Some groups of terminally ill patients are twice as likely to die by suicide, data show

Dear Editor

“Every suicide is a tragedy”.[1] This includes suicide of terminally ill people, as well as suicide among disabled people and the frail elderly who would be eligible for “assisted dying” in jurisdictions such as the Netherlands, Belgium, Luxembourg, Switzerland or Canada. I have known someone who died by suicide who would have been eligible to have his death assisted in such countries [2] and it scandalises me that people might think that we should seek not to prevent but instead to encourage or assist suicide of people in his situation.

To my mind this is comparable to the flawed and unlawful policies that exposed people in care homes to COVID-19.[3] According to the British Geriatrics Society “average life expectancy in UK care homes is 24 months for care homes without nursing and 12 months for care homes with nursing.”[4] This is shorter than life expectancy from COPD or from most cancers (i.e. that the population used for the ONS data). Shorter life expectancy is a reason to make palliative care services available for care home residents and to encourage advanced care planning but it is no reason to be indifferent to avoidable death whether by COVID-19 or by suicide.

It is clear that action should be taken to address suicidality in vulnerable populations but nothing in the ONS data shows “the dangers of this country’s ban on assisted dying”.[5] The largest Swiss right-to-die organisation claims that “EXIT’s option of physician-assisted suicide is actually an effective form of suicide prevention.”[6] Similarly, Dignitas claims that “the option of an assisted/ accompanied suicide… is one of the best methods of preventing suicide”.[7] However, there is no evidence behind any of these claims. Indeed a recent study found “strong evidence that legalisation of assisted suicide is associated with an increase in total suicides, especially for females and older people. There is some evidence that assisted suicide laws are also associated with a smaller increase in unassisted suicide.”[8] This is not an isolated result but reflects what has been found in other studies in different jurisdictions.[9][10][11][12][13] No study in a peer review journal has found evidence that introduction of assisted dying is associated with lower rates of suicide, several have flagged up evidence of increased vulnerability to suicide, especially for women.

The ONS data on suicide among people with a terminal diagnosis discloses a real problem that needs to be addressed, but there is no evidence that legalising “assisted dying” (whether euthanasia or assisted suicide, whether for all those included in the ONS data or for more or for fewer) would help. The available evidence suggests that, if anything, it would lead to more suicide not less. Weakening the law against encouraging or assisting suicide will not help prevent suicide.

[1] Preventing suicide: A global imperative. Geneva: World Health Organization, 2.
[2] Jones DA. Assisted dying and suicide prevention. Journal of Disability & Religion, 2018; 22(3): 298-316. https://doi.org/10.1080/23312521.2018.1486773
[3] End of Life Care in Frailty: Care homes https://www.bgs.org.uk/resources/end-of-life-care-in-frailty-care-homes
[4] Booth R. Covid care home discharge policy was unlawful, says court. Guardian, 27 April 2022. https://www.theguardian.com/world/2022/apr/27/covid-discharging-untested...
[5] Hurley R. Some groups of terminally ill patients are twice as likely to die by suicide, data show. BMJ, 2022; 377 https://ezproxy-prd.bodleian.ox.ac.uk:3453/content/377/bmj.o1014
[6] EXIT. FAQ: ‘What Does Physician Assisted Suicide Mean?’ EXIT - Deutsche Schweiz. https://exit.ch/en/englisch/faq/
[7] Submission 67 by Dignitas to Medical Services (Dying with Dignity) Exposure Draft Bill 2014. Parliament of the Commonwealth of Australia, 11 https://www.aph.gov.au/DocumentStore.ashx?id=9d3ff5aa-2732-4402-ba87-3e7...
[8] Girma S, Paton D. Is assisted suicide a substitute for unassisted suicide?. European Economic Review, 2022; 104113. https://www.sciencedirect.com/science/article/pii/S0014292122000551
[9] Jones DA. Euthanasia, assisted suicide, and suicide rates in Europe. Journal of Ethics in Mental Health, 2022 open volume; (Feb): 1-35.
[10] Paton D, Jones DA. How does legalization of physician assisted suicide affect rates of suicide? South. Med. J., 2015; 108 (10, Oct): 599-604.
[11] Zalman M, Stack S. The relationship between euthanasia and suicide in the Netherlands: A time series analysis, 1950-1990. Social science quarterly. 1996:577-93.
[12] Steck N, Zwahlen M, Egger M. Time-trends in assisted and unassisted suicides completed with different methods: Swiss National Cohort. Swiss Med Wkly. 2015;145:w14153.
[13] Steck N, Egger M, Zwahlen M. Assisted and unassisted suicide in men and women: longitudinal study of the Swiss population. Br J Psychiatry. 2016;208(5):484-90.
[13] Nanner H. The effect of assisted dying on suicidality: a synthetic control analysis of population suicide rates in Belgium. J Public Health Policy. 2021;42(1):86-97.
[13] Canetto SS, McIntosh JL. A Comparison of Physician-Assisted/Death-With-Dignity-Act Death and Suicide Patterns in Older Adult Women and Men. Am J Geriatr Psychiatry. 2021.