I have often argued that, as a matter of logic and intuition, the widespread legalization of assisted suicide will increase both the rate of assisted suicides and the rate of unassisted suicides. After all, many people conflate what is “legal” with what is “right.” Once a state gives its imprimatur to assisted suicide as a way of alleviating suffering and providing “medical aid in dying,” as it is euphemistically called, an ever-increasing number of people will resort to that means of ending their lives. And indeed, some recent studies suggest that in places where assisted suicide is legal, both assisted suicides and unassisted suicides increase.
Advocates of assisted suicide disagree, of course. One argument—which the media often parrots—holds that people with suicidal ideation not caused by terminal illness are unlikely to be influenced by legalization of assisted suicide because “medical aid in dying” is a treatment and not “suicide.” This argument has never rung true for me. That is simply not how the human mind works, particularly when we are in extremis. It has always seemed to me that suicidal people are likely to think that society’s approval of suicides for the terminally ill also applies to them, even if the cause of their existential crisis and misery falls outside the current parameters of legalization.
Even though overall suicide rates have risen considerably throughout the West in recent years, few studies have been conducted to determine whether the legalization of assisted suicide has had any effect on this concerning trend. That is slowly beginning to change. In 2015, a study published in the Southern Medical Law Journal applied CDC suicide data from states where assisted suicide was legal (Oregon, Washington, Vermont, and Montana, where legality remains a matter of dispute). The authors reported that “PAS [physician-assisted suicide] is associated with an 8.9% increase in total suicide rates” (including assisted suicides), and when “state-specific time trends” are included, “the estimated increase is 6.3%.” The authors concluded: “The introduction of PAS seemingly induces more self-inflicted deaths than it inhibits.”
This report, as is usual in professional discourse, was praised and criticized in a responsive paper published in 2017 in Journal of Ethics in Mental Health (JEMH). While the critics recognized some strengths in the earlier study, they noted that suicide rates in Washington and Montana had been increasing before legalization, that the work exhibited “methodological weaknesses” (such as not taking trends in nations such as the Netherlands and Belgium into account), and that “association does not prove causation.” Still, even these critics did not contend that legalizing assisted suicide had no effect on overall suicide rates. Rather, they argued that much more research needed to be conducted “before definitive claims about the effects of legalization of medical assistance in dying on non-assisted suicide can be made.”
Earlier this year, the original authors responded to this criticism in the JEMH. This time, they compared suicide rates in European countries that had legalized euthanasia with demographically similar countries that had not. Again, the authors found a “concerning pattern” where EAS (euthanasia/assisted suicide) is legal. They found, much to my expectation, that in the four jurisdictions they studied in which euthanasia and assisted suicide (EAS) are legal, “there have been very steep rises in suicide.” Moreover, “In none of the four jurisdictions did non-assisted suicide rates decrease after introduction of EAS.” In the Netherlands—which has recorded the highest number of deaths by EAS, “the rates of non-assisted suicide” increased since legalization. Even in Belgium, where “non-assisted suicide decreased in absolute terms, they increased relative to its most similar non EAS neighbor: France.”
A third study was just released also showing an increase in suicide rates associated with assisted suicide legalization, with a particularly adverse effect on women. Two professors, writing for the Centre for Economics Policy Research (CEPR), tested the hypothesis that legalizing assisted suicide would actually reduce suicide rates, and countered with their own hypothesis that doing so would “not only reduce practical barriers to committing suicide but may also lower societal taboos against suicide,” leading to “an increase of suicide rates overall.”
After reviewing data taken from U.S. states that legalized assisted suicide as of 2019, and referencing the studies described above, the authors concluded:
There is very strong evidence that the legalisation of assisted suicide is associated with a significant increase in total suicides. Further, the increase is observed most strongly for the over-64s and for women. To give an idea of the size of the effect, the event study estimates suggest assisted suicide laws increase total suicide rates by about 18% overall. For women, the estimated increase is 40%.
And what about the unassisted suicides in that increase in total suicides?
There is weaker evidence that assisted suicide is also associated with an increase in unassisted suicides. The effect is smaller (about a 6% increase overall, 13% increase for women). It is still statistically significant in the main estimates but not in all of the robustness checks, meaning we have less confidence in that result. However, we find no evidence that assisted suicide laws are associated with a reduction in either total or unassisted suicide rates.
What are we to make of all of this? There is evidence that suggests suicide begets suicide, and that legal assisted suicide has an effect on suicide rates overall. Obviously, we need to undertake more empirical studies and pointed analyses, but if we care as a society about preventing suicides generally—regardless of our beliefs about assisted suicide for the seriously ill—surely the question of assisted suicide contagion should become a pressing concern in fashioning public policy. Before any more states legalize doctor-assisted death, policymakers and the public should focus much more closely on this little-considered aspect of the debate. Human lives literally are at stake.
Wesley J. Smith is host of the podcast Humanize and chairman of the Discovery Institute’s Center on Human Exceptionalism.
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