Aaron Kheriaty is an associate professor of psychiatry and director of the medical ethics program at the University of California at Irvine School of Medicine. This piece is adapted from a longer commentary that appeared in the Southern Medical Journal in October.
The debate over doctor-assisted suicide is often framed as an issue of personal autonomy and privacy. Proponents argue that assisted suicide should be legalized because it affects only those individuals who — assuming they are of sound mind — are making a rational and deliberate choice to end their lives. But presenting the issue in this way ignores the wider social consequences.
What if it turns out that the individuals who make this choice in fact are influencing the actions of those who follow? Ironically, on the same day that Gov. Jerry Brown (D) signed the bill to legalize physician-assisted suicide in California last month, an important study was published by British scholars David Jones and David Paton demonstrating that legalizing assisted suicide in other states has led to a rise in overall suicide rates — assisted and unassisted — in those states. The study’s key findings show that, after controlling for demographic and socioeconomic factors and other state-specific issues, physician-assisted suicide is associated with a 6.3 percent increase in total suicide rates. These effects are greater for individuals older than 65 (for whom the associated increase was 14.5 percent). The results should not surprise anyone familiar with the literature on the social contagion effects of suicidal behavior. You don’t discourage suicide by assisting suicide.
Consider what social scientists call the Werther effect — the fact that publicized cases of suicide can produce clusters of copycat cases, often disproportionately affecting young people, who frequently use the same method as the original case. The name comes from Goethe’s 18th-century novel “The Sorrows of Young Werther,” in which the protagonist, thwarted in his romantic pursuits, takes his own life with a pistol. After the publication of this immensely popular book, authorities in Germany noted a rash of suicides among young men using the same means. This finding has been replicated many times since in rigorous epidemiological studies, including research demonstrating this effect following cases of doctor-assisted suicide.
Because this phenomenon is well validated, the U.S. Centers for Disease Control and Prevention, the World Health Organization and the U.S. surgeon general have published strict journalistic guidelines for reporting on suicides to minimize this effect. It is demoralizing to note that these guidelines were widely ignored in the reporting of recent instances of assisted suicide, with the subject’s decision to end his or her life frequently presented in the media as inspiring and even heroic.
A related phenomenon influences suicide trends in the opposite direction, however; the so-called Papageno effect suggests that coverage of people with suicidal ideation who do not attempt suicide but instead find strategies that help them to cope with adversity is associated with decreased suicide rates. The name comes from a lovesick character in Mozart’s opera “The Magic Flute,” whose planned suicide is averted by three child spirits who remind him of alternatives to death.
The case of Valentina Maureira, a 14-year-old Chilean girl who made a YouTube video begging her government for assisted suicide, illustrates the Werther and Papageno effects. Maureira admitted that the idea to end her life began after she heard about the case of Brittany Maynard, a 29-year-old woman with terminal brain cancer who campaigned prominently for the right to assisted suicide before ending her life last year. But Maureira changed her mind after meeting another young person also suffering from the same disease, cystic fibrosis, who conveyed a message of hope and encouraged her to persevere in the face of adversity. With our laws, we can encourage vulnerable individuals in one of these two directions: the path of Werther or the path of Papageno.
Aside from publicized cases, there is evidence that suicidal behavior tends to spread person to person through social networks, up to three “degrees of separation” away. So my decision to take my own life would affect not just my friends’ risk of doing the same, but even my friends’ friends’ friends. No person is an island.
Finally, it is widely acknowledged that the law is a teacher: Laws shape the ethos of a culture by affecting cultural attitudes toward certain behaviors and influencing moral norms. Laws permitting physician-assisted suicide send a message that, under especially difficult circumstances, some lives are not worth living — and that suicide is a reasonable or appropriate way out. This is a message that will be heard not just by those with a terminal illness but also by anyone tempted to think he or she cannot go on any longer.
Debates about physician-assisted suicide raise broad questions about our societal attitudes toward suicide. Recent research findings on suicide rates press the question: What sort of society do we want to become? Suicide is already a public health crisis. Do we want to legalize a practice that will worsen this crisis?