Though euthanasia is prohibited in Switzerland, assisted suicide is legal, so long as "no selfish interests are involved." But opponents fear vulnerable people could be forced to end their life this way, so researchers from the University of Bern investigated socioeconomic factors linked to assisted suicide.
Publishing the results of their study in the International Journal of Epidemiology, the researchers, led by Prof. Matthias Egger, found that assisted suicide is more common in women and groups that may demonstrate more vulnerability - such as those living alone or those who are divorced.
However, the team also found that those with higher education and a higher socioeconomic position were more likely to opt for assisted suicide.
Whereas euthanasia involves a physician taking an active role in helping the patient to die, assisted suicide means the physician only makes lethal means available to the patient for use when he or she chooses.
Assisted suicide is illegal in most states of the US. However, in Switzerland, the role of physicians involves assessing whether the patient requesting assistance has the capacity to make an informed decision and to prescribe the lethal drug.
Authors of the latest study note that the person requesting assistance does not have to have a terminal illness in Switzerland.
In 2013, the European Court of Human Rights asked Switzerland to make clear whether and under what conditions patients not suffering from terminal illnesses should have access to assisted suicide. This request suggested Switzerland needed to more accurately regulate assisted dying.
Vulnerable groups 'of concern'
To conduct their study, the researchers used data from three right-to-die organizations and linked it to the Swiss National Cohort, which is a longitudinal study of mortality based on census and mortality records.
Results of the study show that women, people from a higher socioeconomic group, those living alone and people with no religious affiliation were more likely to choose assisted suicide.
In total, they followed over 5 million individuals between the ages of 25 and 94 from January 2003 until their death, emigration or the end of the study in 2008. Of these individuals, 1,301 chose assisted suicide.
Results show that assisted suicide was more common in women than men, in people with a higher level of education, in those living alone and in people with no religious affiliation.
Additionally, the researchers found the rate was higher in urban areas, compared with rural areas, and it was higher in wealthier neighborhoods.
Although having children was not associated with a lower risk of assisted suicide in older people, having children was linked to a lower risk in younger people.
"Our study is relevant to the debate on a possibly disproportionate number of assisted suicides among vulnerable groups," Prof. Egger says.
He notes that the higher rates among people with higher education levels and those from a higher socioeconomic level may "reflect inequities in access to assisted suicide," and adds:
"On the other hand, we found a higher rate among people living alone and the divorced. Social isolation and loneliness are well-known risk factors for non-assisted suicides and our results suggest that they may also play a role in assisted suicide."
Although the team says their finding that women die more frequently than men by assisted suicide is "of concern," they note that studies from the Netherlands and Oregon in the US have reported that more men than women die this way.
'New regulation is needed'
The researchers say a previous study conducted by two right-to-die organizations showed that 25% of those who underwent assisted suicide had no fatal illness and instead cited "weariness of life" as a factor.
After analyzing death certificates for an underlying cause of death from their latest study, the team found that in the group of people between the ages of 25 and 64, 57% had cancer, which was followed by 21% who had diseases of the nervous system.
Additionally, 11 people listed a mood disorder as the reason for assisted suicide, while another three had another mental or behavioral disorder.
In 65 to 95 year olds, 41% cited cancer, followed by 15% with circulatory diseases and 11% with nervous system diseases.
"The results indicate that there could well be vulnerable groups," says Prof. Egger. "Social isolation and loneliness are known to be risk factors for suicide, and this might also be the case for assisted suicide."
He talks about potential changes that could be made in terms of regulating assisted suicide:
"We believe that such new regulation should mandate the anonymous registration of assisted suicides in a dedicated database, including data on patient characteristics and underlying causes, so that suicides assisted by right-to-die associations can be monitored."
Belgium recently passed new legislation, making it the first country to allow terminally ill children of any age to undergo euthanasia.