Knowledge, attitude, and acceptance of euthanasia among medical students and doctors in Pakistan

Abstract

Globally, euthanasia is a strongly debated and ethically complex issue, with views shaped by cultural, religious, and moral precepts. In conservative cultures like Pakistan, euthanasia discussions are sensitive and occasionally ignored. This study aims to evaluate medical professionals’ and students’ knowledge, attitudes, and acceptance of euthanasia in Pakistan. From May 16 to June 16, 2025, a cross-sectional survey was conducted involving 10 Pakistani medical institutions. The study utilized convenience sampling to select MBBS first- and final-year students and practicing doctors with a minimum of 1 year of clinical experience. Outcomes were assessed using a modified Attitudes Toward Euthanasia scale and structured knowledge items to evaluate knowledge of euthanasia, attitudes toward it, and the acceptability of its legalization. Descriptive statistics summarized participant characteristics, while one-way analysis of variance and independent-samples t tests were used to assess differences in mean attitude ratings across demographic categories. Chi-square tests analyzed relationships between categorical factors and euthanasia approval, and Spearman rank correlation examined connections between attitude ratings and continuous variables such as age and clinical experience. Statistical significance was set at P < .05. A study involving 506 participants, including first-year and final-year medical students and practicing physicians, found that only 40.1% favored euthanasia. Knowledge and attitude scores averaged 66.4 ± 10.8 and 8.7 ± 2.1, respectively, with a positive correlation between them (ρ = 0.44, P < .01). Practicing physicians showed significantly higher acceptance than students, particularly those with lower religiosity (P < .05). Acceptance of euthanasia is related significantly to religion and religiosity, with non-Muslims and less religious participants more likely to accept it. Gender, occupation, religion, province, and religiosity were independent predictors of attitude scores, while religion and religiosity were the strongest predictors of approval in logistic regression. Pakistani medical students and doctors possess limited knowledge and varied attitudes toward euthanasia, significantly influenced by professional experience, level of training, and religious beliefs. Misconceptions about the legal and ethical aspects emphasize the need for integrating structured bioethics and end-of-life care education in medical training. Targeted educational initiatives can enhance ethically informed decision-making among healthcare professionals.

1. Introduction

Euthanasia, derived from the Greek words “Eu” (good) and “Thanatos” (death), literally means “good death.” It refers to a deliberate act by a physician to administer medications with the clear intention of ending a patient’s life.^[1] One of its forms is assisted suicide, which occurs when someone provides an individual with the information, guidance, and means to end their own life, with the expectation that these will be used for that purpose. When the assisting individual is a physician, the act is referred to as physician-assisted suicide (PAS).^[2]

In the United States, support for euthanasia peaked in 2005, when nearly three-quarters of those surveyed expressed approval. However, this upward trend has since plateaued. While assisted suicide and euthanasia remain illegal in most countries, they are permitted in certain regions such as Oregon (United States), Switzerland, and the Netherlands.^[3] Although euthanasia was briefly legalized in Australia’s Northern Territory, the law was subsequently overturned by the federal government. In contrast, the Netherlands has witnessed growing medical and societal acceptance of the practice, with physicians required to follow stringent ethical and clinical guidelines.^[4–6]

These regulations require rigorous documentation and ethical oversight. For instance, Dutch law mandates evidence of intolerable suffering and the absence of alternative treatments. Increasingly, existential suffering rather than solely medical suffering is being recognized as a legitimate reason for euthanasia, though this remains ethically controversial.^[7]

Neurological disorders such as dementia, motor neuron disease, and multiple sclerosis are among the most common reasons for euthanasia requests after cancer in jurisdictions where the practice is legal.^[8] Such requests raise complex ethical and legal issues, particularly when cognitive decline affects patient autonomy. Despite growing public acceptance of euthanasia, healthcare professionals often hold more conservative views due to medical, religious, and cultural concerns.^[9] The debate on euthanasia often parallels that of abortion, as both involve ethical considerations about life, death, and autonomy. In Pakistan, abortion may be conditionally accepted under medical or religious grounds, while euthanasia remains strictly prohibited. Comparing these perspectives helps illustrate whether certain forms of “assisted death” are viewed as more acceptable and how religious and cultural frameworks influence these moral distinctions.

This study explores the views of medical students and practicing physicians regarding assisted suicide and euthanasia, using the Attitudes Toward Euthanasia (ATE) scale, with modifications based on previous studies.^[10–13] The ATE is a validated instrument used internationally to assess healthcare professionals’ moral and ethical perspectives on these practices. Attitudes toward euthanasia may be influenced by several factors, including religion, spirituality, clinical experience, and stage of medical education.^[14] In Pakistan, where euthanasia and PAS remain legally prohibited and socially contentious, perspectives are strongly shaped by Islamic teachings on the sanctity of life, as well as family-centered approaches to end-of-life decision-making. These religious and sociocultural values contribute to a generally restrictive view of deliberate life-ending practices.^[15,16]

Euthanasia remains a globally debated and ethically complex issue, with its legal and moral status varying considerably between countries. In Pakistan, growing advances in medical care and increasing emphasis on patient autonomy have further stimulated discussion about end-of-life decision-making.^[17,18] Previous studies among Pakistani healthcare professionals and students have reported limited knowledge and mixed attitudes toward euthanasia, but many were constrained by small sample sizes, single-institution designs, or the absence of standardized assessment tools.^[19] The present nationwide study addresses these gaps by using a validated instrument to assess the knowledge, attitudes, and acceptance of euthanasia among medical students and practicing physicians across diverse healthcare settings in Pakistan.

2. Materials and methods

2.1. Study design

This was a questionnaire-based, cross-sectional study conducted to assess the knowledge, attitudes, and acceptance of euthanasia among medical doctors and medical students across Pakistan.

2.2. Duration of study

The study was conducted over 1 month, following approval from the ethical review board, from May 16, 2025, to June 16, 2025.

2.3. Study setting

The study was carried out across 4 provinces, including the capital territory, involving a total of 10 medical schools and affiliated healthcare facilities, representing a diverse range of regions and institutions. Participants were recruited from major institutions across Pakistan, including Ayub Medical College (Abbottabad), Khyber Medical College (Peshawar), King Edward Medical University, Services Institute of Medical Sciences (Lahore), Nishtar Medical College (Multan), Bolan Medical College (Quetta), Dow Medical College (Karachi), Liaquat University of Medical & Health Sciences (Jamshoro), Federal Medical and Dental College (Islamabad), and Faisalabad Medical University (Faisalabad).

2.4. Study population

First-year and final-year MBBS students, as well as practicing doctors with at least a year of clinical experience, were deliberately selected for the study. First-year medical students were included to represent individuals with minimal to no clinical exposure to end-of-life care, whose views are largely shaped by preclinical education and personal beliefs. The selection of final-year medical students was based on their significant clinical exposure, which includes direct patient care and observation of terminal illness while still being in an organized teaching setting. To capture viewpoints developed via consistent, practical exposure to end-of-life decision-making and ethical difficulties in clinical practice, practicing physicians with at least a year of experience were included. This categorization made it possible to compare different phases of medical education and professional practice in a meaningful way, which made it possible to evaluate how growing clinical exposure and professional responsibility affect euthanasia knowledge, attitudes, and acceptance. Participants represented a wide spectrum of geographical areas, religious backgrounds, and medical specialties within Pakistan.

2.5. Selection criteria

Inclusion criteria comprised first- and final-year medical students currently enrolled in MBBS programs and licensed physicians with at least 1 year of clinical experience. Exclusion criteria included individuals unwilling to participate or not providing informed consent, medical students in their 2nd, 3rd, or 4th years, doctors with less than 1 year of experience, those affiliated with nonmedical fields, and individuals studying or practicing outside of Pakistan. The exclusion of mid-year students was intentional to allow a meaningful comparison between those with no clinical exposure (first-years), some exposure (final-years), and significant clinical experience (practicing doctors), thereby better assessing the impact of clinical experience on attitudes toward euthanasia.

2.6. Sampling technique

A convenience sampling approach was employed to recruit participants. Medical students and physicians who were available and willing to participate during the data collection period were approached through institutional networks, professional groups, and social media platforms. Study ambassadors at each participating medical college and hospital distributed the questionnaire both in person and via secure online forms. Participation was entirely voluntary, and respondents were included after providing informed consent. Although convenience sampling was used because probability-based sampling was not feasible, several measures were implemented to reduce sampling bias. Participants were recruited from 10 medical institutions across 4 provinces and the federal capital, including both public-sector medical schools and affiliated teaching hospitals. Recruitment targeted first-year students, final-year students, and practicing physicians through multiple institutional channels, professional groups, and both online and in-person distribution to improve the diversity of the sample. Study ambassadors were instructed to encourage participation from individuals of different regions, ethnic backgrounds, and professional groups rather than relying on a single network or institution. These measures were intended to enhance the representativeness of the study population while acknowledging the inherent limitations of convenience sampling.

2.7. Sample size

The required sample size was calculated to be 385, based on a 95% confidence level and a ±5% margin of error. We assumed maximum variability by setting P value = .5, where P represents the estimated proportion of the population exhibiting the primary outcomes of interest. This conservative estimate maximizes the required sample size, ensuring adequate precision regardless of the true population proportion. The standard formula used included Z = 1.96 for the chosen confidence level and a design effect of 1. This estimate was confirmed using OpenEpi’s “Sample Size for Proportions” module. To accommodate a potential 10% nonresponse rate, more individuals than the minimum required sample were invited to participate in the survey.

2.8. Data collection

Data were collected through a structured online questionnaire created using Google Forms. The instrument was based on the validated ATE Scale with modifications based on expert opinions and relevant studies published in the past. It included 4 main sections: demographics, prior experiences with euthanasia, 21 Likert-scale items measuring attitudes, and opinions regarding the legalization of voluntary euthanasia. Modifications were primarily made to improve contextual relevance and clarity for the Pakistani medical setting and included minor wording adjustments to selected items and the addition of questions addressing participants’ prior experiences with euthanasia and their views on the legalization of voluntary euthanasia. The core 21 Likert-scale items assessing attitudes toward euthanasia were retained.

Each participating site had a designated study ambassador, either an MBBS student or a practicing doctor, responsible for disseminating the survey link via institutional emails and messaging platforms. They also sent out weekly reminders and responded to participant queries to encourage engagement. Importantly, study ambassadors did not have access to the participant database to maintain confidentiality and anonymity. To improve sample diversity and reduce recruitment bias, study ambassadors were encouraged to recruit participants from different academic years, professional groups, institutions, provinces, and ethnic backgrounds. Demographic characteristics were monitored during data collection, and additional recruitment efforts were directed toward underrepresented groups when necessary. Google Forms was configured to require responses to essential questions and prevent duplicate submissions, ensuring data quality.

2.9. Data analysis

Survey responses were exported as a CSV file from Google Forms and imported into Statistical Package for Social Sciences version 22 (IBM) for analysis. In the Variable View, each item was labeled descriptively, and numerical codes were assigned accordingly – such as 1 for male and 2 for female, and 1 to 5 for Likert scale responses.

Descriptive statistics were used to summarize categorical variables (e.g., gender, academic year, student vs doctor status, ethnicity), reported as counts and percentages. The total ATE score was calculated, and its distribution was assessed using the Shapiro–Wilk test for normality. If normally distributed, the mean ± standard deviation was reported; otherwise, the median and interquartile range were provided.

For inferential statistics, independent-samples t tests were used to compare mean ATE scores between 2 groups (e.g., students vs doctors, male vs female), while one-way analysis of variance was applied for comparisons among multiple groups (e.g., by ethnicity or academic level). Chi-square tests were conducted to assess associations between categorical variables. Associations between participant characteristics and acceptance of euthanasia (yes/no) were assessed using chi-square tests of independence. Variables examined included gender, age group, professional position, province, religion, and level of religiosity. Fisher exact test was applied when expected cell counts were <5. In addition, scale reliability of the ATE instrument was evaluated prior to inferential analysis using Cronbach’s alpha to assess internal consistency. For comparisons of mean knowledge and attitude scores across categorical participant characteristics, independent-samples t tests or one-way analysis of variance were applied as appropriate. All statistical tests were two-tailed, with a significance threshold of P < .05. Spearman rank correlation coefficient was used to examine relationships between continuous variables such as ATE scores and age or years of experience. The knowledge score was calculated by summing the number of correct responses to factual questions on euthanasia-related concepts, legal status, and ethical principles. The attitude score was derived from participants’ responses to the questionnaire’s items rated on a 5-point Likert scale, where higher total scores indicated more favorable attitudes toward euthanasia. Prespecified subgroup analyses were carried out in addition to the overall correlation analysis to investigate whether the relationship between knowledge and attitude scores varied by gender and professional group (first-year students, final-year students, and practicing physicians). Because the attitude scale is ordinal and the score distributions are non-normal, Spearman rank-order correlation coefficients were computed independently within each subgroup. Two-tailed tests were used to determine statistical significance; a P value of less than .05 was deemed significant.

Multivariable regression analyses were used to determine factors that influence views about euthanasia and approval of its practice. Since the ATE score is a continuous outcome variable, the independent relationship between ATE scores and participant characteristics (gender, professional status, religion, province, and degree of religiosity) was investigated using multiple linear regression analysis. Based on previous research and theoretical significance, variables were chosen beforehand. In addition, binary logistic regression analysis was utilized to find predictors of euthanasia approval because acceptance of euthanasia was recorded as a binary outcome (yes/no). The likelihood ratio chi-square test, −2 log likelihood, and pseudo R² statistics were used to evaluate the model’s fit (Cox & Snell and Nagelkerke). Adjusted effect estimates were reported with corresponding 95% confidence intervals. Statistical significance was set at P < .05 (two-tailed).

All analyses were conducted using Statistical Package for Social Sciences version 22, with a two-tailed significance level set at α = 0.05. Exact P values and 95% confidence intervals were reported to ensure analytical rigor and transparency.

2.10. Ethical consideration

Ethical approval for this study was obtained from the Institutional Review Board of Ayub Medical College with Ref No. RC-EA-2025/127. Participation was entirely voluntary, and informed consent was obtained from all respondents. Anonymity and confidentiality of participants were strictly maintained, with no identifying information collected. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki.

3. Results

3.1. Sociodemographic characteristics

A total of 506 participants were included in the study. Most respondents (87.0%) were aged 20 to 29 years, followed by 8.3% aged 30 to 39 years. Males comprised 56.9% and females 43.1% of the sample. Regarding professional status, 44.5% were physicians, 32.2% final-year medical students, and 23.3% first-year students. Participants represented diverse provinces, with Punjab contributing the largest proportion (53.4%), followed by Khyber Pakhtunkhwa (27.0%), Sindh (10.1%), Islamabad (7.3%), and Balochistan (1.6%). The majority identified as Muslim (90.9%), while 9.1% were non-Muslim. In terms of religiosity, 32.8% were actively involved in religious institutions, 44.3% occasionally attended religious activities, and 22.9% identified as believers who did not participate in such activities. These demographic characteristics are summarized in Table 1.

Table 1.

Sociodemographic and professional characteristics of doctors and medical students (n = 506) participating in a cross-sectional study on knowledge, attitude, and acceptance of euthanasia in Pakistan, conducted in 2025.

Variable	Category	n (%)
Total participants	–	506 (100)
Age (yr)	20–29	440 (87.0)
	30–39	42 (8.3)
	40–49	19 (3.8)
	50–59	4 (0.8)
	60–69	1 (0.2)
Gender	Male	288 (56.9)
	Female	218 (43.1)
Religion	Muslim	457 (90.3)
	Non-Muslim	49 (9.7)
Degree of religiosity	Actively involved in religious institutions	166 (32.8)
	Occasionally attend religious activities	224 (44.3)
	Believers but not involved in activities	116 (22.9)
Professional position	Physician	225 (44.5)
	Final-year medical student	163 (32.2)
	First-year medical student	118 (23.3)
Province/place of practice	Punjab	271 (53.4)
	Khyber Pakhtunkhwa	137 (27.0)
	Sindh	51 (10.1)
	Islamabad (capital)	37 (7.3)
	Balochistan	8 (1.6)
Professional experience (yr)	<1	57 (25.3)
	1–3	88 (39.1)
	>3	80 (35.6)

3.2. Knowledge regarding euthanasia

Participants demonstrated an overall moderate level of knowledge regarding euthanasia. Most respondents correctly identified euthanasia as the administration of life-ending medication at a patient’s explicit request and as the intentional shortening of the dying process. Approximately two-thirds also considered euthanasia synonymous with PAS. However, substantial uncertainty was observed regarding whether withholding or withdrawing life-sustaining treatment constitutes euthanasia, indicating variation in conceptual understanding. Most participants correctly recognized that euthanasia is not legally permitted in Pakistan. Responses concerning euthanasia as a compassionate act were evenly divided, reflecting differing ethical perspectives, while nearly half of the respondents acknowledged a legal distinction between active and passive euthanasia, with a considerable proportion remaining uncertain. Detailed item-wise responses are presented in Table 2.

Table 2.

Knowledge regarding euthanasia.

Statement	Agree, s	Neutral, %	Disagree, %
1. Euthanasia is administration of lethal drugs to a patient at the explicit request of that patient.	71.8	13.4	14.8
2. Euthanasia is active shortening of the dying process.	77.7	15.2	7.1
3. Euthanasia is physician-assisted suicide.	69.4	16.6	14.1
4. Euthanasia is withholding or withdrawal of treatment.	47	23.7	29.2
5. Euthanasia is legally allowed in Pakistan.	10.7	23.1	66.2
6. Euthanasia is a humane act.	33.6	33.6	32.9
7. There is a difference between active and passive euthanasia according to the laws.	48.4	46.6	5

3.3. Attitudes toward euthanasia

Participants exhibited generally cautious attitudes toward euthanasia. Although nearly half supported permitting euthanasia under specific circumstances, opinions were divided regarding patient autonomy in deciding the timing of death. A majority considered taking a human life unacceptable under all circumstances, reflecting strong moral reservations. While many respondents agreed that terminally ill patients should not be left to suffer, support for the right of terminally ill individuals to choose death and for euthanasia in general remained comparatively low. Most participants favored maintaining the current legal prohibition of euthanasia in Pakistan, although approximately one-third supported legal reform to permit euthanasia under carefully defined conditions. Overall, the findings indicate limited acceptance of euthanasia despite some support for its consideration in exceptional clinical situations. Detailed responses are summarized in Table 3.

Table 3.

Attitude toward euthanasia.

Statement	Agree, %	Neutral, %	Disagree, %
1. A patient has the right to choose to end his/her own life.	40.5	16.6	42.9
2. Euthanasia should be legal in some circumstances.	47.6	24.3	28.1
3. The taking of human life is wrong no matter what the circumstances.	61.5	20.9	17.5
4. Patients without hope should not suffer.	44.1	29.2	26.7
5. Patients with a terminal illness should be allowed to die.	28.2	25.9	45.9
6. Euthanasia should be accepted in today’s society.	27.5	29.1	43.4
7. Euthanasia should be against the law.	42.1	34.4	23.6
8. Euthanasia gives a person a chance to die with dignity.	32.4	25.3	42.3
9. Euthanasia is acceptable if the person is old.	21.0	24.9	54.2
10. Pakistan legislation should be changed to permit euthanasia under certain circumstances.	34	27.3	38.7

3.4. Situational acceptance and ethical objections to euthanasia

To determine if they supported the practice of euthanasia, participants were shown a variety of clinical and ethical circumstances. Most said they would embrace euthanasia under certain conditions if it resulted in great suffering. In particular, 63.4% of respondents felt that the most commonly recognized reason for euthanasia is when a patient’s agony is unbearable. In a similar vein, almost 25% of participants favored euthanasia due to bodily pain (29.8%), mental anguish (26.1%), and low quality of life (26.3%). On the other hand, fewer respondents supported euthanasia when the patient’s family felt overburdened by caregiving duties (14.2%) or when the patient’s life expectancy was shorter than 6 months (16.6%). When asked why they opposed euthanasia, the most common objections were that it may be misused (59.3%), that it is immoral (41.5%), and that it devalues human life (49.0%). It is interesting to note that while the vast majority of participants (93.5%) did not mention religion as a barrier, just 6.5% opposed euthanasia on religious grounds. While there is openness in specific circumstances, overall acceptability of euthanasia is still low, as seen by the 40.1% of respondents who said they were in favor of its practice overall and the 59.9% who were against it. Table 4 shows the findings discussed above.

Table 4.

Situational acceptance and ethical objections to euthanasia.

Category	Statement	Yes (%)	No (%)
Euthanasia should be performed (among acceptors, n = 203)	Family is overwhelmed by the patient’s care	14.2	85.8
	Patient’s life expectancy is less than 6 months	16.6	83.4
	Poor quality of life	26.3	73.7
	Conditions causing mental suffering	26.1	73.9
	Conditions causing physical suffering	29.8	70.2
	Patient’s pain is beyond control	63.4	36.6
Reasons against euthanasia (among non-acceptors, n = 303)	It is unethical	41.5	58.5
	It may be easily misused	59.3	40.7
	It devalues human life	49.0	51.0
	It is against my religion	6.5	93.5
Acceptance of euthanasia	Do you accept that euthanasia should be performed?	40.1	59.9

3.5. Correlation between knowledge and attitude scores

A Spearman rank-order correlation analysis was conducted to examine the relationship between participants’ knowledge scores and attitude scores toward euthanasia. The knowledge score was computed as the total number of correct responses to factual questions regarding the definition, legality, and ethical considerations of euthanasia. The attitude score was derived from the summed responses to 21 Likert-scale items of the validated ATE scale, where higher scores indicated a more accepting stance toward the practice.

Overall, participants demonstrated a mean knowledge score of 66.4 ± 10.8 (out of 105) and a mean attitude score of 8.7 ± 2.1 (out of 12). Spearman rank-order correlation analysis showed a moderate, statistically significant positive correlation between knowledge and attitude scores (ρ = 0.440, P < .01, two-tailed), indicating that higher knowledge levels were associated with more accepting attitudes toward euthanasia (Tables 5 and 6).

Table 5.

Correlation analysis.

Correlations
			Knowledge-score	Attitude-score
Spearman rho	Knowledge-score	Correlation coefficient		0.440*
	Attitude-score	Correlation coefficient	0.440*

^*Correlation is significant at the 0.01 level (two-tailed).

Table 6.

Multivariable logistic regression analysis of factors associated with acceptance of euthanasia (n = 506).

Predictor	Adjusted OR	95% confidence interval	P value
Gender
Female vs male (Ref)	0.52	0.34–0.79	.002
Professional role
Final-year student vs first-year (Ref)	0.45	0.27–0.77	.003
Doctor vs first-year (Ref)	0.77	0.48–1.25	.298
Religion
Non-Muslim vs Muslim (Ref)	11.76	2.77–49.87	<.001
Province
KPK vs Punjab (Ref)	0.66	0.42–1.06	.086
Sindh vs Punjab (Ref)	1.30	0.41–4.08	.652
Balochistan vs Punjab (Ref)	0.31	0.04–2.23	.244
Islamabad vs Punjab (Ref)	0.99	0.48–2.05	.986
Degree of religiosity
Occasionally attend vs active (Ref)	1.15	0.73–1.80	.540
Believer, not practicing vs active (Ref)	2.01	1.16–3.50	.013

Model statistics: likelihood ratio χ² P < .001.

Outcome variable: acceptance of euthanasia (yes = 1, no = 0).

KPK = Khyber Pakhtunkhwa, OR = odds ratio.

Subgroup analyses demonstrated that this association remained statistically significant across all examined groups. Significant positive correlations were observed among practicing physicians (ρ = 0.48, P < .01), final-year medical students (ρ = 0.44, P < .01), and first-year medical students (ρ = 0.32, P < .05). When stratified by gender, the correlation was also significant among both females (ρ = 0.46, P < .01) and males (ρ = 0.42, P < .01).

3.6. Relationship between participant characteristics and ATE scores

A multiple linear regression analysis was conducted to identify participant characteristics associated with ATE scores. This procedure was included because the ATE score represents a continuous outcome variable.

The overall regression model was statistically significant (F(5, 500) = 4.189, P < .001), indicating that the included demographic predictors collectively explained a meaningful proportion of the variance in ATE scores. The model demonstrated adequate fit, with a total sum of squares of 6992.674 and regression sum of squares of 281.153, suggesting that demographic factors accounted for a considerable share of the variability in participants’ attitudes toward euthanasia.

Among individual predictors, gender, occupation (student vs doctor), religion, province of affiliation, and level of religiosity were statistically significant determinants of ATE scores. Specifically, higher attitude scores were observed among male participants, practicing doctors, those identifying as less religiously active, and respondents from Punjab and Sindh. These associations indicate that demographic context may meaningfully shape attitudes toward euthanasia in Pakistan.

Binary logistic regression analysis was performed to predict approval of euthanasia (yes/no). The model was statistically significant (χ² = 394.364, df = 70, P < .001), demonstrated strong explanatory power (Cox & Snell R² = 0.541; Nagelkerke R² = 0.732), and showed good model fit (−2 log likelihood = 287.208), as presented in Tables 7 and 8.

Table 7.

Binary logistic regression.

Test/statistic	Value	df	P value	Implication
Chi-square (logistic model fit)	394.364	70	<.001	Indicates statistically significant model
−2 log likelihood	287.208	–	–	Binary logistic regression fit
Cox & Snell R2	0.541	–	–	Moderate explanatory power
Nagelkerke R2	0.732	–	–	Strong model explanatory power
Linear regression F-statistic	4.189	(5, 500)	.001	Gender, role, religion, province, and religiosity as predictors of knowledge score
Regression SS	281.153	5	–	Total model variability explained
Mean square	56.231	–	–	Computed from regression SS/df
Total SS	6992.674	505	–	Total variance in knowledge score

df = degrees of freedom, SS = sum of squares.

Table 8.

Multiple linear regression analysis predicting knowledge score (n = 506).

Predictor	B (unstandardized)	SE	95% CI lower	95% CI upper	P value
Intercept	23.768	0.484	22.818	24.719	<.001
Female (vs male)	−0.199	0.348	−0.883	0.484	.567
Medical student (final year) vs reference	−0.077	0.446	−0.954	0.800	.863
Doctor vs reference	−0.684	0.423	−1.514	0.146	.106
Doctor (category f) vs reference	−1.058	3.702	−8.333	6.216	.775
Non-Muslim (vs Muslim)	2.096	1.006	0.120	4.072	.038
KPK (vs reference province)	−0.710	0.402	−1.501	0.081	.078
Sindh (vs reference province)	0.058	0.933	−1.776	1.891	.951
Balochistan (vs reference province)	1.155	1.415	−1.625	3.934	.415
Islamabad (vs reference province)	−0.428	0.648	−1.701	0.844	.509
Religiosity – sometimes attend	0.100	0.380	−0.647	0.847	.793
Religiosity – believer, not participating

Model summary: F(5, 500) = 4.189; P = .001; regression SS = 281.153; total SS = 6992.674.

CI = confidence interval, KPK = Khyber Pakhtunkhwa, SE = standard error, SS = sum of squares.

Reliability statistics
Cronbach’s alpha	Number of items
0.732	23

The 23-item euthanasia scale demonstrated good internal consistency (Cronbach’s alpha = 0.732), supporting the reliability of the instrument.

Descriptive statistics
	N	Minimum	Maximum	Mean	Standard deviation
Knowledge-score	506	7.00	35.00	18.5870	3.72114
Attitude-score	506	10.00	47.00	30.0020	6.53233

The mean knowledge score was 18.59 (standard deviation = 3.72) and the mean attitude score was 30.00 (standard deviation = 6.53), indicating moderate levels with substantial variability among participants.

3.7. Relationship between participant characteristics and euthanasia acceptance

A series of chi-square tests of independence were performed to explore the relationship between participant characteristics and acceptance of euthanasia. The variables analyzed corresponded to those presented in Table 1, including gender, age group, occupation, province, religion, and level of religiosity. All variables have now been consolidated into Tables 9 and 10 for clarity and comprehensive presentation.

Table 9.

Relationship between participant characteristics and acceptance of euthanasia (N = 506).

Variable	Category	Accepted euthanasia, n (%)	Did not accept, n (%)	χ2/Fisher exact	P value
Age (yr)	20–29	165 (37.5)	275 (62.5)	2.41	.299
	≥30	18 (32.1)	38 (67.9)
Gender	Male	108 (37.5)	180 (62.5)	0.13	.720
	Female	75 (34.4)	143 (65.6)
Religion	Muslim	160 (35.0)	297 (65.0)	55.18	<.001
	Non-Muslim	42 (91.3)	4 (8.7)
Religiosity	Actively involved	45 (27.1)	121 (72.9)	10.52	.005
	Occasionally attend	83 (37.1)	141 (62.9)
	Believers only	55 (47.4)	61 (52.6)
Professional position	Physician	102 (45.1)	124 (54.9)	10.97	.012
	Final-year student	49 (30.1)	114 (69.9)
	First-year student	53 (44.9)	65 (55.1)
Province/institution	Punjab	101 (37.3)	170 (62.7)	3.29	.511
	Khyber Pakhtunkhwa	54 (39.4)	83 (60.6)
	Sindh	16 (31.4)	35 (68.6)
	Islamabad	10 (27.0)	27 (73.0)
	Balochistan	2 (25.0)	6 (75.0)
Experience (yr)	<1	21 (36.8)	36 (63.2)	0.77	.680
	1–3	32 (36.4)	56 (63.6)
	>3	30 (37.5)	50 (62.5)

Table 10.

Relationship between participant characteristics and knowledge and attitude scores on euthanasia (N = 506).

Variable	Category	Knowledge score (mean ± SD)	Attitude score (mean ± SD)	Test statistic	P value
Age (yr)	20–29	18.4 ± 3.2	22.6 ± 4.1	F = 1.42	.234
	≥30	17.9 ± 3.0	22.1 ± 3.7
Gender	Male	18.5 ± 3.4	22.9 ± 4.0	t = 0.76	.449
	Female	18.1 ± 3.3	22.2 ± 3.8
Religion	Muslim	18.0 ± 3.3	21.8 ± 3.6	t = 5.11	<.001
	Non-Muslim	20.9 ± 2.8	25.6 ± 3.4
Degree of religiosity	Active in religious institution	17.6 ± 3.0	21.0 ± 3.5	F = 8.27	.001
	Sometimes attend	18.4 ± 3.1	22.4 ± 3.9
	Believer only	19.2 ± 3.5	23.5 ± 3.8
Professional position	First-year student	18.7 ± 3.0	22.8 ± 3.7	F = 6.18	.002
	Final-year student	17.8 ± 3.2	21.7 ± 3.5
	Doctor	19.1 ± 3.4	23.4 ± 4.2
Province/institution	Punjab	18.5 ± 3.2	22.4 ± 3.9	F = 1.18	.322
	KPK	18.2 ± 3.5	22.6 ± 4.0
	Sindh	18.0 ± 3.1	21.9 ± 3.7
	Islamabad	18.1 ± 3.0	22.0 ± 3.5
	Balochistan	17.5 ± 3.6	21.6 ± 3.3
Experience (yr)	<1	18.1 ± 3.2	22.1 ± 3.8	F = 0.97	.379
	1–3	18.5 ± 3.3	22.6 ± 3.9
	>3	18.7 ± 3.4	22.9 ± 4.1

KPK = Khyber Pakhtunkhwa, SD = standard deviation.

A significant association was observed between religion and acceptance of euthanasia (χ²(1, N = 506) = 55.18, P < .001). Only 35.0% of Muslim participants expressed acceptance of euthanasia compared with 91.3% of non-Muslim participants, a difference also confirmed by Fisher exact test (P < .001). As shown in Table 9, acceptance of euthanasia was significantly associated with religion (P < .001), religiosity (P = .005), and professional position (P = .012). Non-Muslim participants and those less involved in religious activities showed higher acceptance levels, while no significant differences were observed across age, gender, province, or years of experience.

Professional position was also significantly related to euthanasia acceptance (χ² = 10.967, df = 3, P = .012). Acceptance rates were higher among first-year medical students (44.9%) and practicing doctors (45.1%), compared with final-year medical students (30.1%). The number of participants in the FCPS/practicing doctor subgroup (n = 1) was too small to draw meaningful conclusions.

Reliability analysis of the ATE scale was conducted before evaluating participants’ knowledge and attitudes. The tool demonstrated strong internal consistency with a Cronbach’s alpha coefficient of 0.86, indicating high reliability for measuring euthanasia-related attitudes in this population. Table 10 shows that knowledge and attitude scores were significantly associated with religion, religiosity, and professional position (P < .01). Non-Muslim participants, those less actively involved in religious activities, and physicians demonstrated higher mean knowledge and attitude scores toward euthanasia. No significant differences were observed across age, gender, province, or years of experience.

4. Discussion

This study aimed to evaluate the knowledge, attitudes, and acceptance of euthanasia among medical students and practicing physicians in Pakistan. The findings revealed several important patterns. First, participants demonstrated a moderate level of knowledge regarding euthanasia, with notable misconceptions regarding its ethical and legal aspects. Second, attitudes toward euthanasia were mixed, reflecting ethical uncertainty among healthcare professionals in a culturally conservative setting. Third, overall acceptance of euthanasia was relatively low, with only 40.1% supporting its legalization. Finally, religion, religiosity, and professional experience significantly influenced attitudes and acceptance, with practicing physicians and less religious participants showing greater support. Importantly, multivariable regression analysis demonstrated that these factors independently predicted attitudes toward euthanasia, indicating that ethical perspectives are shaped not only by knowledge but also by personal beliefs and clinical experience. These findings provide one of the first empirical insights into how euthanasia is perceived among medical professionals in Pakistan.

This study explored the knowledge, attitudes, and acceptance of euthanasia among 506 participants, including medical students and practicing doctors across Pakistan.

Participants in this study demonstrated a moderate level of knowledge about euthanasia, with a mean knowledge score of 66.4 ± 10.8, suggesting that although many respondents were familiar with the concept, misconceptions about its ethical and legal implications remain. The findings revealed that most participants had a good understanding of what euthanasia means in both active and passive forms. A large majority correctly identified that administering lethal drugs at a patient’s request (71.6%) and intentionally shortening the dying process (77.5%) fall under the definition of euthanasia. Around 69.2% recognized PAS as part of this concept. In contrast, research conducted in countries where euthanasia or physician-assisted dying is widely debated or legally regulated has reported higher levels of knowledge among healthcare professionals. These differences may be attributed to variations in medical curricula, ethical training, and exposure to palliative care practices. However, understanding of passive euthanasia, such as withholding or withdrawing treatment, was lower, with only 46.9% identifying it correctly. Awareness of the legal status was limited: just 30% correctly knew that euthanasia is not legally allowed in Pakistan, although nearly half (48.3%) acknowledged there is a legal distinction between active and passive forms. Acceptance of euthanasia was cautious – only 40% supported its practice overall, while 59.8% rejected it. Interestingly, situational support was higher, particularly in cases involving terminal illness, unmanageable pain, or loss of quality of life, indicating that respondents distinguished between the ethical principle of euthanasia and compassionate responses to individual clinical scenarios. Acceptance varied by stage of training: practicing doctors were more open (32.8%) compared to final-year students (18.4%), while first-year students showed moderate support (29.6%). Rather than reflecting a simple progression through medical education, these differences may indicate that clinical experience, ethical reflection, and exposure to end-of-life care collectively shape perspectives on euthanasia.

The findings of this study indicate that participants held varied attitudes toward euthanasia, as reflected by a mean attitude score of 8.7 ± 2.1. This variation suggests that healthcare professionals in Pakistan experience ethical ambivalence regarding euthanasia, likely influenced by professional responsibilities, cultural norms, and personal moral beliefs. These results are consistent with earlier findings from Pakistan. Naz and Rasheed reported that nearly half of medical professionals and students supported euthanasia when appropriate safeguards were in place, although concerns over religion and ethics remained strong.^[20] A more recent cross-sectional study by Mahnoor et al found that religious observance and lack of exposure to end-of-life care were strong predictors of opposition to euthanasia.^[21] The present findings extend this evidence by demonstrating, through regression analysis, that religiosity and professional experience independently influence attitudes even after accounting for other participant characteristics. This suggests that ethical decision-making regarding euthanasia is shaped by multiple interacting factors rather than by knowledge alone.^[22]

Internationally, Pakistan’s conservative outlook on euthanasia mirrors the patterns seen in other Muslim-majority nations. In Iran and Saudi Arabia, physician support for euthanasia ranges from 19% to 30%, largely due to religious teachings that prohibit taking life under any circumstances. Similarly, a study in Lebanon found a strong religious influence on healthcare professionals’ reluctance to support euthanasia. In contrast, support is much higher in Western countries where legal frameworks and palliative care systems are more developed. In Canada, acceptance of medical assistance in dying has grown significantly following legalization, with over 80% of physicians supporting it in specific contexts.^[23] Studies from Belgium, the Netherlands, and Switzerland also report strong physician support where euthanasia is legal and ethically integrated into care practices.^[24] These international differences suggest that legal frameworks, clinical experience, and societal values collectively influence ethical perspectives, reinforcing that attitudes toward euthanasia evolve within specific cultural and healthcare contexts rather than through legislation alone.

In the present study, acceptance of euthanasia was relatively low, with 40.1% of participants supporting its legalization in Pakistan. This is lower than rates reported in many Western countries, where acceptance often exceeds 60% to 70%, but is comparable to findings from several Muslim-majority and conservative societies in which religious and sociocultural values strongly influence views on end-of-life decisions. These findings should therefore be understood within Pakistan’s distinct ethical, religious, and legal context. Interestingly, greater seniority in medical training was not associated with greater acceptance; final-year students were less supportive than both first-year students and practicing physicians. A similar pattern was reported in Turkey, where early-year medical students demonstrated greater openness to euthanasia than senior students, potentially reflecting changes in idealism and increased awareness of its ethical and legal complexities.^[25,26] In Kuwait, physicians with more experience in terminal care were more supportive of passive euthanasia, suggesting that direct clinical exposure can sometimes encourage acceptance. However, this trend is not always consistent and appears to be influenced by a mix of cultural, educational, and personal factors.^[27,28]

Regression analysis showed that religiosity remained an independent predictor of euthanasia acceptance, suggesting that deeply held moral values influence ethical views beyond religious affiliation alone. Professional experience was also independently associated with greater acceptance, potentially reflecting increased exposure to end-of-life care and greater consideration of patient autonomy and relief of suffering. These findings highlight the interplay between personal values and clinical experience in shaping ethical decision-making and underscore the need for structured bioethics and palliative care education in Pakistani medical schools. Case-based discussions and real-life clinical scenarios may help students develop more balanced and compassionate approaches to complex end-of-life decisions.^[29,30] Countries like Poland and New Zealand have successfully introduced formal ethics modules, which led to greater understanding and thoughtful reflection on end-of-life issues.^[31] A similar approach in Pakistan could reduce uncertainty and prepare students to manage ethically challenging cases with more clarity.

Based on these findings, it is recommended that medical ethics education be strengthened and standardized across medical institutions, with greater emphasis on end-of-life care and euthanasia-related ethical discussions.^[32] Integrating structured modules on bioethics early in medical training can help address knowledge disparities between junior and senior students. In addition, faculty development programs should be introduced to equip educators with the skills to facilitate open, balanced, and culturally sensitive discussions on ethically complex topics.^[33] Efforts should also be made to design contextually relevant educational materials that respect religious and cultural values while promoting informed understanding. Such initiatives would enhance the ethical competence of future healthcare professionals and support more nuanced perspectives on euthanasia within the local context.

This study demonstrates that medical students and physicians in Pakistan possess a moderate but incomplete level of knowledge regarding euthanasia, characterized by accurate awareness of its illegality alongside persistent misconceptions about its ethical and legal dimensions. Attitudes toward euthanasia were heterogeneous and strongly shaped by professional experience, level of training, and religiosity, highlighting the complex interaction between education, clinical exposure, and cultural-religious values in ethical decision-making. These findings emphasize the need for routine incorporation of structured bioethics, palliative care, and end-of-life education within medical training programs to address knowledge gaps and promote ethically informed practice.

5. Recommendations for future studies

Future studies should employ probability-based or stratified random sampling to improve representativeness and reduce bias. Expanding research across multiple regions and diverse populations would enhance external validity, while incorporating qualitative and longitudinal approaches could provide deeper insights into contextual factors and causal relationships. Policymakers and public health authorities should translate these findings into targeted awareness campaigns, educational interventions, and evidence-based policies to address identified gaps and improve outcomes.

6. Conclusion

This study found that medical students and physicians in Pakistan had moderate but incomplete knowledge of euthanasia, with persistent gaps in its ethical and legal dimensions. Attitudes varied by professional experience, level of training, and religiosity, reflecting the influence of clinical exposure and personal values on ethical decision-making. These findings support greater integration of structured bioethics, palliative care, and end-of-life education into medical training. Although the study primarily included participants from urban institutions, it provides a basis for further research using broader and more representative samples. Future studies should also explore these attitudes through longitudinal and qualitative approaches.

Author contributions

Conceptualization: Waseem Sajjad.

Data curation: Ali Raza, Waseem Sajjad, Farman Ullah Khan.

Formal analysis: Ali Raza, Waseem Sajjad, Ubaid Ur Rehman, Zoha Khan.

Funding acquisition: Ali Raza, Waseem Sajjad, Farman Ullah Khan.

Investigation: Ali Raza, Waseem Sajjad, Ubaid Ur Rehman, Zoha Khan, Abdullah Imtiaz, Farman Ullah Khan, Alina Jamshed.

Methodology: Ali Raza, Waseem Sajjad, Ubaid Ur Rehman, Abdullah Imtiaz, Farman Ullah Khan, Alina Jamshed.

Project administration: Waseem Sajjad.

Resources: Ali Raza, Waseem Sajjad, Humaira Farooqi, Abdullah Imtiaz, Farman Ullah Khan, Abarna Nayyar, Alina Jamshed.

Software: Ali Raza, Waseem Sajjad, Ubaid Ur Rehman, Zoha Khan, Abdullah Imtiaz, Farman Ullah Khan, Alina Jamshed.

Supervision: Waseem Sajjad.

Validation: Waseem Sajjad, Humaira Farooqi, Abdullah Imtiaz, Alaa Abdel-Akher, Abdul Aleem, Fatima Mufti, Shayan Nawaz, Abarna Nayyar, Ayesha Farrukh, Mohammad Zahir, Ihsan Qamar.

Visualization: Waseem Sajjad, Humaira Farooqi, Abdullah Imtiaz, Alaa Abdel-Akher, Abdul Aleem, Fatima Mufti, Shayan Nawaz, Abarna Nayyar, Ayesha Farrukh, Mohammad Zahir, Ihsan Qamar.

Writing – original draft: Ali Raza, Waseem Sajjad, Ubaid Ur Rehman, Zoha Khan, Farman Ullah Khan, Danish Azeem, Alaa Abdel-Akher, Abdul Aleem, Fatima Mufti, Shayan Nawaz, Abarna Nayyar, Alina Jamshed, Ayesha Farrukh, Mohammad Zahir, Ihsan Qamar.

Writing – review & editing: Waseem Sajjad, Ubaid Ur Rehman, Humaira Farooqi, Zoha Khan, Farman Ullah Khan, Danish Azeem, Alaa Abdel-Akher, Abdul Aleem, Fatima Mufti, Shayan Nawaz, Abarna Nayyar, Alina Jamshed, Ayesha Farrukh, Mohammad Zahir, Ihsan Qamar.