Effect of Physician-Assisted Suicide on Suicide Rates
The evidence from suicide rates in states that have legalized PAS is not consistent with Posner's conjecture that such legal changes would lead to delays and net reductions in suicide. Rather, the introduction of PAS seemingly induces more self-inflicted deaths than it inhibits. Furthermore, although a significant proportion of nonassisted suicides involve chronic or terminal illness, especially in those older than age 65, the available evidence does not support the conjecture that legalizing assisted suicide would lead to a reduction in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide or that it acts in this way in some individuals but is associated with an increased inclination to suicide in others.
There are several limitations to the analysis in this study that suggest our results should be treated with some caution. First, whether nonassisted or assisted, suicide raises ethical and existential issues for the individuals concerned and political questions of public policy that are not addressed in this article. The aim of this study was to help inform those decisions but is not intended to imply that the complex issue of assistance in suicide can be resolved purely by statistical analysis. Neither has this article considered whether the prevention strategies that are effective with nonassisted suicide also may inhibit assisted suicide, although this may sometimes be the case. For example, research has shown that "the protective effect of a religious affiliation is evident for both assisted and nonassisted suicides."
Although many suicides occur among people who would not have been eligible for PAS (thereby possibly limiting our ability to identify any direct effect of PAS on nonassisted suicide), our findings of a significant increase in total suicides (and more so in the older-than-65 group) and that there was no significant decrease in nonassisted suicides, even among those older than age 65, provide some reassurance of the robustness of our results. Next, there are still relatively few states that have legalized PAS and it is hard to know how well the effects can be generalized. It also should be noted that all states that have legalized or decriminalized PAS are in the northern United States; indeed, three of the four states share a border with Canada. To date, there are no analogous data for southern US states. Furthermore, for some PAS states, we have few postlegalization observations. It will be important to further monitor the longer-term impact of PAS as more data points become available. Further evidence also may resolve the question of whether there is a significant association between legalizing PAS and increases in nonassisted suicide. The evidence examined here was equivocal on that point.
Finally, our use of state and time effects and state-specific trends allows us to control for many unobservable differences between states. It is possible, however, that there remain other unobservable factors affecting observed suicide rates and that are correlated with the legalization of PAS and that may affect our conclusions. For this reason, we believe it is important that the quantitative approach in this article is supplemented with qualitative research reviewing the circumstances and motivation of those who die by suicide within jurisdictions that have legalized PAS and with research looking at how attitudes toward suicide vary in jurisdictions with different legislative frameworks in place. Such research may help us identify mechanisms that lie behind the bare statistics considered in this study.
Conclusions
The evidence from suicide rates in states that have legalized PAS is not consistent with Posner's conjecture that such legal changes would lead to delays and net reductions in suicide. Rather, the introduction of PAS seemingly induces more self-inflicted deaths than it inhibits. Furthermore, although a significant proportion of nonassisted suicides involve chronic or terminal illness, especially in those older than age 65, the available evidence does not support the conjecture that legalizing assisted suicide would lead to a reduction in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide or that it acts in this way in some individuals but is associated with an increased inclination to suicide in others.
There are several limitations to the analysis in this study that suggest our results should be treated with some caution. First, whether nonassisted or assisted, suicide raises ethical and existential issues for the individuals concerned and political questions of public policy that are not addressed in this article. The aim of this study was to help inform those decisions but is not intended to imply that the complex issue of assistance in suicide can be resolved purely by statistical analysis. Neither has this article considered whether the prevention strategies that are effective with nonassisted suicide also may inhibit assisted suicide, although this may sometimes be the case. For example, research has shown that "the protective effect of a religious affiliation is evident for both assisted and nonassisted suicides."
Although many suicides occur among people who would not have been eligible for PAS (thereby possibly limiting our ability to identify any direct effect of PAS on nonassisted suicide), our findings of a significant increase in total suicides (and more so in the older-than-65 group) and that there was no significant decrease in nonassisted suicides, even among those older than age 65, provide some reassurance of the robustness of our results. Next, there are still relatively few states that have legalized PAS and it is hard to know how well the effects can be generalized. It also should be noted that all states that have legalized or decriminalized PAS are in the northern United States; indeed, three of the four states share a border with Canada. To date, there are no analogous data for southern US states. Furthermore, for some PAS states, we have few postlegalization observations. It will be important to further monitor the longer-term impact of PAS as more data points become available. Further evidence also may resolve the question of whether there is a significant association between legalizing PAS and increases in nonassisted suicide. The evidence examined here was equivocal on that point.
Finally, our use of state and time effects and state-specific trends allows us to control for many unobservable differences between states. It is possible, however, that there remain other unobservable factors affecting observed suicide rates and that are correlated with the legalization of PAS and that may affect our conclusions. For this reason, we believe it is important that the quantitative approach in this article is supplemented with qualitative research reviewing the circumstances and motivation of those who die by suicide within jurisdictions that have legalized PAS and with research looking at how attitudes toward suicide vary in jurisdictions with different legislative frameworks in place. Such research may help us identify mechanisms that lie behind the bare statistics considered in this study.
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