On 10 December, a British satellite television channel telecast the documentary ‘Right to Die’, which shows the assisted suicide of 59-year old US citizen Craig Ewert at the Dignitas clinic in Switzerland. Amyotrophic lateral sclerosis patient Ewert's last 4 days were covered, finally showing him drinking a lethal dose of barbiturates before turning off his lung ventilator with a mouth-operated switch.
Beneath being relevant to the ‘Right to Die’ debate and the question of legalization of doctor-assisted dying,1 another aspect has to be considered urgently. In terms of suicide prevention, an increase of imitative suicides due to the ‘Werther effect’, i.e. the increase of suicide rates after detailed reports about suicide in the media, cannot be excluded.
The Werther effect had been proved for the first time after a twice broadcast (1981, 1982) of the six-episode serial ‘Death of a student’ in Germany.2 The number of railway suicides had increased over extended periods up to 175%, most clearly observable in groups age and sex congruent.2 An Austrian research group showed that after an increase of subway suicides in Vienna between 1984 and 1987, a decrease of 75% could be achieved by a working group of the Austrian Association for Suicide Prevention who had developed media guidelines and initiated discussion with the media over suicide coverage, culminating in an agreement to refrain from reporting suicides.3 Based on such studies, it has to be assumed that even for assisted suicides within the framework of euthanasia a Werther effect could be induced. Especially, the extremely detailed report of a seemingly peaceful suicide in the context of a TV documentation may tempt terminally ill people to choose suicide as both an adequate and acceptable way to solve their problem. Evidence for this comes from a Swiss study: after the media had reported extensively about the assisted double suicide of a prominent couple, a considerable rise of suicides—especially among women older than 65 years—occurred for a period of 2 years after the event.4 Here, the almost enthusiastic kind of reporting might have led to the Werther effect.
The German Association of Suicide Prevention recommend in their media guidelines for reporting on suicides to avoid inadvertently romanticizing or idealizing the suicide or labelling the act as a heroic one (e.g. ‘He didn’t want to be a burden for someone’). Also classifying the suicide as comprehensible, inevitable or even positive may encourage others. As well, the detailed description of the suicide method has to be avoided therefore. But with broadcasting ‘suicide documentations’—in this case the assisted suicide of Craig Ewert—the suicide method is apparent to the highest extend.
Furthermore, it has to be considered that >90% of suicides are based on mental disorders.5 According to the German Alliance against Depression, 40–70% of all suicidents suffer from depressive disorders. Assuredly patients who are terminally ill are a special case and their wish to die cannot be labelled with ‘mental disorder’ just by implication. Current studies, however, demonstrate an association of the wish to die or desire to receive euthanasia and psychiatric illness, especially depression, for the latter group, too. Hopelessness and depression were the most relevant predictors of desire for hastened death in a sample of advanced AIDS patients.6 Similarly, diagnosis of major depression is associated with desire for euthanasia or physician-assisted suicide in palliative cancer patients.7 Even for patients with amyotrophic lateral sclerosis, willingness to contemplate assisted suicide goes along with elevated levels of depressive symptoms and hopelessness.8 These results highlight that also in terminally ill subjects the mental status has to be scrutinized thoroughly, otherwise protection of patients whose choices are influenced by depression might fail. Unfortunately, as results from Oregon show, an adequate screening for depression or psychiatric evaluation cannot be guaranteed and current practice may fail to protect these patients.9,10
Beyond, broadcasting ‘suicide documentation’ on television may evoke a sense of ‘normality’, the feeling that assisted suicide belongs to society and is a standard procedure which a person is entitled to. On the other hand, by propagating assisted suicide, ill and elderly people are pushed over the edge of social community and may feel pressurized to take the decision to end their lives by (assisted) suicide as well.
To sum up, broadcasting assisted suicide on television is a highly precarious matter and may lead to awful consequences, especially if vulnerable, i.e. psychiatric or terminally ill, subjects are left alone with the option of assisted suicide in their living rooms.
Conflicts of interest: None declared.