Assisted-suicide laws foster copycat worries
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.