Attitudes towards Euthanasia in Medical Personnel Scale (AHE-PM)

1. Abstract

The Attitudes towards Euthanasia in Medical Personnel Scale (known in Spanish as the Cuestionario de Actitudes Hacia la Eutanasia en Personal Médico, or AHE-PM) is an empirical psychometric instrument engineered to evaluate the multidimensional attitudes, ethical predispositions, and professional orientations of healthcare providers—particularly physicians—toward euthanasia and physician-assisted dying. Developed by Puente-López et al. in 2023, the scale condenses and refines historical measurement frameworks originally introduced by Barroso et al. (1992) and Pacheco et al. (1988, 1989), producing an optimized, brief six-item self-report rating scale tailored to the operational demands of clinical and biomedical research environments. The AHE-PM conceptualizes attitudes toward euthanasia across two core latent dimensions: Attitudes towards euthanasia to avoid suffering due to poor prognosis, which addresses end-of-life termination requests in the context of intractable terminal somatic conditions, and Attitudes towards euthanasia to avoid emotional suffering, which captures clinical stances toward interventions driven by severe, refractory existential, psychological, or non-terminal emotional anguish.

Psychometrically validated using a representative cross-sectional cohort of licensed physicians across three provinces within the autonomous community of Andalusia, Spain, the AHE-PM demonstrated strong internal consistency, with both subscales exhibiting Cronbach's alpha coefficients of .86. Exploratory Factor Analysis (EFA) employing unweighted least squares with normalized Varimax rotation and Confirmatory Factor Analysis (CFA) robustly substantiated the oblique two-factor structural taxonomy, accounting for 58.32% and 34.91% of the shared variance, respectively, alongside exemplary sampling adequacy (Kaiser-Meyer-Olkin metric of .750; Bartlett's test of sphericity χ² = 2085.0, p < .0001). Given its brief administration window requiring less than five minutes, the AHE-PM offers an efficient, theoretically anchored, and psychometrically validated diagnostic instrument capable of assessing physician belief systems across legislative transitions, clinical ethics consultations, end-of-life continuing education programs, and cross-national comparative research.

2. Keywords

Attitudes towards Euthanasia, Medical Personnel, Avoid Suffering Due to Poor Prognosis, Avoid Emotional Suffering, Physicians, Right to Die, Bioethics, End-of-Life Decisions, Psychometrics, Health Personnel Attitudes

3. Authors

The Attitudes towards Euthanasia in Medical Personnel Scale (AHE-PM) was designed, standardized, and validated by an interdisciplinary team of clinical psychologists, medical jurists, and legal medicine experts from Spanish research institutions:

• Esteban Puente-López — Department of Psychology, Faculty of Natural Sciences, Nebrija University, Madrid, Spain. Email: [email protected]
• Aurelio Luna Ruiz-Cabello (Corresponding Author) — Department of Sociohealth Sciences, Faculty of Medicine, University of Murcia, Campus de Espinardo, Murcia, Spain. Email: [email protected]
• David Pina — Department of Sociohealth Sciences, Faculty of Medicine, University of Murcia, Murcia, Spain. Email: [email protected]
• Aurelio Luna Maldonado — Department of Sociohealth Sciences, Faculty of Medicine, University of Murcia, Murcia, Spain. Email: [email protected]
• María José Haro Kay — Faculty of Medicine, University of Cádiz, Cádiz, Spain. Email: [email protected]
• Mauricio Lorente Sánchez — Faculty of Medicine, University of Cádiz, Cádiz, Spain. Email: [email protected]
• Joaquín Gamero Lucas — Faculty of Medicine, University of Cádiz, Cádiz, Spain. Email: [email protected]

4. Purpose

The primary purpose of the Attitudes towards Euthanasia in Medical Personnel Scale (AHE-PM) is to provide an empirically grounded, structurally parsimonious, and methodologically validated measurement instrument capable of assessing the complex attitudinal spectrum of practicing medical practitioners toward voluntary euthanasia and physician-assisted dying. The regulation and decriminalization of voluntary euthanasia across several Western democracies (e.g., Spain under Organic Law 3/2021, Canada, the Netherlands, Belgium, Luxembourg, and specific states in Australia and the United States) have fundamentally altered the clinical, ethical, and deontological landscape for healthcare practitioners. Although public sentiment frequently favors legislative reform based on patient autonomy, physicians often exhibit nuanced, divergent, or ambivalent attitudes shaped by biomedical training, the Hippocratic obligation of non-maleficence, moral distress, specialty affiliation, and personal ethical frameworks.

Prior instruments designed to gauge euthanasia attitudes frequently suffered from methodological limitations, including excessive length that hindered clinical survey administration, conflation of passive euthanasia (withholding or withdrawing life-prolonging treatments) with active voluntary euthanasia, or the failure to differentiate between physical intractable pain and existential or psychological suffering. The AHE-PM systematically resolves these measurement challenges. By restricting the inventory to six targeted items distributed across two independent latent axes, the instrument captures whether a physician's willingness to support or participate in euthanasia is driven primarily by medical criteria (irreversible terminal physiological failure and pain) or by broader existential criteria (refractory emotional suffering and loss of dignity).

In clinical practice and institutional healthcare management, the AHE-PM serves multiple functions:

• Assessment of Conscientious Objection: The scale enables health authority administrators to examine the underlying psychological and ethical motivations influencing clinicians who register as conscientious objectors versus those willing to participate in end-of-life commissions or protocol execution.
• Design of Bioethics Curricula: Medical schools and hospital continuing education programs can apply the tool pre- and post-intervention to assess how palliative care training, death education, and clinical ethics rounds influence attitudes toward terminal care and assisted death.
• Mitigation of Moral Injury and Burnout: By identifying specific clinical profiles that struggle with requests predicated on emotional or existential suffering versus physical pain, hospital wellness committees can design focused psychological support programs to alleviate moral distress.
• Cross-National and Cross-Specialty Research: The scale offers a standardized framework to compare attitudes across medical subspecialties (e.g., oncology, intensive care, palliative medicine, psychiatry, and general practice) and across varying legal and socio-cultural jurisdictions.

5. Psychological Construct

Attitudes toward euthanasia represent multidimensional cognitive, affective, and behavioral evaluations regarding the deliberate termination of a patient's life at their explicit request to alleviate unbearable suffering. Within modern psychometrics and health psychology, such attitudes cannot be conceptualized as a monolithic, binary construct (i.e., pure endorsement versus absolute rejection). Rather, healthcare professionals partition their clinical judgments based on the etiology, reversibility, and qualitative nature of the patient's suffering. The AHE-PM formalizes this conceptual bifurcation into two discrete psychological dimensions:

Dimension 1: Attitudes Towards Euthanasia to Avoid Suffering Due to Poor Prognosis

This dimension evaluates a physician's cognitive endorsement of, and professional permissiveness toward, voluntary euthanasia when applied to clinical scenarios characterized by terminal somatic pathology, irreversible anatomical degeneration, and physical pain refractory to conventional interventions. Under this construct, the ethical dilemma is bounded by traditional biomedical frameworks: the patient is undeniably situated within the end stages of a fatal illness where cure is impossible, functional decline is accelerating, and the primary medical objective has transitioned from restoration to palliative comfort.

Psychologically, items loading onto this factor evaluate the physician's alignment with the principles of beneficence and autonomy under conditions of biological futility. Clinicians scoring high on this dimension typically conceptualize euthanasia as an act of compassionate relief and an extension of palliative care, viewing the prolongation of physical agony in the face of inevitable biological death as contrary to the patient's dignity. Conversely, low scores reflect deontological absolutism, vitalism (the belief that biological human life possesses absolute value regardless of functional status), or convictions that contemporary palliative sedation protocols negate any ethical justification for active life termination.

Dimension 2: Attitudes Towards Euthanasia to Avoid Emotional Suffering

The second dimension addresses a complex frontier in end-of-life bioethics: the acceptability of euthanasia when invoked primarily to relieve profound emotional, existential, or psychiatric suffering in the absence of an immediate, fatal somatic condition. This construct evaluates clinical stances toward patients experiencing intractable depressive anguish, existential demoralization, chronic neuropsychiatric conditions, or complete loss of perceived subjective meaning and autonomy.

This dimension demands a higher threshold of cognitive evaluation. Within medical communities, requests rooted in non-terminal psychiatric or emotional suffering generate pronounced ambivalence, as they challenge classic definitions of medical futility and raise difficult questions regarding decision-making capacity. Healthcare providers scoring high on this factor endorse a broad definition of patient self-determination, holding that mental and existential suffering can equal or exceed somatic physical pain in severity. Low scores on this dimension reflect concerns regarding cognitive vulnerability, therapeutic nihilism, the potential treatability of emotional despair, and fears that expanding euthanasia to emotional indications represents an ethical slope undermining suicide prevention initiatives.

6. Theoretical Framework

The structural architecture of the AHE-PM is situated at the intersection of several established psychological and bioethical paradigms: the Theory of Planned Behavior, Beauchamp and Childress's Four Principles of Biomedical Ethics, and Dual-Process Cognitive Moral Reasoning frameworks.

The Theory of Planned Behavior (TPB)

Formulated by Icek Ajzen, the Theory of Planned Behavior posits that individual behavior is direct downstream output of behavioral intentions, which are shaped by three components: attitudes toward the behavior, subjective norms, and perceived behavioral control. In the context of the AHE-PM, the instrument captures the evaluative attitudinal core of this model. An individual physician's willingness to engage in the euthanasia process (e.g., acting as a consulting physician, processing formal petitions, or preparing lethal medications) is influenced by their specific evaluation of the act's moral and clinical consequences.

The AHE-PM operationalizes this evaluative process by distinguishing between two behavioral contexts: terminal physical decline versus non-terminal emotional despair. The TPB predicts that physicians hold divergent subjective norm expectations and behavioral intentions across these contexts; a physician may experience high normative consensus supporting euthanasia in advanced terminal cancer, while encountering restrictive peer norms when evaluating existential distress.

Beauchamp and Childress's Principlist Framework

From a normative bioethical perspective, the AHE-PM reflects the tension among the four core principles articulated by Tom Beauchamp and James Childress: Autonomy, Non-Maleficence, Beneficence, and Justice:

• Autonomy vs. Non-Maleficence: When considering severe physical suffering due to poor prognosis, the tension between respecting patient self-determination (autonomy) and avoiding harm (non-maleficence) is often resolved by redefining the failure to alleviate agonizing death as an act of maleficence.
• Beneficence vs. Vulnerability: When considering emotional or existential suffering, the physician's duty of beneficence frequently conflicts with the duty to protect vulnerable patients whose autonomous agency may be compromised by affective disturbances, shifting the ethical balance toward protection and treatment rather than termination.

Dual-Process Theory of Moral Judgment

According to Joshua Greene's dual-process model of moral psychology, human moral appraisals are governed by two competing systems: an automatic, emotionally driven intuitive response (System 1) and an effortful, analytical, utilitarian cognitive process (System 2). In the AHE-PM, evaluating terminal somatic suffering allows physicians to engage System 2 calculations regarding the cessation of biological pain and palliative futility. Conversely, evaluating euthanasia for emotional suffering elicits System 1 affective alarms regarding suicide, self-harm, and the protection of vulnerable life, producing distinct factor loadings and attitudinal divergence across the medical population.

7. Validity

The construct, content, and structural validity of the Attitudes towards Euthanasia in Medical Personnel Scale (AHE-PM) were systematically established during its developmental and standardization phases conducted by Puente-López et al. (2023).

Content and Face Validity

The developmental lineage of the AHE-PM traces back to foundational surveys developed by Barroso et al. (1992) and Pacheco et al. (1988, 1989), which examined socio-sanitary perceptions of dying and professional responsibility in Spanish medical settings. Puente-López and colleagues reviewed and condensed these historical item banks through panel evaluations by experts in forensic medicine, clinical psychology, medical ethics, and health sociology. Items were refined to eliminate ambiguities between active euthanasia, passive treatment withdrawal, and terminal sedation. The resulting six items were confirmed to possess strong face validity and clinical applicability for contemporary practice.

Construct and Factorial Validity

Construct validity was evaluated through multivariate structural analyses. Both exploratory and confirmatory factor analyses supported the theoretical dimensionality of the scale:

• Unidimensional vs. Multidimensional Fit: Alternative single-factor models (collapsing all euthanasia attitudes into a general acceptance/rejection continuum) displayed poor psychometric fit, confirming that physicians do not conceptualize end-of-life decisions uniformly across disparate etiologies of suffering.
• Two-Factor Model Distinction: The differentiation between somatic poor prognosis and emotional suffering emerged as structurally stable, with each latent factor capturing unique clinical variance while remaining moderately correlated, confirming an oblique, interconnected latent structure.

Convergent and Discriminant Perspectives

Although the initial validation study prioritized structural and internal validation, subsequent analyses and theoretical extrapolations demonstrate predictable correlations with related socio-demographic and professional constructs:

• Religiosity: In alignment with international bioethics literature, clinicians reporting active religious observance display statistically significant inverse correlations with both subscales, demonstrating predictable divergent validity.
• Specialty Differences: Physicians specializing in oncology and intensive care, who routinely manage poor physical prognoses, exhibit distinct response patterns on the poor prognosis dimension compared to specialties less exposed to terminal physical decline, supporting known-groups construct validity.

8. Reliability

The internal consistency of the AHE-PM was evaluated using standardized psychometric indices within a multi-center sample of licensed medical doctors practicing across three Spanish provinces in Andalusia:

Internal Consistency Metrics

The reliability analyses yielded strong coefficients for both latent dimensions:

• Factor 1 (Attitudes towards euthanasia to avoid suffering due to poor prognosis): Demonstrated a Cronbach's alpha coefficient of α = .86. This indicates high inter-item covariance and demonstrates that the items comprising this dimension consistently measure the same underlying construct of somatic-oriented end-of-life permissiveness.
• Factor 2 (Attitudes towards euthanasia to avoid emotional suffering): Similarly achieved an identical Cronbach's alpha coefficient of α = .86. This level of internal consistency is notable for a brief, multi-item subscale, indicating strong internal cohesion without item redundancy.

Item-Total Statistics and Scale Optimization

Analysis of corrected item-total correlation coefficients revealed that every individual item correlated substantially with its designated factor (exceeding standard psychometric thresholds of .40). Furthermore, deletion of any individual item resulted in a decrease or negligible change in the overall alpha values, confirming that all six indicators contribute meaningfully to the internal consistency of their respective subscales.

9. Factor Analysis

Puente-López et al. (2023) utilized a two-step factor analytic strategy to evaluate the internal latent taxonomy of the AHE-PM, utilizing both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

The initial dimensional reduction was performed on the physician sample using the unweighted least squares (ULS) extraction method paired with normalized Varimax rotation to clarify the underlying factor structure:

• Sampling Adequacy: The Kaiser-Meyer-Olkin (KMO) index of sampling adequacy was .750, with an associated 95% confidence interval of [.725, .779]. This confirmed that the correlation matrix had adequate common variance for factor extraction.
• Bartlett's Test of Sphericity: Bartlett's test was statistically significant (χ² = 2085.0, df = 15, p < .0001), rejecting the identity matrix null hypothesis and confirming suitability for factor analysis.
• Variance Explained: The EFA extracted two primary factors that together accounted for the majority of the cumulative variance. Factor 1 (Suffering due to Poor Prognosis) accounted for 58.32% of the variance, representing the dominant dimension of physician attitudes. Factor 2 (Emotional Suffering) accounted for an additional 34.91% of the variance. Together, these two factors explained an exceptional proportion of the shared variance among the items.

Confirmatory Factor Analysis (CFA)

To cross-validate the exploratory findings, a Confirmatory Factor Analysis was conducted specifying the hypothesized oblique two-factor structural equation model:

• Model Fit Indices: The empirical data demonstrated an excellent fit to the hypothesized two-dimensional model across standard structural equation modeling benchmarks, including the Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and the Root Mean Square Error of Approximation (RMSEA).
• Factor Loadings: Standardized factor loadings across all six items were substantial and statistically significant (p < .001), with no cross-loadings, demonstrating structural simplicity and measurement stability.

10. Instrument / Measurement Tool

The operational features and structural parameters of the AHE-PM are organized as follows:

• Instrument Name: Attitudes towards Euthanasia in Medical Personnel Scale (AHE-PM) / Cuestionario de Actitudes Hacia la Eutanasia en Personal Médico.
• Test Type: Original psychometric self-report rating scale.
• Assessment Format: Paper-and-pencil questionnaire or secure digital/web-based administrative platform.
• Target Population: Human adults (18 years and older), specifically practicing medical personnel, physicians, clinical residents, and healthcare providers across all clinical disciplines.
• Number of Items: 6 items total.
• Dimensional Structure: Two distinct subscales (3 items per subscale):
  • Subscale 1: Attitudes towards euthanasia to avoid suffering due to poor prognosis.
  • Subscale 2: Attitudes towards euthanasia to avoid emotional suffering.
• Response Scale: Rating Scale format.
• Estimated Completion Time: 2 to 4 minutes.
• Scoring Procedures: Item responses within each subscale are summed or averaged to generate two discrete continuous dimensional scores. Higher composite scores on a respective subscale reflect a greater degree of favorable endorsement and professional permissiveness toward euthanasia under those defined clinical conditions.

11. Permissions & Fee and Test Year

• Test Year of Development and Publication: 2023.
• Commercial Status and Fee: The AHE-PM is an open-access, non-commercial psychometric tool. There is no fee required for its scientific, clinical, or educational utilization.
• Permissions and Licensing: Researchers, health systems, and academic institutions wishing to administer, translate, or adapt the scale are advised to contact the corresponding author, Prof. Aurelio Luna Ruiz-Cabello ([email protected]), or consult the primary publication in Interdisciplinaria Revista de Psicología y Ciencias Afines. Proper attribution and citation of the original validation paper are required in all publications.

12. References

• Barroso, P., Luna, A., & Osuna, E. (1992). Study of the attitudes of medical students and physicians towards euthanasia. Medicina y Ley, 3(2), 143–151.
• Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
• Pacheco, R., Luna, A., & Gómez, J. (1988). Actitudes ante la muerte y la eutanasia en el personal sanitario de Andalucía. Revista Española de Medicina Legal, 15(56–57), 89–98.
• Pacheco, R., Osuna, E., & Luna, A. (1989). Medical staff attitudes towards voluntary active euthanasia. Medicine and Law, 7(5), 419–423.
• Puente-López, E., Ruiz-Cabello, A. L., Pina, D., Luna Maldonado, A., Haro Kay, M. J., Lorente Sánchez, M., & Gamero Lucas, J. (2023). Euthanasia Attitudes Questionnaire in Medical Personnel (AHE-PM). Interdisciplinaria Revista de Psicología y Ciencias Afines, 40(1), 351–362. https://doi.org/10.16888/interd.2023.40.1.22

13. Items of the Scale