Do suicides increase where euthanasia is legal?

This article was published by Mercatornet on May 22.

The euthanasia debate is on the front-burner in Australia, especially in the states of Victoria and Tasmania. In one of the latest salvos, ethicist Professor Margaret Somerville claimed that suicide rates rise in jurisdictions where euthanasia and assisted suicide are legal. This prompted a blast from Neil Francis, a former President of the World Federation of Right To Die Societies and a leading campaigner for euthanasia in Australia. This is Professor Somerville’s response.

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Margaret Somerville

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Neil Francis is correct in criticizing me for a loose statement that "the general suicide rate has increased in every jurisdiction that has legalized assisted suicide." 

Although I believe that my statement will prove to be correct, at this point in time I should have left out the word "every." 

One problem in obtaining the required evidence, is that it’s difficult if not impossible to know how often physician-assisted suicide or euthanasia (PAS-E) is being used in countries where those interventions are legal to commit what we should view as “ordinary suicide”–if one can ever regard suicide as “ordinary”, but for want of a better term. 

“Suicide by police”–a suicidal person engages in conduct with the intention that the police will respond by shooting them - is a recognized phenomenon. Now we can consider “suicide by physician”. 

Two features of legalized PAS-E make “suicide by physician” seem likely: The percentage of deaths occurring from PAS-E, for instance, in The Netherlands and Belgium, is rising by approximately 10 per cent each year and is now around 4 percent of all deaths. And the conditions for access to PAS-E are expanding in both jurisdictions. If one is not terminally or physically ill, neither of which is a legal requirement in either country, is euthanasia “ordinary suicide”? And what about if a person wants PAS-E because they are just “tired of life” or feel they have a completed life as the Netherlands is now contemplating allowing or, as an elderly couple proposed on ABC’s Q&A, simply want to avoid going into a nursing home, should these be classified as “ordinary suicide” cases? 

Cases in which using PAS-E as a substitute means of suicide seems very likely have made headlines around the world. They include the deaf Belgian twins who were going blind; the young gender-dysphoric woman with the botched sex-change operation; the anorexic woman in her 20s; the depressed 34 year old Eva, whose death by euthanasia is focused on in real time in the documentary film, “End Credits”, made by Dutch pro-euthanasia advocates; the convicted rapist and murderer in the Belgium prison. 

Dutch Professor Dr. Theo Boer, a former member of one of Holland’s five Euthanasia Regional Review Committees (2005-2014) has undertaken a study which will be published shortly which, in his words, shows 

Theo Boer

the assumption that euthanasia will lead to lower suicide rates finds no support in the numbers. The percentage of euthanasia deaths of the total mortality rate tripled from 1.3% in 2002 to 4.08% in 2016. During that same period, the suicide numbers did not go down: From being 1,567 in 2002, they went up to 1,871 in 2015, a rise of 19.4%. The suicide rates reached a relative low of 1,353 in 2007, compared to which the 2015 numbers constitute a rise of 38.3%. This is even more significant given the fact that from 2007 on euthanasia started becoming available to people with chronic diseases–psychiatric diseases, dementia, and others. In terms of the percentage of the overall mortality of suicide deaths, the numbers went up from 1.01% in 2007 to 1.27% in 2015.  

…For the sake of comparison, I have looked at the suicide rates of some countries which are close to the Netherlands in terms of ethnicity, age, religion, and language but which, with the exception of Belgium, lack the option of euthanasia. If the suicide numbers in the Netherlands have gone up, one would expect, at least a similar increase in the suicide numbers would occur in countries without the option of euthanasia. However,…the Netherlands of all countries show the biggest increase in the suicide numbers.” 

Mr. Francis dismisses researchers David Jones' and David Paton’s report on suicide data in Oregon on which I relied to show a rise in the state’s suicide rates on the basis that it was “published in a minor journal”, the Southern Medical Journal. This claim is specious, even if it were a “minor journal”. For the record, it is a peer-reviewed medical journal indexed and abstracted in Index Medicus, Current Contents, Science Citation Index, and EMBASE which has published over 45,000 articles. I leave it to others to decide its status. 

Moreover, if Mr. Francis’ claim as to its status were correct and if Jones’ and Paton’s article were, as Mr. Francis describes it, “a wobbly econometric modelling study”, it stands to reason that the journal would be more accessible in terms of publishing rebuttals or questions about the article. To date, to my knowledge, no one has done so, not there, not anywhere. 

Mr. Francis’, at best, woolly statements about what Jones’ and Paton’s study found need clarifying. They write: 

[W]e found that legalizing PAS was associated with a 6.3% (95% confidence interval 2.70%–9.9%) increase in total suicides (including assisted suicides). This effect was larger in the individuals older than 65 years (14.5%, CI 6.4%–22.7%). Introduction of PAS was neither associated with a reduction in nonassisted suicide rates nor with an increase in the mean age of nonassisted suicide. (Emphasis added)  

Conclusions: Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. 

As Jones and Patton recall, pundits claimed at the time of the public debate in Oregon about legalizing physician-assisted suicide that having access to assisted suicide would reduce “nonassisted” or “ordinary suicide”, which it clearly did not. This is something Australian legislators should note. 

I will just mention California, which has very recently legalized physician-assisted suicide. There was concern that people who were involuntarily hospitalized because they were mentally ill and “dangerous to themselves (they were suicidal) or others” could not have access to physician-assisted suicide. This has now been “remedied” and a special process established to allow them to apply to have physician assistance in killing themselves. 

Finally, I want to address Mr Francis’ ad hominem attack on me. I respectfully suggest that regarding this attack Mr Francis should take my advice, which he quotes, about the necessity to get one’s facts correct in order to act ethically. 

Mr Francis’ quote from Judge Hanson is taken out of context. It referred to my not being an expert in child psychology, which I have never purported to be and which I myself confirmed when giving evidence on oath on deposition. In other words, Judge Hanson based his ruling on my own evidence of having no expertise in that particular area of research. Here’s how that ruling came about. 

I participated as an expert witness in the Iowa same-sex marriage case, which Mr Francis cites, as an academic with expertise in the ethics and law of assisted human reproduction, including the technologies used in such interventions. These technologies are relevant to same-sex marriage because, as the Court of Appeal of Ontario ruled in the Halpern case, a Canadian same-sex marriage case, same-sex couples can use them to exercise the right to found a family that marriage gives them. 

Lawyers on each side try to undermine the credibility of opposing expert witnesses by denying the relevance of their expertise to the issues the case raises and discrediting their evidence. The plaintiffs’ lawyers did this by asking me, on oath, whether I was “an expert in developmental child psychology” and whether I had carried out “empirical research” in that area. I laughed and said, “Of course not”, as they were fully aware. These statements were then entered in evidence by the plaintiffs’ lawyers. 

Trial judge Robert Hanson ruled that only evidence from experts on child developmental psychology was relevant and cited my deposition evidence that I was not such an expert to exclude me as an expert witness and make the derogatory statements about me Mr. Francis repeats in his article. On appeal, seven Iowa Supreme Court judges reversed this exclusion and my affidavit expert evidence was admitted in evidence, but, like Mr. Francis many people who try to discredit my arguments and me have continued to use Judge Hanson’s statement with no clarification. It seems that when people who oppose my views and values have no strong arguments to bolster their opposition, they turn to Judge Hanson's ruling, wrongly apply it, in general, and fail to disclose it was overruled. This is hardly a completely honest approach. 

The claim that I eschew methods of logical reasoning in favour of “moral intuition” is misleading. Increasingly scientific research is showing that we have multiple, valid “human ways of knowing”, including moral intuition and reason. I believe that reason is “a secondary verification mechanism” (secondary only in terms of chronology) that is crucially important to ensure we’ve not gone off-track using these other ways. 

In short, ethical decision-making is a complex phenomenon and nowhere more so than when we are making decisions about what should and should not be our societal norms and values–what is ethically right and wrong–including with respect to legalizing the intentional infliction of death through physician-assisted suicide or euthanasia. 

Margaret Somerville is Professor of Bioethics in the School of Medicine at the University of Notre Dame Australia.