Author: Mark Taubert, NHS Consultant and Professor of Palliative Medicine, Cardiff, UK
It can be a challenge finding data on assisted dying and euthanasia in jurisdictions where it is legal. In some areas the data is not made available, elsewhere not much is recorded or observed beyond patient demographics. Finding detail on complication rates and reasons why people opt for an assisted death can also be difficult. Studies that are published in another language and are hidden behind a paywall also do not help. Here, we focus on a study from southern Germany, published in German only, but have selected salient points so that they can be useful to a wider audience.
Introduction:
Assisted suicide is legal in Germany, but there has been very little data forthcoming about trends, demographics and reasons for choosing an assisted death. A study, unique in Germany, evaluated deaths from 2020 onward in one location, the city of Munich. Contrary to commonly held beliefs, the majority of service users were not terminally ill. And the majority were elderly females from affluent backgrounds.
Recent discussions in the UK have centred around how best to legislate for the proposed terminally ill adults bill, with some politicians arguing that being too stringent and strict on safeguards will not make for safer practice. The German example may act as a salutary lesson.
The Study:
The analysis was conducted by researchers from Munich’s health department and forensic medicine institute, looking at all cases of assisted suicide in the city since 2020.(1) The team analysed all death records in Munich over two years, providing the first comprehensive examination of assisted suicides in Germany. Death certificates of all persons who died in Munich from 01.01.2020 to 31.12.2022 were analysed, as well as public prosecutor’s files, autopsy reports and toxicological reports of all assisted suicides. After the standardised data entry, the data was anonymised and descriptively evaluated. The findings challenge common assumptions about who seeks assisted suicide and highlight the lack of regulatory oversight, prompting experts to call for stricter controls, such as the introduction of a “four-eyes principle” (a system requiring two independent reviews).
In Germany, the background of assisted suicides remains largely unstudied, making Munich’s investigation a pioneering effort. Individuals in Germany can end their lives by ingesting a lethal medication, typically prescribed or provided by a third party. Contrary to widespread belief, the research revealed that the vast majority of those opting for assisted suicide were not terminally ill. Out of 77 cases identified, only one individual had an acutely life-threatening condition prior to their death. This finding upends the stereotype that assisted suicide is primarily sought by people facing imminent death due to severe illness. Average age at death was 78.9 years. The coroners attested to an unnatural manner of death in all cases. They reported an average of 3.5 underlying diseases, most often diseases of the nervous system. An autopsy was commissioned in 4 cases, a toxicological report in 3 cases. Euthanasia organisations were involved in 36 cases; the most used drug was thiopental. Half of the suicides with previous, non-assisted dying suicide attempts were not examined by psychiatric specialists.
There were 24 documented ‘diseases of the nervous system’. These included cognitive impairment (4 cases), dementia (1 case), corticobasal degeneration (1 case), autism (1 case), depression (8 cases), Parkinson’s disease (4 cases), hydrocephalus with incontinence (1 case), vertigo syndrome with tendency to fall (4 cases). In the 3 cases with mental health disorders, long-term use or dependence on sedatives and hypnotics were documented.
Assisted Suicide services in Munich are provided by only a small group of doctors who otherwise do not work in the city. The patient’s ordinary physicians only provided assisted suicide help in exceptional cases. A euthanasia organisation was involved in almost all Munich AS deaths; only in one case did all steps take place through a close relative of the suicidal person, who was also a doctor. In the city of Munich, 3 supra-regionally active euthanasia organisations were active during the study period. In 5 cases, the public prosecutor’s files showed that a video documentation of the event had taken place. The original recordings could not be included in the evaluation.
Seven individuals had had known suicide attempts (by other means than Assisted Suicide) in the past. Only in 4 of these cases was a psychiatric assessment carried out before the formal AS. 3 cases in which this was not the case are presented below. In one case, the assisting physician, a gynaecologist, had taken over all functions of the AS (expert opinion, assistance and finally post-mortem examination). The documented duration of the conversation was 55 minutes. The period between the completed dated report and the day of the AS was 1 day. In case 2, the assisting physician was a first-degree relative of the suicidal person, there was no expert opinion on mental capacity. In case 3, where the assisted death took place in 2022, the file contained a mental capacity evaluation from 2017. According to this, the patient had “written a living will in full possession of [his] mental faculties … and [is] capable of giving consent ….”
Discussion:
This data comes at a time when Germany’s legal framework for assisted suicide remains in flux. In 2020, the Federal Constitutional Court ruled that individuals have a constitutionally protected right to self-determined death, including the freedom to seek assistance from others. German parliament has struggled for years to establish clear guidelines. This legislative limbo has fuelled debates about how to balance individual autonomy with the need to prevent abuse.
In Munich, the study’s findings have sparked calls for reform. One of the authors, Dr Sabine Gleich, advocates for a “four-eyes principle”, where two independent professionals should verify the circumstances of an assisted suicide request—ensuring, for example, that the decision is voluntary and well-considered. Gleich believes such measures would bring greater clarity and safety to the process. Palliative care experts in Germany also support clearer regulations, but caution against over-normalizing assisted suicide. Checklist-style approaches—focused solely on procedural steps like obtaining multiple opinions or enforcing waiting periods—may risk overlooking the deeper emotional and psychological distress driving these decisions.
The article provides context on how assisted suicide is currently practiced in Germany, and who accesses it. Service users were predominantly female, over the age of 70, and from a wealthy and/or academic background, which is consistent with data from other countries. Only 1 service user had a documented life-expectancy of 6 months or less. Organizations like the German Society for Humane Dying (DGHS) assist individuals seeking to end their lives, charging 4,000 euros for a single person or 6,000 euros for a couple. The process has become more common since the 2020 court ruling: DGHS reported 419 assisted suicides in 2023, up from 229 in 2022 and just 18 in 2020.
Conclusion:
The demographics of those choosing assisted suicide are also interesting to law makers in Germany and elsewhere. The average age at death was 78.9 years, indicating that older individuals are disproportionately represented. While the article does not delve into specific reasons beyond the absence of terminal illness, it implies that factors like loss of independence, or existential suffering may play more significant roles—areas that warrant further investigation. Referrals to palliative care or for psychiatric evaluation, according to the study’s data, were mostly absent.
As the German Bundestag continues to grapple with this issue, the findings from Munich serve as a critical reference point, urging policymakers to reconcile individual rights with more stringent societal safeguards. UK lawmakers who are too quick to dismiss the importance of safeguarding amendments to the Terminally Ill Adults Bill for England and Wales, should take note.
References:
(1) Gleich, S., Peschel, O., Graw, M. et al. Assistierte Suizide in München – eine erste kritische Analyse. Rechtsmedizin 34, 24–30. https://doi.org/10.1007/s00194-023-00668-3 10.1007/s00194-023-00668-3
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