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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Perception and Attitude towards Passive Euthanasia among Doctors in a Tertiary Care Hospital in Northeast India: A Cross-sectional Study
Correspondence Address :
Dr. Chibi Rushitha,
Assistant Professor, Department of Community Medicine, Government Medical College, Tiruppur, Tamil Nadu, India.
E-mail: dr.rushitha03feb@gmail.com
Introduction: The medical fraternity now has more control over the processes of life and death due to advances in medical technology and equipment. Euthanasia has been debated around the world for more than half a century and it continues to raise important questions in medical ethics, moral theology, civil rights and liberty. Physicians’ attitudes to life and death emerge to relate their end-of-life decision-making, although usually carried out at the request of ailing person. Physicians’ contemplation on euthanasia is a vital building block in the path towards any change, in the euthanasia situation in a country.
Aim: To determine perception and attitude towards passive euthanasia among doctors and to evaluate the association between attitude and variables favourable to passive euthanasia.
Materials and Methods: A cross-sectional survey in the Regional Institute of Medical Sciences (tertiary care hospital), Manipur, India, between October 2018 and September 2020, in Northeast was carried out among 673 doctors. A self-administered questionnaire was designed and approved by three specialists with expertise in palliative care and medical ethics. The questionnaire had a total of 46 questions in English language, of which 15 questions were on socio-demographic profile, 13 were attitude questions and 18 were questions on perception towards passive euthanasia. Attitude questions were scored using 5-point Likert scale from strongly disagree (-2) to strongly agree (+2). Total attitude score ranges from -26 to +26. Score above zero was considered to have positive attitude and vice-versa. There was no scoring to determine perception towards euthanasia. The questionnaires were given to the doctors and postgraduate trainees of clinical and non clinical specialities in a tertiary care hospital in North Eastern India during their work hours. Data were summarised using descriptive statistics. Chi-square test was used to assess factors favouring attitudes toward passive euthanasia.
Results: Age of the respondents ranged from 24 years to 63 years, with a mean age of 37.1±10.7 years and mean duration of experience was eight years. Out of 577 respondents, 368 (63.8%) were postgraduate trainees and 209 (36.2%) were doctors. Majority 463 (80.2%) of the respondents had positive attitude, 97 (16.9%) had negative attitude and 17 (2.9%) had neutral attitude. Total 543 (94.1%) respondents agreed that declaration from patient/family members must be obtained before the act of passive euthanasia. Also, the quality of life as viewed by the patient himself (452, 78.3%) and humanitarian basis (372, 64.4%) were the important factors in influencing decision making regarding passive euthanasia on a terminally ill patient. There was no significant association between sex, age, religion, working category, specialisation, Intensive Care Unit (ICU) experience and attitude towards passive euthanasia.
Conclusion: Majority of the respondents had positive attitude towards passive euthanasia in the face of intractable suffering and terminal illness. Hastened death looks easier to the patients and family because of physical suffering and financial burdens they are subjected to. The doctors got request for euthanasia by the patients and relatives which reflects the public awareness on euthanasia.
Legal aspects, Patient preference, Physician decision making
Deliberate and intentional killing of a person for the gain of that person in order to lighten him from pain and suffering is described as euthanasia (1). Euthanasia can be categorised into two broad types: (a) Active-when a person directly and deliberately does something, which results in the death of patient; (b) Passive-withholding of medical treatment or withdrawal from life support system for continuance of life (2),(3). The medico-technical advances in no way cure the terminally ill patients but prolong their longevity of life with more pain and suffering (4).
Doctors contemplation on euthanasia is an important building block in the path towards bringing about any change in the acceptance of euthanasia. Physicians’ attitudes to life and death emerge to relate their end-of-life decision-making, although usually carried out at the request of ailing person. It is important that the doctor’s perception and attitude towards passive euthanasia should include social, ethical, legal and medical aspects.
A study done in Oregon reported that majority of doctors were willing to withhold or withdraw treatment which would sustain patient’s life (5). Likewise a study based in New Delhi, India, showed similar findings for seriously ill cancer patients. They consider that patients have the right to decline life-saving curative treatment (6). Similarly a study in South India in 2010 found that nearly 70% of doctors working in a tertiary care hospital backed the euthanasia concept. Option to euthanise was taken into account because of physical pain and suffering (7). However, acceptance of euthanasia among Indian doctors was low compared with medical fraternity in United States. This gap shows the difference in social and legal atmospheres in different countries.
Hence, the present exploratory study was conducted at a tertiary care hospital with the objective to determine the perception and attitude towards passive euthanasia among doctors and to document variables favourable to passive euthanasia.
A cross-sectional survey was conducted among doctors in Regional Institute of Medical Science (RIMS) (tertiary care hospital), Manipur, India, between October 2018 and September 2020. Approval was obtained from the Institutional Ethics Committee before the beginning of study (letter no A/206/REB-Comm(SP)/RIMS/2017/199/67/2018).
Inclusion criteria: All postgraduate medical students (clinical/non clinical) who joined RIMS during the academic years 2016-2017; 2017-2018; 2018-2019 and RIMS doctor employees on payroll which was 673 were included in the study.
Exclusion criteria: Those who could not be contacted even after three consecutive visits and refused to participate were excluded from the study.
Study Procedure
A self-administered questionnaire was designed and was examined and approved by three specialists with expertise in palliative care and medical ethics. The questionnaire had four sections:
Section A: It had 15 questions pertained to the background information and socio-demographic profile of the participants.
Section B: It had 13 statements that recorded the attitude of the participants towards passive euthanasia.
Scoring was given only for the attitude questions. The responses to each statement were scored on a 5-point Likert scale ranging from strongly disagree (-2) to strongly agree (+2). The statements included 11 positively keyed items and 2 negatively keyed items (reverse scoring). Maximum and minimum obtainable score was +26 and -26, respectively. Score above zero was considered to have positive attitude and vice-versa. An overall positive score reflected a positive attitude and overall negative score indicated a negative attitude and score zero for neutral attitude. For the purpose of analysis those with neutral attitude were excluded from the study.
Section C: It had six statements that described what had to be done before the act of passive euthanasia on a terminally ill patient.
Section D: It had 12 questions dealing with the factors influencing decision making in passive euthanasia.
The questionnaires were distributed during the work hours. The filled-in questionnaires were returned to the investigator within a day. Data collected was sorted and checked for completeness and consistency. Confidentiality was maintained.
Statistical Analysis
Data was analysed using International Business Machines Corporation Statistical Package for the Social Sciences (IBM-SPSS) software version 21.0. Data were summarised using descriptive statistics. Chi-square test was used to assess the association between background characteristics and other variables with attitude. The p-value <0.05 was considered as significant.
Out of 673 participants, 577 were included in the study and 394 (68.3%) were males. Age of the respondents ranged from 24 years to 63 years with a mean of 37.1±10.7 years and mean duration of experience was eight years. Out of total respondents, 368 (63.8%) were postgraduate trainees and 209 (36.2%) were doctors. Of the respondents, 446 (77.3%) felt that physicians should initiate the discussion about passive euthanasia on a terminally ill patient and 59.3% felt that hospital ethics committee need to be consulted when making decisions about passive euthanasia. None of the respondents got any request for passive euthanasia in their practice so far.
From (Table/Fig 1), about half (49%) of the respondents disagreed that withdrawal of life sustaining treatment in passive euthanasia is same as murder. Majority (78.4%) agreed that there should be strict legislation regulating passive euthanasia procedures. Overall mean score of all the respondents was 5.63 and the maximum and minimum score obtained were 22.0 and -13.0, respectively.
Of the respondents, 463 (80.2%) had positive attitude, 17 (2.9%) neutral attitude and 97 (16.9%) had negative attitude towards passive euthanasia (Table/Fig 2). For analysis purpose those with neutral attitude were excluded.
(Table/Fig 3) shows that 543 (94.1%) respondents agreed that declaration from patient/family members must be obtained before the act of passive euthanasia and 3/4th (75.9%) agreed that withholding and withdrawing treatment in case of passive euthanasia are ethically the same.
(Table/Fig 4) shows that majority of the respondents felt that quality of life as viewed by the patient and family members were important. Patient unlikely to survive as there are not much alternative treatments and financial costs to patient/family. Also, the quality of life as viewed by the patient himself (452, 78.3%) and humanitarian basis (372, 64.4%) were the important factors in influencing decision making regarding passive euthanasia on a terminally ill patient the important factors in influencing decision making regarding passive euthanasia on a terminally ill patient.
(Table/Fig 5) shows that there is no significant association between sex, age, and marital status, religion, working category, specialisation, Intensive Care Unit (ICU) experience and attitude towards passive euthanasia.
This study showed that the concept of passive euthanasia is acceptable to a large section of doctors (80.2%) in a tertiary care hospital in Manipur, India. This could be due to the fact that, in the contemporary world of diseases like cancer, stroke etc., the quality of life of the terminally ill patients becomes subsided and to alleviate them of pain and agony, dying seems to to be the logical alternative. No means of complete and curative recovery and the moribund patient himself making the option to end-his-life made these professionals in favour of euthanasia. Furthermore, worldwide acceptance of passive euthanasia may be noted in response to a questionnaire as in the present study, but when the physicians genuinely face such situation in actuality the support may decrease even though it is legalised (8).
A study in New Delhi, India, showed that withholding or withdrawal of treatment was accepted by majority of physicians (6). Earlier studies from India proclaimed contrasting results [9,10]. However, Hagelin J et al., found that the phrasing of the questions may have affected the results as evidenced from the fact that in this study the questions were pointed towards passive euthanasia specifically (11).
In the current study, more than half of the respondents agreed that patients who are terminally ill should be allowed to die with dignity (63.8%) as compared to Kamath S et al., study (57.1%) (7). Similarly, 71.8% of the respondents favoured the practice of painkillers such as morphine and palliative sedation to keep the patient comfortable which was similar to Gielen J et al., study (6). Experience and training of treating terminally ill patients changed their attitude towards euthanasia.
In the study, majority (80.2%) of the respondents had positive attitude regarding passive euthanasia as compared to Kamath S et al., (69.3%) (7). The most common reason for favouring euthanasia was to curtail physical suffering of a terminally ill patient (63.5%) and there should be strict legislation to perform passive euthanasia on a terminally ill patient (81.7%). Among those who had negative attitude, more than half felt that passive euthanasia could be considered same as murder and that legislation of passive euthanasia may lead to less aggressive treatments when compared to Kamath S et al., (66.2%) and Subba SH et al., (37.4%) (7),(12). The study pointed out that physical suffering and financial burdens were patients’ factors that need to be considered while performing passive euthanasia. Likewise, the explanation for not justifying passive euthanasia were allied to ethical and legal dilemmas. These reasons were similar to findings reported by Subba SH et al., (12).
In this study, no association was found between age, sex and being in favour of the concept of passive euthanasia, similar to previous studies (7),(13),(14). This may be due to the fact that the knowledge gained by medical curriculum at young adulthood might have influenced their perception towards passive euthanasia and might be unchanged over years. Also, in this study, majority (70.7%) of the respondents were aged 24-40 years and younger generation of Indian doctors might be more open and receptive to the idea of passive euthanasia.
In the study, 70.1% felt that religious belief had no influence on their attitude regarding passive euthanasia whereas in a study by Kamath S et al., (75.9%) had similar opinion (7). Also, there was no significant association between religion and attitude towards passive euthanasia in contrary to other studies (7),(9),(15),(16). This could be due to the fact that doctors irrespective of religion, might be of the opinion that, assisting in ending a painful life is performing a good deed and hence fulfilling their moral obligation. On the contrary, studies showed that many Islamic scholars agreed that curative or life sustaining treatment ought not to be forgone (17),(18).
In this study, there was no significant association between area of specialisation and attitude towards passive euthanasia in contrary to study done by Emanuel EJ, which found doctors in certain specialties to be more in favour of euthanasia (8). Studies showed that Geriatricians, Palliative Care specialists, Oncologist were less likely to actively fasten death of a patient (13),(19),(20). This may be because of their speciality they are more likely to treat more terminally ill patients in their practice.
This survey focused on passive euthanasia in all dimensions compared to other surveys in India, which did not make a clear distinction between active and passive euthanasia. The study respondents were doctors from various specialties who were directly or indirectly related to decision making about euthanasia which adds an edge over other studies.
Limitation(s)
One of the key limitations is that, since this study relied on self-reported responses, there was no objective way to know whether the perception of passive euthanasia remains unchanged when they actually face the situation in reality. The study did not explore other areas of relevance such as patients’ and family members’ perceptions. In addition, the study was done among doctors from one institution only and this somewhat restricts the generalisation of the results to the whole doctor population in India.
Majority of the doctors had positive attitude towards passive euthanasia. Sex, age, marital status, religion, area of specialisation and ICU experience did not influence their attitude towards passive euthanasia. Opinion of larger representative population about passive euthanasia will be needed in order to understand better the concept, because of the increasing number of patients subjected to palliative care and life sustaining treatments.
The authors wish to thank all the participants for their co-operation. The authors also acknowledge Professor and Head, Brogen Singh Akoijam, Professor H, Sanayaima Devi and Associate Professor, Shantibala K for reviewing the manuscript.
DOI: 10.7860/JCDR/2023/61677.17665
Date of Submission: Nov 22, 2022
Date of Peer Review: Dec 23, 2022
Date of Acceptance: Feb 01, 2023
Date of Publishing: Mar 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 25, 2022
• Manual Googling: Jan 11, 2023
• iThenticate Software: Jan 28, 2023 (10%)
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