Yves here. Perhaps readers will disagree, but this article strikes me as utterly clueless about suicide among the elderly. And even if the authors stumbled across directionally accurate conclusions, their methods are so shoddy that the findings can’t be trusted.
Suicides are underreported for a whole bunch of reasons: wanting to make sure survivors get life insurance benefits (as in the person killing themself makes his death look like an accident), avoidance of liability, attending physicians listing another cause of death out of assumed or actual desire of the family not to have the death reported as a suicide.
But assisted suicides are NOT underreported! So for this paper to have a scintilla of validity, it needs to attempt to adjust suicide rates in states that bar assisted suicide rates for hidden suicides.
My mother had six good friends in her old age. Two were long-standing buddies from earlier in her life, four were local. Of the six, two committed suicide. One had had several bouts of cancer. When it came back again, in her late 70s, she was a widow living in a retirement facility. Her lungs would fill with fluid and she’d have to have a tube shoved down her trachea to drain them. She didn’t want to be subjected to that any more, particularly since her prognosis was iffy. She’d saved up a lot of sleeping pills and took them all one night.
I can pretty much guarantee the facility’s physician did not record her death as a suicide. I am also highly confident she would have gone the assisted suicide route if it had been available. She would have wanted to say goodbye to her friends.
Another friend of hers similarly had had her husband die. She has children and a lot of friend in the areas. However, she had a fall, the hospital discharged her too early to skilled rehab, and something bad happened to her there so that she wound up wheelchair bound. She had the money to have aides but didn’t want to have people bathing her and lifting her. She stopped eating and stopped taking her meds. She was Catholic so I am again pretty sure her death was not listed as a suicide.
My father by contrast shot himself because he was no longer able to take the horrible side effects of a terminal illness, so I am sure that was depicted accurately. But he might not have shot himself that day if assisted suicide were available. He was not willing to be hospitalized (Lambert’s “Insert tubes and extract rents”) and lose control of his situation.
But this paper does address an important issue, so I hope better constructed studies follow.
By Sourafel Girma, Professor of Industrial Economics, University of Nottingham, School of Economics and David Paton, Professor of Industrial Economics, Nottingham University Business School. Originally published at VoxEU
Richard Posner argued that legalising assisted suicide may have the counter-intuitive effect of reducing unassisted and possibly even total suicide rates. This column examines the empirical evidence for this idea using data from ten US states that implemented an assisted suicide law up to the end of 2019. In contrast to Posner’s hypothesis, the real-world data suggest that assisted suicide laws lead to a substantial increase in total suicide rates and, if anything, are associated with an increase even in unassisted suicides. This effect is most pronounced amongst women.
An increasing number of jurisdictions around the world have implemented some form of legalised assisted suicide (or are actively considering doing so). It is a highly contentious issue and one in which debates are rightly driven primarily by considerations of rights, morals, and ethics. However, one key argument in many of these debates has been a more practical issue, namely, whether such laws lead to an increase or decrease in suicide rates.
This aspect of the debate has become even more pressing, given the concerns about the effect COVID-19 restrictions and lockdowns have had on mental health, with obvious potential implications for suicide (Ribeiro 2020).
It is natural to think that legalising an activity should reduce its costs and lead to an increase in the amount of that activity. In this case, legalising assisted suicide should not only reduce practical barriers to committing suicide but may also lower societal taboos against suicide. Hence, we might expect to observe an increase in suicide rates overall (Dugdale and Callahan 2017). In 1995, however, Richard Posner proposed the alternative view that the legalisation of assisted suicide could reduce suicide rates in some circumstances. How did he arrive at such a counter-intuitive conclusion?
The Posner Hypothesis
Posner (1995) used a formal economic model to explain his hypothesis, but his underlying intuition is quite simple and based on the option value of future suicide. People who have no immediate wish to die by suicide get reassurance from knowing that they can exercise the option of suicide at some point in the future, should their life experience deteriorate. Someone in the early stages of a degenerative illness might worry that when their quality of life has deteriorated to such an extent that they no longer wish to live, they will no longer be able to die by suicide without assistance. As a result, some people in that situation may choose to die by suicide at an early stage.
Now, if people have the assurance that assisted suicide will be available should they end up wishing to die in the future, some of them may be less likely to take their own lives in the earlier stages of their illness. Put another way, assisted suicide will substitute for unassisted suicide. Further, at the point when the person believed they would want to die by suicide, they may find that they no longer wish to do so. Or a diagnosis may be wrong or unduly pessimistic and the person finds that future life is less painful or debilitating than originally expected. In either event, the person may never actually take up the option of suicide.
There are two key empirical predictions from Posner’s hypothesis. First, legalising assisted suicide should reduce unassisted suicides to some extent. Second, it is possible that under some circumstances legalisation could reduce the total number of suicides (assisted and unassisted) combined.
Posner argues that the key to understanding these counter-intuitive ideas is to recognise that unassisted and assisted suicide are two distinct ‘goods’ which substitute for each other and that:
“…lowering the price of the second (by legalising it) will reduce the demand for the first and nothing in economics teaches that this reduction must be fully offset by the increased demand for the second good” (Posner 1995: 250)
Testing the Posner Hypothesis
Posner’s work pre-dated Oregon’s 1997 assisted suicide law (the first in the US) and so he was unable to provide any empirical evidence to test his hypothesis. This has not stopped his hypothesis from being used as part of arguments in favour of assisted suicide laws (see, for example, Carter vs Canada (Attorney General) 2015, Dignitas 2014).
Since 1997, assisted suicide laws have been implemented in an increasing number of US states, meaning empirical analysis of his ideas is now possible. This is the task we took on in our paper (Girma and Paton 2022). We examine suicide rates in ten US states that implemented an assisted suicide law up to the end of 2019. Our basic research design is to compare changes in suicide rates before and after legal implementation relative to changes in states that did not pass such laws. The analysis considers both total suicide rates (i.e. including assisted suicides) and unassisted suicide rates.
An obvious issue with this type of analysis is whether states that legalise assisted suicides are sufficiently similar to other states to allow us to be confident that we are truly estimating a causal effect of the laws. We deal with this problem in two ways. First, we use an event study approach on panel data. In addition to including fixed effects to control for time- and state-specific unobservable factors, we control for trends in suicide rates in the years before the law was introduced and test to confirm that these trends are similar on average in other states (the so-called parallel trends assumption). We also control for other factors which are known to affect suicide rates, such as demographics (Stack and Kposowa 2007), availability of firearms (Lang 2017), substance abuse (Freeman 2007), and unemployment (Nordt et al. 2015).
Our second approach to establishing causality is to use a synthetic control method. This method involves constructing an artificial set of non-legalising states which are otherwise similar (based on a range of demographic and economic variables) to states legalising assisted suicide before legalisation. We can then compare relative trends in suicide rates after the passage of the law.
Do the Data Support Posner?
Both approaches yield similar results. There is very strong evidence that the legalisation of assisted suicide is associated with a significant increase in total suicides. Further, the increase is observed most strongly for the over-64s and for women. To give an idea of the size of the effect, the event study estimates suggest assisted suicide laws increase total suicide rates by about 18% overall. For women, the estimated increase is 40%.
There is weaker evidence that assisted suicide is also associated with an increase in unassisted suicides. The effect is smaller (about a 6% increase overall, 13% increase for women). It is still statistically significant in the main estimates but not in all of the robustness checks, meaning we have less confidence in that result. However, we find no evidence that assisted suicide laws are associated with a reduction in either total or unassisted suicide rates.
The results from our paper are consistent with another recent paper looking at trends in European countries that have introduced either assisted suicide or euthanasia (Jones 2022) and which concluded that there is “no reduction in non-assisted suicide relative to the most similar [non-legalising] neighbour and, in some cases, there is a relative and/or an absolute increase in non-assisted suicide”.
The finding that assisted suicide laws have a relatively bigger effect on women is also consistent with previous research (Canetto and McIntosh 2022). Given that unassisted suicide rates tend to be much lower amongst women than men, one interpretation of this finding is that the higher take-up of assisted suicide reflects women being empowered to take control over end-of-life decisions. Canetto and McIntosh (2022) propose an alternative view. They suggest that higher take-up may reflect the disempowerment of those who are more vulnerable to social pressure to die by suicide – for example, through feeling a burden to relatives or society – and that women are overrepresented in such groups.
Conclusion
To date, there seems to be little if any real-world evidence in support of Posner’s hypothesis that assisted suicide laws might reduce suicide rates. That does not necessarily mean that Posner got it completely wrong. It is possible, for example, that assisted suicide laws do induce some substitution from unregulated to assisted suicide, but that this effect is neutralised by an increase in unassisted suicide arising from, say, a reduction in societal taboos associated with suicide.
So where does this leave debates over assisted suicide? The ethical basis for those in favour of assisted suicide laws is that they promote the right to self-determination and bodily autonomy. In contrast, those opposing assisted suicide argue that such laws infringe the rights of vulnerable people, such as the elderly, disabled and terminally ill, and those who may be placed under undue pressure to choose to end their lives prematurely. The empirical evidence that assisted suicide laws increase suicide rates overall does not resolve the principle of the underlying ethical debates, but we can hope that it helps to put those debates into some sort of practical context.
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Yes, this is a very important issue, especially in the US, where the cost of end-of-life care depletes family financial resources quickly. Having a planned and affordable method of transferring to the afterlife, for those who want it, is genuinely compassionate. (The Pope be damned!)
Biden and Crew just may well accelerate this transfer to the afterlife with his taunting of Russia.
I will probably be put on perrmanent moderation for confessing to commenting on a post I haven’t yet read in its entirety – something I intend to do when I return from today’s activities. But just the byline triggers a visceral reaction. The correct framing for this topic is “medical aid in dying” NOT “assisted suicide”. As for women being more prone to take advantage of this legal right, my personal (sexist?) theory is women are genetically or sociologically better equipped to face and follow through on tough choices.
“Assisted suicide” is a term of art. And you are killing yourself. I don’t see the point in trying to pretend that killing yourself with a doctor’s help is fundamentally different than shooting yourself, as my father did, taking pills, as my mother’s friend did, or getting the protocol from the Hemlock Society and using that.
Euthanasia.procon calls it “Legal Physician-Assisted Suicide”: https://euthanasia.procon.org/states-with-legal-physician-assisted-suicide/.
Cornell Law also calls it physician-assisted suicide: https://www.law.cornell.edu/wex/physician-assisted_suicide
As does the AMA: https://journalofethics.ama-assn.org/article/physician-assisted-suicide-law-and-professional-ethics/2003-01
Your father and your mother’s friend were made of sterner stuff than many of us. Can’t help but wonder how many people are alive not because they want to be but because they don’t have the personal strength and courage to do what your father and mother’s friend did. It must have been hard for you but I have nothing but admiration for people in their circumstances who do what they did.
For the rest of us “killing yourself with a doctor’s help IS fundamentally different than shooting yourself, as my father did, taking pills” because we have the assurance the job will be done correctly and with a minimum of suffering.
There is something deeply flawed in an article that attempts still another analysis of the thinking of Richard Posner, a guru of the Law & Economics fraud that has corrupted U.S. law schools even further. Are we still attempting to pretend that Posner, Milton Friedman, Gary Becker, and the extreme case of Ayn Rand are anything but immoralists? They spent careers validating neoliberalism, and we have the untoward results.
Posner makes the usual Law & Economics mistakes of applying a pseudoscience, economics, to the rather sloppy world that is the common law.
Note the economic terms that he invokes. A demand for suicide? Really, we want to talk about life and death as supply and demand? One doesn’t have to be Pope Francis or a good Buddhist to see where that sort of talk leads.
Further, the authors don’t seem to bother showing enough data. In the USA, regional variation in suicides would be telling: The more Catholic / Lutheran / non-believing North v. the evangelical South.
Further, and as is often the case, Yves Smith’s headnote is better than the article. Suicide, like marriage, childbirth, and funerals–like one’s death itself–is an unusual, one-time event (yes, even if you get married several times). So economic analysis is weak here. Also, generalizing is weak. As Yves Smith points out, and as we all know, death can be very a private and ambiguous decision. Plenty of people with terminal illnesses are “allowed to die.” Is that assisted? Or is it more along the lines of acknowledging the difficulty of being human and many shadows in our psyche and our existence?
There is a similar matter related to abortion: Truly, the issue isn’t whether you happen to approve or approve. How can you claim to know enough to judge the action of a woman?
I recall, too, that a nickname for pneumonia is “the old man’s friend” or “the old person’s friend.” It is a (relatively) uncomplicated way toward death. Is it an assist?
If anything, the article is why we have to stop having economists lecture us and have politics instead. We don’t even have to have religious views–we have to have politics, some kind of civic discourse that matters.
I read recently where Alain Delon, now in his 80’s, has elected assisted suicide in Switzerland with the help of his son. He cites ongoing physical pain & impediments as reasons, but the primary engine seems to be a general weariness with life & antipathy for humankind.
A very interesting fellow is Delon.
Around 1980, at least, women were more likely to attempt suicide (largely pills) and men were more likely to succeed (guns and hanging).
Is the impact from more effective suicide?
Women are more likely to use a method that can be stopped part way through, while men go for instant methods.
Not so sure. Men are way more likely to have and be comfortable using a pistol than women. We joked about my father, “Well, as a hunter, he knew how to do the job.”
If I were to try a gun, I’d worry my hand might slip and I’d mis-aim and blow off half my face but still be able to be rescued. So you might live and be severely mentally impaired and a huge money and energy suck for family members.
Obviously they could hang themselves but that takes more work than pills. And if you don’t snap your spine (and women with lower body mass are less likely to) it could take a while to asphyxiate yourself. So it could be a bad way to go.
In other words, I think risk aversion is the bigger driver, that the death is not painful and if you botch the attempt, you have not permanently damaged your body.
I think another motivation is not leaving a distressing image for whoever finds you. My mother was the one who found my father’s body. Fortunately she was a very tough bird but still…..
Oh, and in her tiny but upscale suburb, the police cleaned up the crime scene. What if a family member had to do that? Outside big cities, I don’t think you can readily fine “clean up gruesome events” services for hire and even when you can, they cost money.
I feel like overall suicide rates are a poor metric for goodness. Many suicides are bad, but I think that some suicides are probably good, as they avoid suffering and the expenses of keeping suffering or unconscious people alive. The same overall suicide rate could be comprised entirely of kids who had just suffered their first heartbreak, or entirely of 100 year olds with terminal diagnosis, and I would feel very differently about it. I guess that it’s usually good to have data, but without disaggregating suicides that I abhor from ones that I approve of it’s hard for me to see great value in this study.
Indeed, thanks Yves for your words. Love this site for this reason, though you are ‘upper class’, you never cease to look at the ‘big picture’……I saw the headline, and I went OH NO. but you made it right. I can attest being around tons of down in dumps people in SF, since the early 80’s, that many young people that die are NOT recorded as suicides either. When a user takes a bigger jump, knowing the dose….that is suicide. I would suggest that many of the 100,000 over doses a year now, are many many suicides. I’ve known a few. And others…from real despair……older peers now, that just gave up on trying to navigate and beg the ‘health care’ system…and just went to sleep.
Thanks for your kind note. It is very important to me and I am sure Lambert and Jerri that we get perspectives from people of all walks of life. America is so balkanized, not just by class but also geography, line of work, that there’s a tremendous amount of ignorance about how other people live, as we can see starkly in the policies coming from DC.
It should have occurred to me that a fair bit of what police classify as drug ODs among the homeless and poor are suicides. Being homeless has to be grindingly hard and it must be difficult to find the energy to navigate all the huge difficulties. Thanks for bringing that to my attention.
“Further, and as is often the case, Yves Smith’s headnote is better than the article.”. I second the motion.
Posner sometimes becomes a parody of Posner. Using Posner’s approach, everything from genocide to on-line harassment qualifies as “goods”.
A few thoughts:
A suicide done in the face of a looming and often painful death is not the same as a suicide to “end life” when there is a life to be lived. Nobody I know would call the people who jumped from the top floors of the World Trade Center suicides; the choice was death by fire or smoke inhalation versus a terrifying ten second trip through the air. In many cases of great pain and terminal illness I believe that what we call suicide is more like the decision of the World Trade Center workers than that of a person who simply can’t face the future. And I generally don’t make judgments on either.
Second, Induced suicide and assisted suicide are not the same. “Induced” is Jack Kevorkian soliciting and encouraging what turned out to be a largely female and lonely clientele. “Assisted” means helped. This should be a two-step process; the person and loved ones first make a decision and second, someone else assist. The roles should not be the same. That still leaves me with the uncomfortable case of a person who prefers suicide to a slow family bankruptcy.
Third, the very act of having a public campaign that leads to laws legalizing assisted suicide will legitimize suicide and make more people be willing to admit to suicide. Plus people who are from “no assist” states may move to make the suicide legal.
i am concerned about the COVID situation and how it relates to elder suicide.
would like to see some discussion of this not just in comments but in links and/or entries on the blog.
no we should not simply abandon efforts to protect the elderly from getting COVID.
nor should we abandon efforts to save their lives when they do get it.
yet, nor should we refuse them the option to choose to pass if they would prefer to do so rather than, for example, continue painful, horrible treatment in an ICU.
in the COVID context the meaning of “let them die” has gained a new twist.
of a total nursing home population who get covid, how many of them are already perhaps “ready to go”–perhaps even being kept alive longer than they wished, or would wish if they could express a wish?
one thing is sure, we’re going to see a lot more elder suicides, both with COVID and with our healthcare system (such as it has been) now in collapse.
yves’s examples here of the choices that face the elderly are telling.
we elders will be telling such stories to one another and doing the best we can, with, hopefully, more mutual support, as more and more we will find ourselves simply left “on our own.”
I live in WA State, which has a death with dignity law. https://doh.wa.gov/you-and-your-family/illness-and-disease-z/death-dignity-act. Last September I witnessed the death of a friend who used this law to end his life. After dealing heroically with the effects of MS for decades, my friend could tell that his mental faculties were failing and it was time to go. He passed peacefully amid chanting, incense, flowers and scented oils. I want to emphasize that he had to pass through many gates and much paperwork to get to that point. Additionally, he had to be physically capable of taking his “cocktail” without assistance.
We washed and dressed the body after an appropriate amount of time had passed, then processed with the body to the hearse with the ringing of bells. It was a loving, moving experience for all present.
I know and care for many single, elderly women with various physical and mental issues. I fit that description myself. None of us wants to end our days in one of private equity’s fetid warehouses for the elderly. For us, the ability to make a decision about death at a time and in a place of our own choosing is a gift. So I suppose the premise that laws like WA State’s increase suicide rates might be proved prescient in the future. Judging from the attitudes of my acquaintances, this generation is less squeamish about assisted suicide and more likely to choose it rather than suffer through death in a hospital or long-term care facility. I only hope that enough of my friends survive to give me a gentle send off when my time comes. Thank you, Yves, for prompting this important discussion. Blessed be.
What is the insurance industry’s position on assisted suicide?
pebird – I left the life insurance industry before Washington passed their law, but the standard policies generally exclude paying death benefits if a person commits suicide within the first two years from the issue date. After that benefits are normally payable.
I would suggest the rise of hospice care in the US totally muddles the grossly economic analysis attempted here. I recently sat at the bedside of a sister who refused further treatment and peacefully passed away while in hospice care (plus good care in her care home) and I can’t help but wonder if that choice shouldn’t be classified as suicide for this sort of analysis. I also wonder at the point of this kind of analysis for other than political reasons. I live in Oregon and the number of physician assisted suicides is remarkably low and stable over time. Admittedly that could be due to the fact that so many conditions make it impossible to qualify since you both have to be deemed to die within 6 months by two docs and must be able to administer the barbituate cocktail yourself which excludes dementias and motor neuron diseases.
This stuff really needs to be talked about ahead of time with ones who will respect and honor your wishes– and who have the capability and capacity to honor your wishes.
The taking of life isn’t always a bad thing, though most of us (thankfully) can’t do it. And those who command it should certainly have hands in the deed– unless you’re a total sociopath, it is a very intimate experience and one that will never leave you… …it has a way of chilling one’s passions and will forevermore inform your thinking. Once we had Ike and JFK, now what? War-happy chicken-hawks… …sorry, I digress.
It really sucks watching a loved-one slowly pass, especially not knowing if they are suffering or not due to their inability to communicate (think stroke or dementia), and leaving all in a state of limbo or uncertainty, second-guessing and doubt. It could suck worse if you are that one, I suppose, but who really thinks that it will happen to them?
Got any advice as far as solid advance directives on the cheap? I’d rather the money go to good whiskey a-plenty for my friends than to the shareholders of some HMO.