If it were me…. Austrian undergraduate medical students’ attitudes towards end-of-life decisions: a cross-sectional study

End-of-life (EOL) decisions such as active euthanasia (AE), palliative sedation (PS), therapy withdrawal/withholding (TWW), and assisted suicide (AS) are increasingly relevant in medical ethics, particularly in light of shifting legal frameworks and a growing emphasis on patient autonomy. Austria presents a notable case: the 2022 Assisted Suicide Act marked a pivotal legal and ethical shift, permitting assisted suicide under specific conditions. Given these developments, it is essential to explore how future physicians understand and evaluate various EOL decisions. We conducted an exploratory cross-sectional survey among all undergraduate medical students at the Medical University of Vienna between May 13 and June 25, 2023. The anonymous online questionnaire, informed by a systematic literature review, included case vignettes, attitudinal items on EOL practices, and legal perspectives. A total of 332 medical students participated in the survey, with a mean age of 24.8 years and a balanced gender distribution. The majority expressed support for PS (94.9%) and TWW (95.8%), while attitudes towards AS (63.0%) and AE (57.2%) were more divided. Support for legalisation followed similar trends. Religious affiliation, belief, and attendance were significantly associated with attitudes towards EOL practices and their legalisation, with non-believers and less religiously active individuals showing greater support. Correlations between attitudes for hypothetical patients and for themselves were significant across all EOL types, with the strongest alignment for AE. This study provides insight into how future physicians approach ethically complex EOL decisions in the context of evolving legal standards. While medical students support measures prioritising autonomy and symptom relief, such as PS and TWW, attitudes toward AS and AE remain more cautious and divided. Religious belief emerged as the most influential factor, suggesting that personal values shape ethical positions within a shared professional environment. The tendency to view EOL practices slightly more favourably for patients than for oneself also points to a complex interplay between professional responsibility and personal morality. These findings underscore the need for ethics education that clarifies legal frameworks, fosters reflective engagement with personal and societal values, and equips students with the resilience to navigate EOL decisions across diverse clinical and cultural contexts.