As­sisted-sui­cide laws fos­ter copy­cat wor­ries

The Washington Times Daily - - FRONT PAGE - BY BRAD­FORD RICHARD­SON

Physi­cians, re­searchers and ethi­cists are grap­pling with the copy­cat ef­fect of sui­cide and ris­ing U.S. sui­cide rates as ju­ris­dic­tions en­act laws to al­low the ter­mi­nally ill to take their own lives with the help of a doc­tor.

Dr. Wil­liam Tof­fler, na­tional di­rec­tor of Physi­cians for Com­pas­sion­ate Care, says sui­cides do not oc­cur in a vac­uum but among oth­ers who might be moved to im­i­tate the act, a phe­nom­e­non called the “Werther ef­fect.” An in­crease in sui­cides should be ex­pected where as­sisted sui­cide is le­gal be­cause so­ci­ety is send­ing the un­mis­tak­able mes­sage that killing one­self is a proper re­sponse to life’s chal­lenges, he says.

“Es­sen­tially the mes­sage is, ‘I’ll avoid th­ese prob­lems by

killing my­self,’” says Dr. Tof­fler, a prac­tic­ing physi­cian for more than 35 years in Ore­gon, which be­came the first state to im­ple­ment an as­sisted sui­cide law in 1997.

Still, whether right-to-die laws con­trib­ute to a sui­cide con­ta­gion is dif­fi­cult to de­ter­mine: The only study at­tempt­ing to do so was pub­lished last year by a pair of Bri­tish re­searchers in the South­ern Med­i­cal Jour­nal.

Sui­cide rates in­creased by 6.3 per­cent in states af­ter physi­cian-as­sisted sui­cide laws were en­acted, the study found. But when con­trol­ling for ter­mi­nally ill peo­ple who killed them­selves with the help of the law, the change in the sui­cide rate still in­creased but was not sta­tis­ti­cally sig­nif­i­cant.

Although that study has been touted by op­po­nents of physi­cian-as­sisted sui­cide, Dr. Michael J. Strauss, a prac­ti­tioner of pre­ven­ta­tive medicine in Rockville, Mary­land, says the data show no ev­i­dence to in­di­cate that aid-in-dy­ing laws in­crease the gen­eral in­ci­dence of sui­cide.

“When in the anal­y­sis one re­moves the cases of aid-in-dy­ing physi­cian-as­sisted sui­cide, there is no sta­tis­ti­cally sig­nif­i­cant re­sult,” says Dr. Strauss, who will soon pub­lish his own re­search on the topic. “So there is no as­so­ci­a­tion be­tween aid-in-dy­ing law and what I’ll call tra­di­tional sui­cide — sui­cide rates that ex­clude aid in dy­ing. Doesn’t ex­ist. The au­thors agree with that. It’s only when you in essence ob­scure it by in­clud­ing aid-in-dy­ing cases.”

Colorado be­came the sixth state to per­mit med­i­cal aid in dy­ing in Novem­ber, when vot­ers ap­proved a bal­lot mea­sure 65 per­cent to 35 per­cent. Fol­low­ing Ore­gon’s ex­am­ple, Cal­i­for­nia, Ver­mont and Wash­ing­ton have en­acted physi­cian-as­sisted sui­cide leg­is­la­tion. The Mon­tana Supreme Court also has ruled that noth­ing in state law pro­hibits doc­tors from help­ing to kill ter­mi­nally ill pa­tients who wish to die.

A “Death With Dig­nity Act” is well on its way to be­com­ing law in Wash­ing­ton, D.C., where the leg­is­la­tion cur­rently sits on the desk of Mayor Muriel Bowser for ap­proval. It passed the D.C. Coun­cil by a veto-proof ma­jor­ity and would re­quire con­gres­sional in­ter­ven­tion to de­rail it.

The surge in right-to-die laws co­in­cides with a years­long uptick in na­tional sui­cide rates among all age groups. Ac­cord­ing to data re­leased in Novem­ber by the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, ado­les­cents aged 10 to 14 are now more likely to die by end­ing their lives than in car ac­ci­dents, at­trib­ut­able to a sharp in­crease in the sui­cide rate as well as im­prove­ments in au­to­mo­bile safety.

Spikes in self-harm have been doc­u­mented in re­sponse to pub­lic­ity sur­round­ing some sui­cides, such as when a celebrity takes his or her life.

The CDC and the World Health Or­ga­ni­za­tion have pub­lished guide­lines to pre­vent re­ports of sui­cide from con­tribut­ing to the Werther ef­fect — named for the pro­tag­o­nist of Goethe’s “The Sor­rows of Young Werther” whose fic­tional sui­cide in­spired a se­ries of real-life copy­cats in 18th cen­tury Ger­many. They ad­vise jour­nal­ists against pre­sent­ing sui­cide as a so­lu­tion to life’s prob­lems, ro­man­ti­ciz­ing the vic­tim or doc­u­ment­ing the sui­cide method.

For whom the bell tolls

Dr. Tof­fler, the Ore­gon physi­cian, says me­dia cov­er­age of the physi­cian-as­sisted sui­cide move­ment — es­pe­cially of Brit­tany May­nard, a cham­pion of right-to-die leg­is­la­tion who took her life in 2014 — has bro­ken all of the rules.

“This is a very bad mes­sage to send to a teenager in high school who’s be­ing bul­lied or is de­pressed about a girl­friend that broke up with him,” Dr. Tof­fler says, adding that his views do not rep­re­sent those of his in­sti­tu­tion. “What we’ve done is we’ve cre­ated a men­tal­ity that the so­lu­tion to suf­fer­ing is to kill your­self, and that is a hor­ri­ble mes­sage to send.”

But Dr. Strauss points to his forth­com­ing re­search, in which he finds no dis­cernible dif­fer­ence be­tween chang­ing sui­cide rates na­tion­wide and those in Ore­gon and Wash­ing­ton, the first two right-to-die states.

The ar­ti­cle, which will ap­pear in the up­com­ing edi­tion of the jour­nal Mary­land Medicine, shows that the sui­cide rate in Ore­gon ac­tu­ally dropped be­tween 1998 and 2001, in the years im­me­di­ately af­ter the le­gal­iza­tion of physi­cian-as­sisted sui­cide. The na­tional sui­cide rate also reached its nadir in 2001.

The re­search does show that sui­cide rates in Ore­gon and Wash­ing­ton are sig­nif­i­cantly higher than the na­tional av­er­age, but Dr. Strauss says at­tribut­ing those trends to physi­cian-as­sisted sui­cide is mis­lead­ing.

“They al­ways have had very high sui­cide rates — the high­est in the coun­try,” he says. “And if you track what hap­pened in those states and fol­low it with what hap­pened na­tion­ally, they track in par­al­lel curves. So Ore­gon’s rate came down start­ing in 1998 un­til around 2001, and then climbed up, and it’s ex­actly what hap­pened to the rate na­tion­ally.”

“To me there’s no ob­vi­ous im­pact with the change in law in a hand­ful of states,” he says.

Dr. Aaron Khe­ri­aty, di­rec­tor of the Med­i­cal Ethics Pro­gram at Univer­sity of Cal­i­for­nia, Irvine Health, says the point of the South­ern Med­i­cal Jour­nal study was to test a hy­poth­e­sis ad­vanced by fed­eral ap­pel­late Judge Richard Pos­ner, who posited that physi­cian-as­sisted sui­cide laws would ac­tu­ally lower the gen­eral sui­cide rate.

“Their ar­ti­cle did not pro­vide any sup­port for that hy­poth­e­sis,” says Dr. Khe­ri­aty, au­thor of “The Catholic Guide to De­pres­sion.” “In fact, it un­der­mined that hy­poth­e­sis. It showed an in­crease in the over­all sui­cide rate, and then it showed an in­crease, though not sta­tis­ti­cally sig­nif­i­cant, in the rate of unas­sisted sui­cide.”

Dr. Khe­ri­aty says that, with a larger sam­ple size, the in­crease in unas­sisted sui­cides may prove to be sta­tis­ti­cally sig­nif­i­cant.

“Is it an open-and-shut study that proves that this is go­ing to have a so­cial con­ta­gion ef­fect?” Dr. Khe­ri­aty says. “No, but I think it is sug­ges­tive.”

Dr. Gra­zie Pozo Christie, a Florida ra­di­ol­o­gist and pol­icy ad­viser to The Catholic As­so­ci­a­tion, says it is dif­fi­cult to demon­strate sta­tis­ti­cally the re­la­tion­ship be­tween physi­cian-as­sisted sui­cide laws and the over­all sui­cide rate.

“I don’t think there’s any way that you can pin­point that,” she says. “But sui­cide in gen­eral, we know what causes in­creases in the rates of sui­cide. When sui­cide is pub­li­cized, there’s a copy­cat ef­fect. When peo­ple hear about sui­cide, more sui­cides oc­cur. I think you have to as­sume that that’s some­thing that hap­pens, and I think you have to ap­ply it in this case too.”

Dr. Christie says physi­cian-as­sisted sui­cide laws may be es­pe­cially in­flu­en­tial be­cause they coopt two in­sti­tu­tions that peo­ple are brought up to trust — the law and medicine.

“The law is a teacher,” Dr. Christie says. “When the law says that sui­cide is an hon­or­able, com­pas­sion­ate so­lu­tion for suf­fer­ing, it would only make sense that sui­cide would in­crease in so­cial ac­cep­tance for other cases. It’s like mar­i­juana laws. When you make med­i­cal mar­i­juana le­gal, then it in­creases the so­cial ac­cept­abil­ity of mar­i­juana in gen­eral.”

Para­phras­ing English poet John Donne, Dr. Tof­fler says each of us is vul­ner­a­ble when sui­cide is seen as a so­lu­tion to life’s prob­lems.

“We are not is­lands,” he says. “We should sup­port and help peo­ple get through their dif­fi­cul­ties and their fears.”


Brit­tany May­nard’s high-pro­file physi­cian-as­sisted sui­cide brought at­ten­tion to the is­sue — some say for bet­ter, oth­ers for worse.

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