Reasons for Wanting Assisted Suicide

A Retrospective Evaluation of Telephone Inquiries

The debate on assisted suicide is as topical as ever in Germany. Since the German Federal Constitutional Court declared § 217 of the German Criminal Code (Strafgesetzbuch, StGB) to be invalid in February 2020, it is unclear whether and, if so, which legal regulation will be passed. From a terminological perspective, a distinction needs to be made between assisted suicide and euthanasia on demand. One often hears about medically assisted suicide; however, anyone can assist a suicide.

The reasons for making use of assisted suicide are manifold. According to data from the German “Assisted Dying Association” (Verein Sterbehilfe), 139 assisted suicides took place in Germany in 2022, 132 of which were for physical and four for mental health reasons (1). Social factors, experiencing a lack of care, as well as concern regarding life in old age also play a role (2, 3, 4). In order to provide information regarding the legal situation and recommendations for dealing with individuals wishing to end their lives, the German Society for Palliative Medicine (Deutsche Gesellschaft für Palliativmedizin, DGP) has published corresponding recommendations on courses of action (5). The desire to die should be openly discussed. Suicide prevention measures play an important role.

The aim of the present study was to assess the motives for wanting assisted suicide as well as the effects of suicide prevention counseling.

Methods

All telephone inquiries to the office of the DGP regarding assisted suicide (11/2020–10/2021) were retrospectively evaluated. The individuals making these inquiries either wanted to explore the possibility of assisted suicide or expressed an acute desire to die. Contact was made on the basis of published articles, talks, reports in the media, or Internet research. The telephone number of the DGP is placed prominently on the society’s homepage. All individuals making inquiries were informed that the advice given would be anonymously documented, to which they gave their consent.

To record inquiries in a structured manner, a documentation aid was developed (5). This included questions regarding age, sex, disease, living situation, communicating the desire to die to relatives, contact with support services, reasons, knowledge gaps, and outcome of the telephone conversation. At the beginning of the telephone calls, inquirers’ questions included, among others: “Who can help me end my life?” and “Assisted dying is allowed now, isn’t it?”

The gathered data were anonymously evaluated using IBM SPSS Statistic Version 28.0.1.1 and Microsoft Excel 2020 Version 16.42. For the continuous variable of age, a normal distribution test was performed. Mean, median, and standard deviation were determined. Categorical variables were recorded in absolute numbers and relative frequencies were calculated. The study was approved by the Ethics Committee of the Heinrich Heine University Düsseldorf, Germany (Study No. 2022–2266).

Results

During the study period of 12 months, the office of the DGP received 53 telephone inquiries regarding assisted suicide. The mean age of callers was 69 years (median 71 years, 20–89 years, SD 17.4 years), and age did not follow normal distribution. Overall, more inquiries were made by men than by women (62.3 versus 37.7%). Five inquirers (9.4%) expressed an acute desire to die, while all others sought legal information and wished to explore options for dealing with loss of autonomy and uncontrollable suffering. Table 1 summarizes the diseases in question, Table 2 the reasons for desiring assisted suicide. Only around a quarter of callers had discussed this thought with those close to them (n = 13, 24.5%). Information relating to previous attempts at suicide was obtained from 21 individuals making inquiries, but most callers had not attempted suicide (n = 17, 81%). All of those making inquiries assumed that palliative medicine was only available for cancer patients. None of the individuals seeking advice had been informed about the options of voluntarily abstention from food and drink or targeted sedation for symptom relief. A total of 69.8% (37/53) of callers believed that hospices were an option only for cancer patients. Callers were not aware of outpatient hospice and palliative services. After receiving information during their phonecalls, only 3.8% (2/53) wished to further pursue their desire for assisted suicide. These individuals belonged to the group of callers with an acute desire to die. They were given the contact details of self-help groups, suicide prevention centers, as well as their local palliative team. The other callers in this group wished to talk to their primary care providers about symptom control options.

Table 1

Diseases cited by individuals making telephone inquiries

Table 2

Reasons for inquiring about assisted suicide

Discussion

We were able to show that by presenting callers with the available scope for action, care structures (for example, outpatient specialty palliative care [OSPC]) as well as options for symptom relief, most callers did not further pursue their desire to die at that point in time. These results underscore the need to take inquiries regarding the desire to die seriously and to explore the background to these wishes. This requires that healthcare staff receive training on how to deal with patients’ desire to die.

Most of the individuals making inquiries lived alone. Studies have shown that care-dependent people who live alone are those most likely to consider assisted suicide for themselves (4). These individuals should receive intensive support and advice. In our cohort, over 90% of callers did not harbor an acute desire to die—it was far more the case that they wanted to explore various options. This clearly shows how important it is to provide information and intensify suicide prevention measures. This explicitly includes hospice and palliative care. Palliative care was a concept familiar to many callers, but only in association with cancer at the end of life. In addition, few people are aware of the options of symptom control offered by OSPC in the outpatient setting.

A limitation of the study that should be mentioned is that it only represents a small proportion of people with a desire to die who contacted the DGP by telephone, which could result in a sampling error. Inquiries to other organizations could produce a different picture.

In the case of an ongoing desire to die, the focus should lie on all possible options for managing death. Rather than being seen as an impasse, the desire for assisted suicide should be seen as a turning point at which to present care options and possible courses of action as well as to promote autonomy and self-efficacy.

Yann-Nicolas Batzler, Heiner Melching, Manuela Schallenburger, Jacqueline Schwartz, Martin Neukirchen*, Claudia Bausewein*

*These authors share last authorship.

Interdisciplinary Centre for Palliative Medicine, Düsseldorf University Hospital, Heinrich-Heine-University Düsseldorf, Germany (Batzler, Schallenburger, Schwartz, Neukirchen) [e-mail]

German Association for Palliative Medicine, Berlin, Germany (Melching)

Department of Anesthesiology, Düsseldorf University Hospital,, Heinrich-Heine-University Düsseldorf, Germany (Neukirchen)

Department of Palliative Medicine, Munich University Hospital, Ludwig-Maximilians-University, München, Germany (Bausewein)

Conflict of interest statement
HM declares that the telephone conversations took place during the course of his work as Managing Director of the German Association for Palliative Medicine (Deutsche Gesellschaft für Palliativmedizin, DGP).

CB has received honoraria for talks delivered to the German Ethics Council (Deutscher Ethikrat), the Caritas Ethics Council Munich (Caritas Ethikrat München), the Schober Foundation (Schoberstiftung), Halle University and the Technical University of Munich, the Catholic Academy of Munich (Kath. Akademie München), Evangelical Academy of Tutzing (Ev. Akademie Tutzing), hospice and palliative care centers, the Academic Forum of the Diocese of Augsburg (Diözese Augsburg).

The remaining authors declare that no conflict of interests exists.

Manuscript received on 22 May 2023, revised version accepted on 13 July 2023.

Translated from the original German by Christine Rye.

Cite this as:
Batzler YN, Melching H, Schallenburger M, Schwartz J, Neukirchen M, Bausewein C: Reasons for wanting assisted suicide—a retrospective evaluation of telephone inquiries. Dtsch Arztebl Int 2023; 120: 754–5.

DOI: 10.3238/arztebl.m2023.0178

References

1. Verein Sterbehilfe: Jahresrückblick 2022 in Zahlen. www.sterbehilfe.de/jahresrueckblick-2022-in-zahlen/ (last accessed on 6 April 2023).

2. Vilpert S, Bolliger E, Borrat-Besson C, Borasio GD, Maurer J: Social, cultural and experiential patterning of attitudes and behaviour towards assisted suicide in Switzerland: evidence from a national population-based study. Swiss Med Wkly 2020; 150: w20275

3. Borovecki A, Curkovic M, Nikodem K, et al.: Attitudes about withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide, and physician assisted suicide: a cross-sectional survey among the general public in Croatia. BMC Med Ethics 2022; 23: 13

4. Stolz E, Mayerl H, Gasser-Steiner P, Freidl W: Attitudes towards assisted suicide and euthanasia among care-dependent older adults (50+) in Austria: the role of socio-demographics, religiosity, physical illness, psychological distress, and social isolation. BMC Med Ethics 2017; 18: 71

5. Deutsche Gesellschaft für Palliativmedizin. Empfehlungen der Deutschen Gesellschaft für Palliativmedizin: Zum Umgang mit dem Wunsch nach Suizidassistenz in der Hospizarbeit und Palliativversorgung. 2021. www.dgpalliativmedizin.de/images/230509_Broschu%CC%88re_Suizidassistenz_v2.pdf (last accessed on 7 August 2023).