Suicides are at crisis levels. The number of people who kill themselves in the United States has risen 30% since 2000. Indeed, so many people kill themselves that according to the Center for Disease Control and Prevention (CDC), suicide is one of the country’s leading causes of death, with 45,979 self-killings in 2000.[i] (In comparison, in the same year, 38,824 people were killed in U.S. auto accidents.[ii]) And that shocking number doesn’t take into account those who think seriously about suicide—12.2 million American adults—or the 1.2 million who attempt it and live. Something has clearly gone very wrong with our culture.
The causes of the suicide crisis are many and complex and beyond fully exploring here. But one aspect of the question of causation seems highly relevant, and yet, barely receives the attention it deserves among suicide experts. That question is this: What role does advocacy for—and legalization of—assisted suicide/euthanasia have, if any, in increasing the number of suicides?
As a matter of logic and intuition, assisted suicide advocacy would seem to logically have an upward impact on the kind of increased suicide rates we are experiencing. Legalizing assisted suicide not only sends the nihilistic societal message that public policy does not unequivocally oppose all suicides, but once a state gives its imprimatur to self-killing as a means of alleviating suffering, the “pro-some suicides” message that sends will be heard by suicidal people who may have reasons for wanting to kill themselves beyond those allowed by laws legalizing assisted suicide.
Medical Aid in Dying is Suicide
Before we discuss the few studies conducted on this question, let’s set the full table. Assisted suicide advocacy, by definition, promotes suicide—of the terminally ill who want to die in this country, but which countries like the Netherlands, Canada, Belgium, and others open to suicidal people with chronic diseases, disabilities, age-related morbidities, and mental illnesses. That presents a political problem for activists. They know that suicide per se is not popular. So they deploy word engineering tactics by calling assisted “suicide” something that people will find less off-putting.
These terms have shifted over time. The formerly-favored term in euthanasia advocacy was “death with dignity.” These days, the euphemism of choice is the focus group-tested “medical aid in dying” [iii]—which usually goes by the acronym MAID to further obscure the lethality of what is being described.
Here is the scam. Because (in the U.S) laws that legalize assisted suicide restrict doctor-prescribed death (for now) to the terminally ill, and but for being diagnosed as dying, these patients would otherwise want to live, when they take a lethal overdose of barbiturates, they are not really committing suicide. Rather, they are merely receiving a medical treatment known as MAID. Thus, under euthanasia activists’ reckoning, if the distraught owner of, say, a failed business intentionally takes an overdose of prescribed sleeping pills, it’s suicide. But if the same man takes the pills because he has cancer, and the doctor prescribed the pills for that purpose, it is not suicide.
This is specious nonsense. Suicide describes what is done, not why. Suicide is defined as “Suicide is defined as “the act or an instance of taking one’s own life voluntarily and intentionally.”[iv] Assist means “to give support or aid.”[v] When a suicidal person is prescribed an overdose by a doctor, that person is being aided in the suicide, hence, “assisted suicide.” Thus, the term, “assisted suicide,” is both accurate and descriptive of the subject being discussed.
Adding to the confusion, laws that legalize assisted suicide specifically redefine the act as not being suicide. For example, Oregon’s “Death with Dignity Act,” states: “Actions taken in accordance with [the statute] shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law’[vi] Some states even require prescribing doctors to lie on death certificates of their patients whose suicides they assisted that the cause of death was the underlying disease.[vii] Such sophistry may be politically expedient, but it does not change the nature of the act.
Suicide Prevention Organizations Ignore Assisted Suicide Advocacy
The legal definitions in statutes are not the only means by which assisted suicide is made to disappear as relevant to the suicide crisis. Suicide prevention campaigns have joined the chorus, or better stated, have validated the false distinction by failing to address the issue in their campaigns and on their websites. Indeed, if one looks closely at most contemporary suicide prevention advocacy, it is as if assisted suicide advocacy doesn’t exist.
Perhaps, these organizations—which tend to be very establishment in outlook—worry that their fund-raising would be impeded by taking on such a divisive issue. This is certainly understandable. But it is not excusable. In this context, silence equals consent, perhaps even approval. But pretending that assisted suicide advocacy isn’t relevant abandons some of the very despairing people these organizations and their prevention campaigns are supposed to protect.
Space only permits a partial list of these abdicating groups and institutions. Let’s start with the federal government. The CDC recently published a “strategic plan” to prevent suicide. And yet, despite the thousands of assisted suicides that have taken place in this country[viii]—which, as stated above are suicides—there is no mention of “assisted suicide,” “euthanasia,” “MAID”, “aid in dying,” or any reference to the impact of doctor-prescribed death on suicide statistics.[ix] This despite the “Vision” enunciated in the Strategic Plan being, “No lives lost to suicide.”[x]
Other suicide prevention organizations are similarly AWOL. The American Foundation for Suicide Prevention does not grapple with the issue of assisted suicide in promoting its laudable goal of saving the lives of suicidal people. Indeed, the organization’s website even discusses the role of doctors in this quest—without mentioning assisted suicide at all:
Health professionals regularly encounter individuals who are at risk for suicide. Despite the comorbidity or co-occurrence of mental health conditions and suicide, the vast majority of mental health professionals — a group that includes psychiatrists, psychologists, social workers, licensed counselors, and psychiatric nurses — do not typically receive routine training in suicide assessment, treatment, or risk management. Primary care providers are also in a unique position to identify patients at risk of suicide and enact appropriate intervention methods. Of people who die by suicide, almost half had contact with their primary care provider in the month before death, and three out of every four had contact with their primary care provider in the year before death.[xi]
The Website doesn’t even urge doctors who may be asked to write lethal prescriptions to say no and instead, engage prevention services for their at-risk patients. Worse, its white paper on training doctors to prevent suicide makes no mention of the issue.[xii] Indeed, using the search function on the website found no mention whatsoever of “assisted suicide,” “euthanasia,” “aid in dying,” or the like.
One organization—the American Association of Suicidology (AAS) doesn’t ignore the issue but actively advocates for denying suicide prevention to terminally ill patients who want assisted suicide unless they are found to have impaired judgmental capacities:
While many forms of end-of-life care may be helpful, including palliative and hospice care, a patient’s choice of PAD [physician assisted death] that satisfies legal criteria is not an appropriate target for “suicide” prevention.[xiii]
In other words, the AAS does not believe assisted suicide of the terminally ill should be prevented–despite its unequivocal mission statement, that reads: “To promote the understanding and prevention of suicide and support those who have been affected by it.”[xiv]
Making matters even more alarming, the Statement foresees a time when assisted suicide is expanded beyond the terminally ill (my emphasis):
Nor does the fact that suicide and PAD are not the same indicate that some cases identified as suicides may not be deaths that have a great deal in common with PAD, especially those in which poor health is a precipitating factor. Although such cases are typically labeled ‘suicide’ if the person initiated the causal process leading to death, medical conditions associated with suicide risk in potentially terminal illness—including (among the best studied) cancer, cardiovascular disease, COPD, Huntington’s, HIV/AIDS, multiple sclerosis, ALS, Parkinson’s, renal disease, and Alzheimer’s—may arise from the motivation to avoid a protracted, debilitating, and potentially painful bad death.[xv]
Did you get that? The AAS statement is softening the ground for expanding supposedly not suicide “aid in dying” laws to include situations that “have a great deal in common with PAD,” e.g., people with disabilities, chronic illnesses, and progressive conditions. This is a betrayal of the very people suicide preventers are supposed to help.
Legalizing Assisted Suicide Increases Suicide[xvi]
Now, let’s explore whether the above has impacted overall suicide rates. Frustratingly, even though the nation ‘s first assisted suicide law passed in Oregon 30 years ago, few studies have been conducted to determine whether legalization has had any effect on the increasing rates of suicide. But 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 (at the time, Oregon, Washington, Vermont, and Montana). 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%.”
As is usual in professional discourse, the above study was praised and criticized in a 2017 responsive paper published in the 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.”[xvii]
In 2022, one of the authors of the original paper responded to this criticism in the JEMH. This time, he compared suicide rates in European countries that had legalized euthanasia with demographically similar countries that had not, and reported a “concerning pattern” where EAS (euthanasia/assisted suicide) is legal. The study found (much to my expectation) that in the four jurisdictions 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.”[xviii]
In 2022, a third study was published 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 their hypothesis that legalizing assisted suicide 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.”
And indeed, 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%.
Did the increase in suicides include unassisted suicides? Yes.
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.[xix]
What are we to make of all of this? There is evidence that suggests suicide begets suicide, and that legal assisted suicide increases suicide rates overall. Obviously, more empirical studies and pointed analyses need to be undertaken, 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.
Turning Suicide into a Human Right
There may not be much time. Assisted suicide advocacy is pushing Western society toward transforming suicide from a tragedy into a liberty interest. Lest the reader think I am alarmist, in Germany suicide and assisted suicide have already been transformed from actions that can be prevented legally into a fundamental human right.
A recent ruling from Germany’s highest court cast right-to-die incrementalism aside and conjured a fundamental right both to commit suicide and to receive assistance in doing it. Moreover, the decision explicitly rejected limiting the right to people diagnosed with illnesses or disabilities. As a matter of protecting “the right of personality,” the court decreed that “self-determined death” is a virtually unlimited fundamental liberty that the government must guarantee to protect “autonomy.” In other words, the German people now have the right to kill themselves at any time and for any reason—and receive help from anyone in doing it. From the decision (published English version, my emphasis):
The right to a self-determined death is not limited to situations defined by external causes like serious or incurable illnesses, nor does it only apply in certain stages of life or illness. Rather, this right is guaranteed in all stages of a person’s existence. . . . The individual’s decision to end their own life, based on how they personally define quality of life and a meaningful existence, eludes any evaluation on the basis of general values, religious dogmas, societal norms for dealing with life and death, or consideration of objective rationality. It is thus not incumbent upon the individual to further explain or justify their decision; rather their decision must, in principle, be respected by state and society as an act of self-determination.
The court wasn’t done. The right to suicide also includes a right to assist suicide:
The right to take one’s own life also encompasses the freedom to seek and, if offered, utilize assistance provided by third parties for this purpose. . . . Therefore, the constitutional guarantee of the right to suicide corresponds to equally far-reaching constitutional protection extended to the acts carried out by persons rendering suicide assistance.
The court also opined that Germany’s drug laws might have to be changed to facilitate the absolute right to die that “the state must guarantee”:
Sufficient space must remain in practice for the individual to exercise the right to depart this life and, based on their free will and with the support of third parties, to carry out this decision on their own terms. This not only requires legislative coherence in the design of the legal framework applicable to the medical profession and pharmacists but potentially also requires adjustments of the law on controlled substances.[xx]
This is stunning and appalling: The court’s ruling is so encompassing that it seems to apply even to children capable of making autonomous decisions, since being underage is a “stage of existence.”
Western society is no longer anti-suicide, but anti-some-suicides. It still energetically seeks to prevent youth and veteran suicides. And the media assists in that effort. But at the same time, media, popular culture, and the law promote assisted suicide as a means of “dying on one’s own terms. For example, CNN named Brittany Maynard, who moved to Oregon from California to commit assisted suicide after being diagnosed with terminal brain cancer, one of its “11 Extraordinary People of 2014.”[xxi]
Assisted suicide advocacy is certainly not the only factor in our worsening suicide crisis. It may not even be the most impactful cause, which include the increasing nihilism of society, the opioid catastrophe, family breakdown, the isolation caused by COVID policies, the loss of community, the growth of nihilism, etc.. But I do think the entire assisted suicide phenomenon plays a prominent role, still insufficiently appreciated or understood. Indeed, if there is a “right to die,” how can it be limited to restricting categories? After all, as the old saying goes, in for a penny—in for a pound.
In all of this, I am reminded of the prophetic lament by Canadian journalist Andrew Coyne written more than twenty years ago. Reacting to his country’s strong public support for a father who murdered his disabled daughter as a supposed act of compassion, Coyne wrote: “A society that believes in nothing can offer no argument even against death. A culture that has lost its faith in life cannot comprehend why it should be endured.”[xxii]
True. If we don’t change our current cultural trajectory, we will not only become pro-some suicides but suicide-embracing all-in-all.
[ii] U.S Department of Transportation’s National Highway Traffic Safety Administration, “NHTSE Releases 2020 Traffic Crash Data, Marcy 2, 2022. NHTSA Releases 2020 Traffic Crash Fatality Data | FARS | NHTSA
[iii] See for example, Compassion and Choices, “Medical Aid in Dying” is not Assisted Suicide or Euthanasia,” Medical Aid In Dying is Not Assisted Suicide, Suicide or Euthanasia (compassionandchoices.org)
[vi] Oregon Death with Dignity Act, “127.880 s.3.14. Construction of Act.” Oregon Health Authority : Oregon Revised Statute: Oregon’s Death with Dignity Act : Death with Dignity Act : State of Oregon
[viii] According to Encyclopedia Britannica, “State by State Physician-Assisted Suicide Statistics,” January 28, 2019, between 1998 and 2019, 2, 814 people died from taking lethal prescriptions, with more than 4000 such prescriptions written. State-by-State Physician-Assisted Suicide Statistics – Euthanasia – ProCon.org
[xi] American Foundation for Suicide Prevention, “Health Professional Training in Suicide Assessment, Treatment, and Management,” Training health professionals in suicide assessment, treatment & management (State priority) (afsp.org)
[xii] American Foundation for Suicide Prevention, “Policy Priority: Training for Health Professionals in Suicide Assessment, Treatment, and Management,” February 18, 2022. 1650599248-afsp-health-professional-training-issue-brief.pdf (datocms-assets.com)
[xiii] American Association of Suicidology, “Suicide is Not the Same Thing as ‘Physician Aid in Dying,’” October 30, 2017, AAS PAD Statement Approved 10.30.17 ed 10-30-17 (suicidology.org)
[xv] AAS, “Suicide is not the Same,” Supra.
[xvi] Some of the material in this section was taken from Wesley J. Smith, “Suicide Contagion,” First Things, May 19, 2022. Suicide Contagion | Wesley J. Smith | First Things
[xviii] David Albert Jones, “Euthanasia, Assisted Suicide, and Suicide Rates in Europe,” JEMH, Open Volume 11, 2022. JEMH article EAS and suicide rates in Europe – copy-edited final.pdf
[xix] Sourafel Girma and David Paton, “Assisted Suicide Laws Increase Suicide Rates, Especially Among Women,” CEPR, April 29, 2022. Assisted suicide laws increase suicide rates, especially among women | VOX, CEPR Policy Portal (voxeu.org)
[xx] The Federal Constitutional Court, “Criminalization of Assisted Suicide Services Unconstitutional,” February 26, 2020. Bundesverfassungsgericht – Press – Criminalisation of assisted suicide services unconstitutional
[xxii] Andrew Coyne, “The Slippery Slope That Leads to Death,” Globe and Mail, November 21, 1994.