"Women, divorcees and atheists are most likely to choose assisted suicide," the Mail Online reports, "with nearly 20% saying they are 'simply weary of life'".
The Mail’s headline is misleading. The story comes from a study of assisted suicides in Switzerland, where the practice is legal.
The study found that in 16% of assisted suicides, no underlying cause of death was recorded.
This is important, but there is no evidence that these cases were “weary of life”, an expression which the Mail has taken from another study.
This study found that cancer was the most common cause given for assisted suicides. It also found that assisted suicide was more likely in women than men, those living alone than those living with others (particularly divorced older women), and those with no religious affiliation (compared with Protestants and Catholics).
This is a small study of 1,301 assisted suicides and its findings may be based on incomplete data. Since as the authors point out, at present in Switzerland, there is no obligation for such deaths to be recorded centrally.
However it is a useful contribution to the debate as to whether some vulnerable groups – such as those living alone – may be more likely to opt for assisted suicide than others.
It is important to stress that, despite some media reports to the contrary, there is a range of effective palliative care options that allow people with terminal and debilitating conditions to pass away, unassisted, in dignity.
Where did the story come from?
The study was carried out by researchers from the University of Bern, the Federal Statistical Office, the Hospital of Psychiatry Muensingen and University Hospital of Psychiatry, all in Switzerland. It was funded by the Swiss National Science Foundation. The authors declared that they had no conflicts of interest.
The study was published in the peer-reviewed International Journal of Epidemiology.
The Mail Online’s reporting of the study was inaccurate. The headline used an expression taken from another study quoted by the researchers in which the authors conclude that “weariness of life” may be an increasingly common reason for people choosing assisted suicide.
The paper has conflated the two studies to give the false impression that one fifth of people opting for assisted suicide say they are weary of life.
Also, defining those with no religious affiliation as ‘atheists’ is inaccurate. It could be some of these people had religious beliefs but did not subscribe to the tenets of an organised religion.
What kind of research was this?
This was a population based cohort study which examined a range of factors associated with assisted suicide in Switzerland.
Assisted suicide is when someone who is typically suffering from severe illness, takes their own life with assistance from someone else.
It is sometimes confused with voluntary euthanasia, in which a person makes a conscious decision to die but someone else – usually a doctor – performs the final act, usually to relieve pain and suffering.
Assisted suicide is legal in Switzerland, and usually involves help from right-to-die organisations such as Dignitas, although doctors may be involved in prescribing lethal medication.
Euthanasia is prohibited in Switzerland.
The authors point out that there are concerns that vulnerable or disadvantaged groups are more likely to choose assisted suicide than others, with some opponents arguing there is evidence of a ‘slippery slope’.
The fear being that that instead of a last resort option, vulnerable groups who could have other viable treatment options, may be coerced into choosing it.
What did the research involve?
The researchers linked the mortality records of suicides assisted by right-to-die organisations from 2003-2008, with a national cohort study of mortality, based on Swiss census records.
They looked at a number of factors, including:
- age (in 10 year bands)
- religion (Protestants, Catholics, no affiliation)
- education (compulsory, secondary and tertiary)
- marital status (single, married, divorced, widowed)
- type of household (single person, multi person, institution)
- having children (yes or no)
- urbanisation (urban, semi-urban, rural)
- a national neighbourhood index of socio economic position (based on factors such as rent, living space, etc.)
- language region (German, French, Italian)
- nationality (Swiss or foreign)
Separate analyses were done for younger (25-64 years) and older (65-94 years) people.
Their analysis is based on the 2000 census. Individuals in this census were followed from January 2003 until their death, emigration or the end of the study period in 2008.
Researchers used information from three right-to-die associations active in Switzerland at the time, all of which assist people who wish to commit suicide. These three associations provided anonymous data on all deaths of Swiss residents they assisted between 2003 and 2008 to a government statistics office. The researchers identified these deaths in the national cohort, based on data including the cause of death, date of death, date of birth, gender and community of residence.
They determined the underlying cause of death using the International Classification of Diseases (ICD-10) and examined which underlying causes of death were associated with assisted suicide.
They also identified factors associated with death certificates that did not list any underlying cause.
What were the basic results?
The researchers analysis was based on 5,004,403 Swiss residents and 1,301 assisted suicides (439 in the younger and 862 in the older group).
They found that in 1,093 (84.0%) assisted suicides, an underlying cause was recorded. Cancer was the most common cause (508, 46.5%), followed by nervous system disorders such as motor neuron disease, multiple sclerosis, and Parkinson’s disease (81, 20.6%).
In both age groups, assisted suicide was more likely in women than in men (for all causes except Parkinson’s Disease), those living alone compared with those living with others and in those with no religious affiliation compared with Protestants or Catholics.
The assisted suicide rate was also higher in more educated people, in urban compared with rural areas and in neighbourhoods of higher socioeconomic position.
In older people, assisted suicide was more likely in the divorced compared with the married.
In younger people, having children was associated with a lower rate of assisted suicide.
How did the researchers interpret the results?
The researchers say their findings are relevant to the debate on whether a disproportionate number of assisted suicides occur among vulnerable groups.
The higher rates among the better educated and those living in neighbourhoods of high socio-economic standing does not support the ‘slippery slope’ argument but may reflect inequalities in access to assisted suicide, they argue.
On the other hand, the higher rate of assisted suicide among people living alone and the divorced suggest that social isolation and loneliness may play a role in assisted suicides. The observation that women die by assisted suicide more frequently than men is also of concern.
They also point out that in 16% of death certificates no underlying cause of death was recorded despite the fact that only those who suffer from an incurable illness, intolerable suffering or a severe disability are eligible for assisted suicide. They note that the cause should have been recorded on the death certificate.
They mention a previous study which found that in about 25% of assisted suicides no fatal illness was present and which concluded that “weariness of life” may be an increasingly common reason for people opting for assisted suicide. They also argue that it should be compulsory to register assisted suicides and to include data on patients’ characteristics, so they can be monitored.
Further research is needed to explore reasons for the differences in assisted suicide rates found in the study and to what extent they reflect greater vulnerability, they argue.
As the authors point out, there is no obligation to report assisted suicides to any central registry, so it is possible these findings are based on incomplete information.
It’s important to note that this was a small study involving 1,301 assisted suicides and the findings are based on quite small numbers – for example, 665 women were assisted suicides compared to 505 men.
The debate over assisted suicide and concerns as to whether some vulnerable groups are more likely opt for assisted suicide – for example, those living alone – is important.
Further research is required in this area rather than jumping to the conclusion that people living alone and the divorced are opting for assisted suicide due to loneliness.
It is likely to be multifactorial, including ability to care for themselves, illness status, prognosis, family and social support and access to medical and nursing care.
There are several alternative approaches and options for people with terminal conditions or those experiencing intolerable suffering, such as palliative sedation, where a person is given medication to make them unconscious and, therefore, unaware of pain.
Analysis by Bazian
Edited by NHS Website
Links to the headlines
Mail Online, 19 February 2014
Links to the science
International Journal of Epidemiology. Published online February 18 2014