religion was the most 

significant variable that had a negative 



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Volume 13     Number 22     December 2020 

impact (n = 7) (6 - 8, 11, 12, 14, 16), 

followed by religiosity (n = 5) (6, 12, 

14,15,18) as the second most significant 

variable. Moreover, university of origin for 

the medical students (n = 3) (12, 14, 16) and 

previous experience with euthanasia or 

palliative sedation in a relative (n = 1) (11) 

were other named variables. Non-significant 

variables included the followings: (i) age (n 

= 3) (6, 12, 17); (ii) previous academic 

experience regarding end-of-life decisions (n 

= 2) (11, 16); (iii) family income (n = 1) 

(12); and, (iv) size or place of residence (n = 

1) (16). Variable of gender in influencing the 

students’ opinions showed mixed results: 

significant (6, 16) and non-significant (11, 

12, 14, 17, 18). Similarly, for variable of 

medical students’ current academic year, 

three studies considered it to be significant 

(9, 15, 17) and one study reported it as 

irrelevant (6). The summarized results are 

shown in Table 3. 
 

 

 

 

Table 3- Significant variables that affect the posture of medical students towards euthanasia or 

PAS 

Article Country Significant variables Nonsignificant variables 

Gutierrez and Gutierrez, 

2018 (6) 
Mexico 

Religion (affiliation), 

Religiosity, Gender 
Age, Level (Preclinical) 

Jacobs and Hendricks, 

2018 (7) 

South 

Africa 
Religion (affiliation) - 

Bator et al., 2017 (8) Canada Religion (affiliation)  

Marais et al, 2017(9) 
South 

Africa 
Level (Clinical/Preclinical)  

Roelands et al., 2015 

(11) 
Belgium 

Religion (affiliation) 

Previous experience with 

euthanasia/ palliative sedation  in a 

relative 

Gender, Duration of 

education and having had a 

course about end-of-life 

decisions 

Lucchetti et al., 2014 

(12) 
Brazil 

Religion (affiliation), Religiosity, 

University characteristics 
Age, gender, family income 

Loria et al., 2013 (14) Mexico 
University characteristics, Religion 

(affiliation), Religiosity 
Gender 

Hassan et al., 2013 (15) Pakistan Religiosity, Level - 

Leppert et al., 2013 (16) Poland 
Gender, Religion (affiliation), 

University characteristics 

Size/Place of residence, 

palliative care classes 

Stronegger et al., 2011 

(17) 
Austria Level Gender, age 

Kontaxakis et al., 2009 

(18) 
Greece Religiosity Gender 

 

 

 

 



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Volume 13     Number 22     December 2020 

Discussion 

Despite the great diversity of opinions 

regarding AE, PE and PAS, the percentage 

of approval for AE was lower than those of 

PE or PAS in all analyzed scenarios (6-18). 

Regarding AE approval, the study of 

Kontaxakis et al. was the only one that 

reported an acceptance percentage higher 

than 50%, under special circumstances (18). 

If these results are compared to those of 

other groups, such as general population 

(19) or post-graduate students (11), the 

approval rate is usually higher than 50%. In 

contrast, physicians tend to show a negative 

attitude toward the topic (19, 20). The 

relevance of clinical experience, as a 

variable that could influence the acceptance 

of euthanasia or PAS, was discussed by 

Marais et al. (9) and Hassan et al. (15), who 

reported different results depending on 

whether the students were at preclinical level 

(without active experience with patients) or 

on clinical rotations. Marais et al. stated that 

higher clinical-level correlated to medical 

students’ greater empathy towards patients 

and respect for their autonomy. This 

correlation was demonstrated by a 20% 

difference in acceptance rate for AE between 

preclinical and clinical students, which 

dropped to 10% when they were asked if 

they will perform an assisted-dying 

procedure (9). Hassan et al. found lower 

acceptance rate for euthanasia or PAS 

among senior medical students; the attitude 

toward euthanasia, however, split to 50% 

against and 50% undecided, highlighting a 

higher percentage of indecision among 

seniors than freshmen (15). Seniors stated 

that through clinical exposure, medical 

students become more aware that some 

diseases are incurable (15). However, a 2018 

study by the authors of article (6) did not 

identify academic rank as a variable that 

could influence medical students’ attitude 

toward this topic.  That study focused only 

on preclinical students in the first three years 

of medical school, justifying the uniformity 

of opinions and highlighting that exposure to 

patients affected medical students’ views 

regardless of their academic school year.  

Until now, AE has been legalized in 

Belgium (11), the Netherlands (19), 

Luxemburg (19), Colombia (21), Uruguay 

(21), and Canada (8); Three countries where 

AE is legal are European (11, 19), which 

justify that why the majority of the papers 

that met the present study’s inclusion criteria 

were published in this continent where the 

debate is open. In Belgium, the only country 

included in this study where AE is currently 

legalized, Roelans et al. reported that the 

approval percentage of the legalization of 

euthanasia to be 97% (11); a real legal 

environment, along with personal or 

professional experience in scenarios of 

assisted death, can create more favorable 

attitude among medical students (11). In 

Canada, another country where these 

practices are legalized, the study by Bator et 

al. was performed a year before the 

Canadian laws’ modification to abolish the 

penalization of euthanasia (8). These 

political discussions may affect medical 

students’ attitude toward acceptance. 

Religion is defined as a moral institution 

with a unified system of values, beliefs and 

practices related to what is considered sacred 

(22-23). Religion is one of the most common 



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Volume 13     Number 22     December 2020 

variables mentioned by researchers to 

influence medical students’ views on 

euthanasia (6-8, 11, 12, 14-16, 18). 

Moreover, religion affects several other 

areas of medicine, such as adherence to 

treatment or the decision-making process in 

high-risk procedures (22). In seven studies 

that described religion as a relevant variable, 

five found Catholicism to be the most 

frequently self-reported religion (6, 11, 12, 

14, 16), and less frequently ones were 

Christianity (7) and Islam (15). Conversely, 

the medical students who considered 

themselves atheists or those who did not 

actively practice any religion tended to have 

a more positive view towards AE, PE, and 

PAS for both patients and themselves (8, 11, 

12, 14-16, 18). Different, sometimes 

conflicting views can be observed among 

various religions. In 2007, Sprung et al. 

studied the attitude of physicians towards 

PE; Catholics, Protestants and those with no 

religious affiliation compared to Jews, Greek 

Orthodoxies or Muslims had higher 

acceptance rate for therapy withdrawal (23). 

According to the Roman Catholic religion, 

practitioners are not obligated to ward off 

death at all costs, but they should not 

deliberately intervene to accelerate this 

process (24). The principle of “sanctity of 

life” categorizes life as a basic value as it 

establishes a direct relationship with God, 

and condemns any intervention that seeks to 

end this relationship (24). This principle 

could explain a more negative attitude 

toward AE and a mildly open posture toward 

PE. Studies that described a majority of the 

Catholic population and addressed the 

attitude of PE had acceptance rate higher 

than 50%, except one study from Poland 

(16). Leppert et al. did not separate the 

opinions in favor of or against AE, PE, or 

PAS, and considered that the students’ view 

could be influenced by the statements of the 

last Polish Pope, John Paul II (16). 

Regarding Islam, negative attitude is 

generally stated toward the topic (7, 15, 23). 

The Quran forbids self-harm and consenting 

to end life, which can be related to 

terminally-ill patients consenting to 

euthanasia (25). In Islam, death is not the 

final destination, and therefore a believer 

should keep facing difficulties despite 

suffering to stay alive (25). However, the 

concept of religion has to be differentiated 

from religiosity or religiousness, referring to 

the influence of religion on daily life and 

intrinsic values. A positive experience with 

religion, mainly described as a growing 

spirituality or closeness to God, empowers 

patients to undertake greater risks in their 

treatments (22). Regarding euthanasia, the 

greater the religiosity, the more opposition 

towards euthanasia (6, 15). This association 

is in line with our previous study’s findings, 

where the participants who were described 

as strong believers showed a predominant 

negative view towards AE and PAS as well 

as inflexibility to change their original 

position in different scenarios (6). Similarly, 

Hassan et al. reported the lowest acceptance 

rate for AE, in a study involving 

predominately Muslim participants, which 

17% of them identified themselves as very 

religious (15).  



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Volume 13     Number 22     December 2020 

The main arguments on euthanasia are 

related to the bioethical principles. 

Autonomy, the most common argument 

stated by the medical students to support this 

practice (6-8, 11, 16, 17), derives from the 

Greek auto (self) and nomos (rule) and 

refers to the individuals’ ability to make 

independent choices about their treatment 

(7). However, the state of autonomy in 

relation to euthanasia varies depending on 

whether autonomy is considered an intrinsic 

or moral value. In the former, patients would 

have free will in decision-making about their 

life or death (26), and in the latter —

according to the Kantian perspective—death 

threatens autonomy by eliminating the 

individual who would otherwise exercise 

autonomy (27). Another argument to support 

euthanasia is relief from suffering, based on 

the principle of beneficence, as it considers 

the induction of death as a better alternative 

to avoid unnecessary suffering (28). The 

opponents of euthanasia argue that the 

elimination of suffering by death may not be 

the best alternative considering the 

followings: (i) increasing interest and 

research on palliative care and (ii) 

management of patients’ psychiatric 

conditions (e.g., depression), which may 

adequately relieve their suffering (28, 29). 

The most common arguments against these 

practices were as follows: (i) personal and 

religious beliefs (7, 8, 15, 18); (ii) risk of 

abuse, sometimes referred to as the “slippery 

slope” argument (7, 8, 16, 18); and, (iii) the 

physicians’ role in preserving life (7, 18). 

According to the argument of the “slippery 

slope”, if specific types of actions receive 

permission, then society will be coerced in 

permitting further morally wrong actions 

(30, 31). As a classic example of this 

argument, in the Netherlands, where initially 

euthanasia was only approved for 

terminally-patients, the criteria were later 

expanded to allow euthanasia for 

chronically-ill patients and those suffering 

from severe psychiatric conditions. 

Subsequently, euthanasia was legally 

allowed for incompetent patients, including 

children (31). Opponents of the “slippery 

slope” argument state that for euthanasia to 

be considered as part of the risk of abuse 

argument, it must initially be condemned as 

morally wrong, an argument that in their 

opinion is dependent merely on personal 

experience (31). The final argument against 

euthanasia is the Hippocratic Oath’s view of 

the physicians’ role as healers. The 

Hippocratic Oath was first proclaimed in 

400 BC and established one of the earliest 

codes of ethics for the medical profession 

(32). Because of its tradition and relevance, 

it is still frequently taken by medical 

students during their training or upon its 

completion. One of its lines states that 

physicians will not give poison to anyone 

though asked to do so, nor they would 

suggest such a plan (6), a line that 

contradicts modern-day views of euthanasia. 

This presumptive allegiance to the 

Hippocratic Oath may explain why students 

from newer, urban, public, and bigger 

universities usually have a more positive 

attitude towards euthanasia and PAS than 

students from older schools with more 

traditional values (12, 14, 16).  

The relevance of understanding the medical 

students’ attitudes towards euthanasia and 



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Volume 13     Number 22     December 2020 

PAS lies not only in their values as present-

time insights, but also as input data to 

generate strategies that optimize their 

education and address future medical 

dilemmas. Even though medical students 

usually have sufficient knowledge about 

euthanasia (15), they lack understanding of 

end-of-life care. Eyigör stated that most 

medical students believe that they have not 

received a complete education on palliative 

care or training on communication skills 

regarding palliative-care patients (33). A 

better understanding of end-of-life care, 

including euthanasia and PAS, for medical 

students, is essential, even if these practices 

are not currently legalized in their countries 

as related debates on the topic are not 

expected to end shortly. 

A major limitation of this study was the use 

of non-standardized questionnaires to 

research the main focused questions, as they 

provide varied responses that are difficult to 

categorize and analyze adequately. Even if a 

students’ view on euthanasia or PAS is 

markedly positive or negative, the format of 

the questionnaire may not accurately address 

the real answer. Moreover, questions asked 

directly may obtain different answers than 

those asked indirectly; questions with 

clinical case scenarios or with only binary 

true or false answers could further alter the 

results. Another limitation was the use of 

only two electronic databases, which could 

narrow results. This limitation could also 

limit the number of countries included in the 

study, which may prevent the global 

perspective from being reflected. 

 

Conclusion  

Seeking a global perspective from medical 

students over a particular course and then 

describing that perspective is complex. This 

complexity is not only due to the great 

diversity of opinions, but also due to the 

geographical, social, cultural, and temporal 

context influencing their decisions. This 

study aimed to objectively describe the 

medical students’ attitude towards AE, PE, 

and PAS practices as well as to analyze the 

variables and arguments surrounding these 

practices. To summarize, PE and PAS are 

more accepted than AE, and the most critical 

arguments in favor of these practices are the 

respect for autonomy and the relief of 

suffering. Personal beliefs and the social role 

of the physician as a healer are the most 

common arguments against these practices. 

Even though a consensus may not be 

reached easily or soon, continuing the 

discussion about end-of-life decisions is 

essential because the debates over these 

practices and the necessity for such 

decisions will unavoidably linger.  Medical 

students must be aware of different 

perspectives on the topic to make an 

informed decision in related circumstances.  

 

Conflict of Interests   

The authors declare that they have no 

conflict of interests. 

  



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Volume 13     Number 22     December 2020 

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