Medical-ethical knowledge, moral attitudes and end-of-life decision- making among physicians attending intensive care medicine training courses in Germany: A national survey

In the high-stakes environment of an intensive care unit, where machines breathe for patients and monitors track the faintest signs of life, doctors face decisions that no textbook can fully prepare them for. These are moments when the medical team must decide whether to continue aggressive treatments that keep a body alive but may not restore a person's life, or to step back and allow a natural death to occur. This process involves weighing the patient's own wishes, often written down in advance, against the hopes of family members and the doctor's own moral compass. The core question is not just what is medically possible, but what is ethically right. In Germany, the laws governing these choices have shifted significantly in recent years, granting more weight to a patient's written instructions and clarifying that stopping treatment is not the same as killing a patient. Yet, knowing the law and feeling comfortable with the decision are two different things. As a new generation of doctors enters the field, carrying with them diverse cultural backgrounds and personal beliefs, understanding how they navigate these profound choices becomes essential for the future of care.

A team of researchers set out to map the moral landscape of these young German physicians. Between March 2024 and March 2025, they invited doctors who were currently training in intensive care medicine to participate in an anonymous online survey. The goal was to listen to the voices of 1,152 doctors who had completed the questionnaire, most of whom were in their early thirties and still in the midst of their specialist training. The researchers asked them about their knowledge of German laws regarding end-of-life care, their personal religious beliefs, and how they would handle specific, difficult scenarios involving patients at the end of life. They wanted to see if the doctors' personal lives influenced their professional choices and how their views compared to those of older generations of doctors and their international peers.

The survey revealed that a doctor's personal life is deeply intertwined with their professional decisions. The most consistent factors shaping a doctor's attitude toward stopping or starting life-sustaining treatment were their religious affiliation and how actively they practiced their faith. Doctors who identified as having no religious affiliation, or those who were Catholic or Protestant but did not actively practice their faith, were more likely to agree that it is ethically acceptable to withhold or withdraw treatment. In contrast, doctors who were religiously active, or those who identified as Muslim or Orthodox, tended to hold more restrictive views, finding it harder to agree with stopping treatment. The size of the town where the doctor worked also played a role; those practicing in larger, more urban cities were generally more open to limiting treatment than those in smaller communities. This suggests that while medical training provides the technical skills, the moral weight of these decisions is carried on a foundation of personal values and cultural upbringing.

When the researchers asked the doctors what mattered most when deciding to limit treatment, the answer was overwhelmingly clear: the patient's own wishes. Nearly all respondents agreed that what the patient wanted was the single most important factor, surpassing even the opinions of family members or the doctor's own prognosis of the disease. This marks a distinct shift from the past. When compared to a similar study of German doctors conducted in 2012, the current group of trainees showed a much stronger focus on patient autonomy. They were less likely to rely on a paternalistic approach where the doctor decides what is best, and more likely to follow the instructions a patient left behind. However, this shift toward respecting the patient's voice came with a gap in legal knowledge. While the 2012 doctors felt more confident about the laws surrounding active euthanasia, the current trainees admitted to knowing less about the specific legal regulations, despite the laws having been updated in the intervening years.

A fascinating and persistent tension emerged when the doctors were asked to distinguish between two specific actions: withholding treatment (not starting it in the first place) and withdrawing treatment (stopping it after it has begun). Ethically and legally, German courts and medical guidelines treat these two actions as equivalent. If a patient does not want a ventilator, it is just as permissible to never turn it on as it is to turn it off later. Yet, when the doctors were presented with a realistic case study of a patient on a ventilator, they hesitated. While they agreed in the abstract that stopping treatment was acceptable, they were significantly more willing to withhold a treatment than to withdraw one. They preferred to let a patient die without starting a machine rather than to start a machine and then turn it off. This hesitation suggests that even when doctors understand the rules intellectually, the emotional and psychological weight of "doing" something to stop life feels heavier than "not doing" anything at all.

The study also highlighted the collaborative nature of these decisions in Germany. Unlike in some other parts of the world where the senior doctor might hold the final say, German trainees placed a high value on the input of the entire team. They believed that nurses, family members, and senior physicians should all have a voice in the decision-making process. This reflects a move toward a more shared model of care, where the burden of the decision is distributed among those who know the patient and the medical situation best. However, the researchers noted that this reliance on others might also stem from the fact that these doctors are still in training and feel a need for guidance from more experienced colleagues.

Ultimately, the picture that emerges is one of a profession in transition. The doctors of tomorrow are more focused on the patient's voice than their predecessors were, and they are more comfortable with the idea of letting nature take its course when that is what the patient desires. Yet, they carry the heavy baggage of their own religious and cultural backgrounds, which can create friction in diverse medical teams. They also face a confusing legal landscape where the rules are clear in theory but often feel uncertain in practice, particularly regarding the distinction between stopping and starting treatment. The researchers conclude that to support these young doctors, medical education needs to do more than teach the law; it must provide structured training on how to navigate the emotional and ethical complexities of end-of-life care, helping them bridge the gap between what they know is right and what they feel they can do.