192 Suicide and Life-Threatening Behavior 33(2) Summer 2003 2003 The American Association of Suicidology

The Werther Effect and Assisted SuicideANDREAS FREI, MD, TANJA SCHENKER, MD, ASMUS FINZEN, MD,VOLKER DITTMANN, MD, KURT KRAEUCHI, PHD,AND ULRIKE HOFFMANN-RICHTER, MD

In the course of a large epidemiological study in the region of Basle, Swit-zerland, from 1992 to 1996, a considerable rise in suicides assisted by the right-to-die society EXIT was uncovered after wide press coverage of an assisted doublesuicide of a prominent couple in that region in March 1995. Further investigationrevealed that the rise of assisted suicides for a period of 2 years after the criticalevent was statistically significant compared to the 2 years previous to the doublesuicide. This was especially true for women older than 65 years. Hence, the almostenthusiastic kind of reporting about this event was apt to induce imitation suicidesor a “Werther-effect.”

The existence of suicide as a consequence of gions of England and the United States wherenewspapers had covered suicides. Since then,its reporting in the media is no longer chal-

lenged. Philips (1974) introduced the now a lot of research on this issue has been done.The risk of copycat suicides after me-well-known notion of the “Werther effect” in

suicide research, based on J. W. Goethe’s novel dia coverage of “celebrity” suicides is welldocumented (Stack, 1987; Wassermann, 1984).“The Sorrows of YoungWerther” (1774/1775).

In his work, Phillips showed that between 1947 Contrary to Wassermann, Stack (1990a) claimsthat there is a risk of imitation with the re-and 1968, suicide rates had risen in those re-porting of suicides of non-celebrities as well.In his meta-analysis of 42 studies concerning

ANDREAS FREI is head of the forensic-psy- media impacts on suicide, however, Stackchiatric service of the Psychiatric Clinic of Lu-himself found that studies using entertain-cerne. TANJA SCHENKER is a junior registrar at

the Psychiatric University Clinic (PUK) of Basle. ment or political celebrity suicides were 14.3ASMUS FINZEN is Professor of Psychiatry and the times more likely to find a copycat effect thanActing Director of the Psychiatric University studies that did not (Stack, 2000).Clinic (PUK) of Basle. He has initiated a working Gould, Wallenstein, Kleinmann, O’Car-group for the investigation of suicide in the region

oll, and Mercy (1990) stressed the particularof Basle. VOLKER DITTMANN is Professor for Fo-rensic Medicine and Psychiatry at the University vulnerability of adolescents to imitation sui-of Basle and Director of the Institute for Forensic cides. According to Stack (1990b, 1991),Medicine (IRM). KURT KRAEUCHI is a Biologist there also exists a risk of copycat suicides forand works in the Department of Biological Psy- the elderly who, like adolescents, are oftenchiatry at the Psychiatric University Clinic (PUK)

not fully integrated in social life. This is es-of Basle. ULRIKE HOFFMANN-RICHTER is a lead-ing psychiatrist at the Swiss Accident Insurance pecially the case if the publicized stories dealCompany (SUVA) in Lucerne and head of the with victims in similar life circumstances asSwiss Society for the Prevention of Suicide. the readers.

Address correspondence to: Andreas Frei, There is also evidence that advice con-Psychiatrische Klinik, Kantonsspital, CH-Luzerncerning effective suicide methods published16, Switzerland. E-mail: andreas.frei@ksl.ch

FREI ET AL. 193

by “right-to-die” societies is followed (Mar- 1992 and 1996. The Basle region consists ofthe two semi-cantons Basle-City and Basle-zuk, Tardiff, & Leon, 1994). As far as assisted

suicide is concerned, the question of copycat Country. It is a comparatively secluded re-gion with about 400,000 inhabitants. Thesuicide or a Werther effect has not yet been

raised. In the course of a large, 5-year re- registration of extraordinary deaths in the re-gion is almost complete.search project about suicide in the Basle re-

gion of Switzerland, a sudden and massive The analysis of all EXIT-assisted sui-cides was performed by consulting the ar-rise in the prevalence of suicides assisted by

the right-to-die society EXIT was noticed. In chive of the Institute of Forensic Medicine(IFM) of Basle (Frei et al., 2001). The meanthis paper, we examine whether the cause of

this rise was due to a Werther effect. age of people committing EXIT-assisted sui-cide was significantly higher than that of peo-ple committing ordinary suicides: Almost twiceas many women committed EXIT-assistedBACKGROUNDsuicide compared to men; that is, the genderratio was almost inverse to that known fromAssisted suicide in Switzerland is not a

felony, as long as it is not performed for a the international literature (La Vecchia, Luc-chini, & Levi, 1994) and still different fromselfish motive. This is the basis of the private

right-to-die society “EXIT—Society for Hu- the 1:1 gender ratio that has been reportedlately from Oregon, where physician assistedmane Dying,” which was founded in 1982 in

order to counter the paternalistic attitudes of suicide was legalized in 1997 (Sullivan, Hed-berg, & Hopkins, 2001). There were less peo-physicians as regards the needs of their pa-

tients. Members who wish to die must approach ple suffering from cancer than reported inthe international literature about physicianEXIT of their own free will. The applicant is

then visited by an EXIT-dying companion, assisted suicide (Sullivan, Hedberg, & Flem-ing, 2000; Van der Maas et al., 1996; Van dernot necessarily a medical professional, who

brings a lethal drug, usually a barbiturate, which Waal & Onwuteaka-Phillipsen, 1996). In 11out of the 43 EXIT cases, there was no evi-has to be swallowed by the applicant. Accord-

ing to EXIT’s own rules, the person con- dence of a seriously impairing or incurabledisease to be found in the files.cerned has to suffer from a medically con-

firmed incurable disease or from intolerable The EXIT cases were not equally dis-tributed over the considered period of 6 yearsimpairment. EXIT does not, however, want

to leave decisions concerning ending life to (see Figure 1). Closer analysis reveals a sud-den increase of EXIT-assisted suicides afterthe medical body; it insists on an assumption

of competence of its clients to make such de- the first two suicides of the year 1995. Theseconcerned the double suicide of the locallycisions and consequently it is not concerned

with any kind of suicide prophylaxis (Frei et well-known and respected couple “G.” onMarch 8, 1995. The name of “G.” is of sig-al., 2001).nificance in the Basle region since it standsfor the name of a world-wide acting companywhich provides the region with thousands ofMETHODSplaces to work. The news of this double sui-cide was publicized after March 19, 1995, inPatientsthe local and national print media and dis-cussed nationwide.In a recently published paper, 43 con-

secutive cases of EXIT-assisted suicides com- If there was an imitation effect due tothe publicizing of the double suicide, it shouldmitted in the Basle region between 1992 and

1997 were analyzed (Frei et al., 2001). They thus have occurred after March 19, 1995. Inorder to compare similar time intervals, wewere compared with 425 “ordinary” suicides

which took place in the same region between considered suicides that occurred between

194 THE WERTHER EFFECT AND ASSISTED SUICIDE

Figure 1. Exit Suicides from 1992 to 1997

March 20, 1993, and March 19, 1997, which that during the second period using chi-square for significance. According to the re-amounted to 33 patients. A reanalysis re-

vealed that an elderly couple who had been sults of the first study (Frei et al., 2001), itseemed reasonable to examine whether onemembers of EXIT had committed another

double suicide according to EXIT’s recom- of the four different age/gender groups wasespecially vulnerable to a putative Werthermendations by ingesting a lethal dose of bar-

biturates. They had, however, received the effect. Since the numbers in the respectivegroups were comparatively small, the oddsnecessary prescription from a source other

than EXIT. They were included in the study ratio to commit EXIT-assisted suicide in thesecond period of each of these four differentas well. Hence, there was a total of 35 EXIT

cases, 7 in the period between March 20, groups (women below and above 65 yearsand men below and above 65 years) was cal-1993, and March 19, 1995, and 28 in the pe-

riod between March 20, 1995, and March 19, culated.1997. There were 159 ordinary suicides inthe first period and 167 in the second period, Newspaper Reportswhich amounts to a total of 326.

Since some peculiarities of EXIT-assisted suicides concerning age, gender, In November 1989, a national work-marital status, and somatic disease were re- shop in the United States was held with thevealed in the first study (Frei et al., 2001), participation of suicidologists, officers of pub-these factors were given particular attention lic health agencies, researchers, psychiatrists,in this study. psychologists, and news media professionals in

order to develop recommendations on generalStatistics issues to be considered when suicides are re-

ported in the media. These recommenda-tions have been approved by the Centers forStatistical calculations were performed

using the statistics program SPSS 10th edi- Disease Control (CDC) (O’Caroll & Potter,1994). According to the CDC, the followingtion (2000). The frequency of all kinds of sui-

cides during the first period was compared to factors promote imitations suicides:

FREI ET AL. 195

TABLE 1• Presenting simplistic explanations forsuicide Comparison of Suicide Methods Between

May 20, 1993, through May 19, 1995,• Engaging in repetitive, ongoing, orexcessive reporting of suicide in the and May 20, 1995, through May 19, 1997,

in the Region of Baslenews• Providing sensational coverage of

Total 1st Period 2nd Periodsuicide• Reporting “how-to” descriptions of Gunshot 108 51 57suicide Hanging 65 34 31

• Presenting suicide as a tool for ac- Intoxication 42 22 20complishing certain ends Fall 37 16 21

EXIT* 35 7 28*• Glorifying suicide or persons whoTrain 20 12 8commit suicideDrowning 17 8 9• Focusing on the suicide completer’sCO 7 4 3positive characteristicsPlastic bag 7 4 3Others 7 2 5

The recommendations of CDC were fol- Hair dryer 6 2 4lowed in the reporting of the suicide of rock Chemical agents 5 2 3

Cutting 5 2 3star Kurt Cobain, whose case was consideredAll 361 166 195as particularly prone to induce imitation sui-

cides. No rise in the suicide rate of the popu- *Chi-square (df1) = 10,535, p > 0.01.lation at risk, namely adolescents, was ob-served ( Jobes, Berman, O’Caroll, Eastgard,& Knickmeyer, 1996). Age, Gender, and Marital Status

We searched the archives of the mostimportant local newspaper, Basler Zeitung, for There were some marked, but still sta-stories and death notices about the suicide of tistically insignificant fluctuations concerningthe “G.” couple, as well as the archives of the the ordinary suicides in the different age/most important Swiss media publisher, Rin- gender groups observed (Table 2). Except forgier-Verlag, for stories about the event. The the age/gender group of women above 65articles were analyzed to see whether they years, the proportion of EXIT-assisted sui-were apt to promote imitation suicides in ac- cides among suicides in general was still smallcordance with the CDC’s recommendations. in the second period. There is, however, aThe death notices were assessed as to whether rise in the rates of men below 65 years tothey revealed hints about the cause of death. be noted (Table 3). Elderly women were very

TABLE 2RESULTS Age and Gender of the Ordinary Suicides

Between May 20, 1993, through May 19, 1995,and May 20, 1995, through May 19, 1997,Suicide Methodsin the Region of Basle

Thirteen kinds of suicides were classi- 1st Period 2nd Period Totalfied. Single cases such as burning or one case

Women above 65 8 22 30of physician-assisted suicide without any in-Men above 65 30 24 54fluence of EXIT were classified as “others.”Women below 65 45 32 77The rise of EXIT-assisted suicides during theMen below 65 77 88 165second period compared to the first was high-Total 159 167 326ly significant (see Table 1).

196 THE WERTHER EFFECT AND ASSISTED SUICIDE

TABLE 3 was a man above 65 years, the remaining ninewere women above 65 years.Age and Gender of the EXIT Suicides

Between May 20, 1993, through May 19, 1995,and May 20, 1995, through May 19, 1997, Analysis of Newspaper Reportsin the Region of Basle and Death Notices

1st Period 2nd Period TotalOn March 15, 1995, ten days after the

Women above 65 3 13 16 suicide of the “G.” couple, a death notice wasMen above 65 3 6 9 published in the local newspaper Basler Zei-Women below 65 1 3 4 tung. The text “did we accept their sincereMen below 65 0 6 6 wish” is a clear hint to suicide as the cause ofTotal 7 28 35 death. No such hint could be found in the

necrology which was published the next day(Freivogel, 1995) in the Sonntags Zeitung, oneof two important national Sunday newspa-much at risk of committing EXIT-assisted

suicide in the second period compared to the pers, which appeared the day after. Mr. “G.”was called a great citizen of Basle and a Mae-other age/gender groups (Table 4). Only those

women above 65 years who were involved in cenas, who in spite of being a millionaire haddedicated his life to science. His wife hada double suicide were (still) married.been suffering from a deteriorating lung can-cer. Mr. “G.” himself had been slightly suf-Lethal or Seriously Disabling Illnessesfering from old age, he had, however, earlierconfessed to close friends that he did notEleven of the original 43 EXIT cases

were not suffering from a lethal or seriously wish to go on living without his wife. Every-thing including the funeral had been ar-disabling illness as stipulated by EXIT (Frei

et al., 2001). If one includes the two cases ranged before the suicide. In the article, thepossible participation of EXIT was discussedwho committed suicide according to EXIT’s

recommendations, but without the presence (Anderegg, 1995). In the rival newspaperSonntagsblick of the same day, a friend of theof an EXIT dying companion, the number

grows to 13 out of 45. Of these 13, two oc- family was quoted: “It fits well with the greatpersonality of ‘G.’ that he wished to leave incurred during the first period between March

1993 and March 1995, ten during the second this way together with his wife.” The articlewas completed by a picture of the couple’sbetween March 1995 and March 1997, and

one after this date. Thus, 10 out of 28 people grave, ornamented with flowers of formercolleagues, and by information about EXITwho committed suicide in the second period

were not suffering from one of the conditions (Sonntagsblick, 1995).During the following weeks, EXIT gotstipulated in EXIT’s guidelines. One of them

TABLE 4Comparison of the Odds Ratios to Commit EXIT-Assisted Suicide of the Different Age/Gender GroupsBetween May 20, 1993, through May 19, 1995, and May 20, 1995, through May 19, 1997,in the Region of Basle

Rate EXIT/Ordinary Suicides Odds Ratio Confidence Interval

Women above 65 13/22 5.71 2.40–13.60Men above 65 6/25 1.55 0.57–4.20Women below 65 3/32 0.73 0.24–2.26Men below 65 6/88 0.23 0.90–0.61

FREI ET AL. 197

nationwide publicity. A homestory in Swit- licizing of its activities in the media. In hismemoirs, a former manager and dying com-zerland’s most popular illustrated magazine

with the president of EXIT, a former profes- panion of EXIT talks about the circumstancesof the first EXIT suicides, which were per-sor of epidemiology who had assisted the

double suicide, was titled: “I am amazed how formed in the region 8 and 9 weeks after thedouble suicide of the “G.” couple: The wifepeacefully ill people can die” (Capus & Rein-

hardt, 1995). of an influential man, but not a celebrity,asked to commit suicide together with herAt least four of the issues which are

called harmful by CDC concerning imitation husband, mentioning unequivocally the “G.”case. Both were suffering, but not from a le-suicide can be seen in the articles cited above:thal illness. According to his memoirs, thedying companion assisted the two with a time• The reporting of he event in great

detail, the mentioning of EXIT and interval of 10 days in order not to leave thepublic with an unfavorable image of EXITa homestory with its president, who

assisted the suicide, complies with promoting some kind of “widow burning”(Sigg, 1998).excessive reporting of the critical

event. For Gould (1990), consistency of theassociation on replication is a criterion for a• In none of these reports are any al-

ternatives to suicide discussed: Sui- putative Werther effect. In the case men-tioned above, there is no doubt about a copy-cide is presented as the consequence

of the decision of a determined man. cat effect. There were two more such suicidesin May, one in June, one in August, and one• Suicide as a means to stay together

after death is glorified. in early October 1995. On October 18, 1995,the wife of a well-known professor of medi-• “G.” is characterized as a strong per-

sonality who wanted to decide about cine, who himself had just died in hospitalfrom a chronic disease, committed suicide athis own death.his hospital bed. The death notice concern-ing the couple’s death was highly equivocal,There has been, however, nationwide debate

in the press about the case, including some suggesting a double suicide assisted by EXIT.One more assisted suicide happened in thestrong criticism of EXIT and its practice of

assisting suicide expressed by the children of same month, as well as one each in Novem-ber and December 1995. Worth mentioningthe deceased (Habegger, 1995).in this connection is the previously men-tioned double suicide from October 1996, inwhich the couple had been prescribed the le-DISCUSSIONthal dose of sodium pentobarbital by a retiredprofessor of surgery for “ethical and philo-As with other epidemiological work

about imitation suicides, unequivocal proof sophical considerations” (as reported in thepolice report available from the files of thethat a significant rise in the suicide rate was

the consequence of the publicizing of one IFM Basle).Gould (1990) also stresses the impor-or several suicide events, such as the case of

the “G.” couple, cannot be presented. Gould tance of evaluating the plausibility of a copy-cat effect. According to Stack (1990b, 1991),(1990), who describes imitation suicide as a

kind of infection occurring in a confined people who live in similar circumstances assuicide victims whose death has been reportedunity like a geographical region or a socio-

logical community, talks of “suicide clusters.” in the news are at high risk of committing animitation suicide. This is especially the caseIn this case, the cluster would be the Basle

region, where the name of “G.” is of great for elderly women, who are by far the largestgroup in the study of the 43 EXIT suicideslocal importance. EXIT itself seems to be

very conscious of the importance of the pub- (Frei et al., 2001). Ahronheim (1997) claims

198 THE WERTHER EFFECT AND ASSISTED SUICIDE

that elderly women are particularly helpless number of EXIT-assisted suicides in the regionof Basle, however, dropped to 7. InMarch 1999,because of their specific sociodemographic

conditions, because they suffer from poor EXIT was prevented at the very last minutefrom assisting a young, physically healthymedical services, and because they are often

unable to express their needs concerning cor- woman who was suffering from a psychiatricdisease (Frei, Schenker, Finzen, & Hoffmann-rect care and sufficient pain treatment. It

should be kept in mind that the rise in EXIT Richter, 1999). This event was reviewed in amost critical way by the media. In the followingsuicides cannot merely be explained by medi-

cal conditions, since a great proportion (10 year, only two EXIT-assisted suicides were ob-served in the Basle region (Volker, Dittmann,out of 28 cases after the “G.” double, 9 of

which were elderly women) did not suffer personal communication, 2000).The rise in the total number of sui-from the medical conditions stipulated by

EXIT’s own rules. Since assisted suicide exe- cides during the observed period was not sta-tistically significant. The possibility that thecuted by a right-to-die society can be seen as

a kind of “service” which has to be publi- rise in EXIT suicides concerned people whowould have committed suicide anyway (i.e.,cized, an excessive reporting of EXIT in the

media can be considered as a kind of en- that there was a mere shift of methods), asobserved by Marzuk et al. (1994), cannot behanced availability. The enhanced availability

of a suicide method, however, means that this ruled out. But, as already mentioned, womenabove 65 years are strongly overrepresentedmethod is increasingly used (Hawton, Faff,

Simkin, Hariss, & Mallberg, 1998; Marzuk et in the second period. The hypothesis that allthese victims would have chosen an alterna-al., 1992).

There still are some objections against tive means of suicide seems to be fairly un-likely.a proper Werther effect. Gould et al. (1990)

in their paper about suicide clusters consider It was not the purpose of this paper todiscuss the pros and cons of assisted suicidea time span of 2 months and not 2 years after

the critical event. It can be said, however, with suffering and lethally ill people. Our ex-perience with EXIT, however, showed that inthat within the 2 year span, there were no

major socioeconomic changes in that region a great proportion of cases non-medical rea-sons were behind the wish to die. Winebergto be observed. The sustained rise in EXIT

suicides could mean a different attitude to- and Purser (2000), who analyzed 43 cases ofphysician assisted suicides in Oregon fromward this issue in general (Kelleher, Cham-

bers, Cochran, Keeley, & Williamson, 1998). 1997 to 1998, do not come to the same con-clusions as Sullivan and colleagues (2000)For example, the cantonal government of

Zurich in Switzerland has formally allowed with the same patients. Sullivan et al. claimthat social factors were of minor importanceEXIT to execute assisted suicides in the old

people’s homes administrated by the city when these terminally ill patients chose phy-sician assisted suicide as the means to die.(Frei et al., 2001). Hence, one could speak of

a change of paradigm. Unfortunately, there Wineberg and Purser (2000) found that 3.2times more patients who were divorced andare no official data on EXIT-assisted suicides

in Switzerland, and the accuracy of reporting 4.2 more patients who never had been mar-ried chose assisted suicide than married ones.of extraordinary deaths varies from canton to

canton. In an interview after the “G.” double Even Sullivan in his latest paper (Sullivan etal., 2001) about physician assisted suicide insuicide, some 40 to 60 EXIT-assisted suicides

per annum were mentioned (Capus & Rein- Oregon reports an increase in the number ofpatients who fear to become a burden to fam-hardt, 1995). Two years later, the new chair-

man of EXIT mentioned a rate of up to 200 ily, friends, and caregivers.Gould (2001) in her comprehensive ar-cases per annum (Meier, 1997). Hence, the

rise in EXIT-assisted suicides could be more ticle about suicide and the media stresses theimportance of educating the media. The abovethan a mere local phenomenon. In 1998, the

FREI ET AL. 199

mentioned CDC recommendations have sue in the discussion of media impact on sui-cide. Taking into account the findings of thisbeen updated partly and are more specific on

how to report about suicides if the event is study and the considerable role of non-medi-cal reasons behind the wish to die by assistednewsworthy at all. The fact that in many

cases suicides are fatal complications of dif- suicide, it would be preferable from the pointof view of suicide prevention if the mediaferent types of mental illnesses, many of which

were treatable, is stressed. Guidelines have observed similar rules in reporting of suchevents as has been suggested for ordinarybeen implemented in other countries, too.

Assisted suicide has not yet been an is- suicides.

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