The finding: 
Physician-assisted suicide (PAS) is now legal in an ever-increasing number of countries including Germany in 2020, bringing this topic to the focus of social and legal debates. PAS involves the prescribing of medication which the patient takes independently with the intention to end their lives. In contrast, voluntary euthanasia is a procedure where the doctor is authorized to administer the lethal medication.  Most previous studies focus primarily on the attitudes of the general population and the associated legislation, as well as on medical staff, such as doctors and nurses. However, perspectives about PAS shaped by a person’s own lived experience of suicide bereavement are still missing.

In this study, the authors conducted a cross-sectional survey recruiting 529 participants from social media, 168 of whom were survivors of suicide loss using the Norwegian Bioethics Attitude Survey (NOBAS) and attitudes (NOBAS) and opinions (open response format) towards PAS and voluntary euthanasia. Individuals were excluded if they lost someone through PAS.

Participants who had not experienced a loss by suicide had a significantly more liberal attitude towards the legalization of PAS in Germany than people who had experienced a suicide loss. Survivors of suicide loss were significantly less understanding of the general wish for PAS; however, the effect is minimal and both groups have almost identical mean values. As such, the authors conclude that the difference is minimal and only statistically and not clinically and ethically significant. Individuals in the oldest subgroup showed the most negative attitudes towards the legalization of voluntary euthanasia for terminally ill patients. Interestingly, people with the highest level of education showed a more negative attitude towards voluntary euthanasia than the other subgroups. Those with no religious beliefs showed the most liberal attitude but difference in mean values were minimal. 

This study also did a qualitative analysis of optional open question asking participants for their opinion on PAS. Some participants noted feeling that having control over their own death and not having to wait for it to occur naturally was viewed as allowing one to die with dignity. Regarding access for people without a physical illness, participants were rather divided in their attitudes. These results are in line with studies on attitudes in the general population.

Strength and weaknesses:
Per the authors, this study is the first to analyse attitudes towards PAS and voluntary euthanasia while considering individual’s own experience of suicide loss. They note that their sample is sufficiently large and heterogeneous in terms of age, level of education, religious belief, and experience of loss. The qualitative data collected also allowed them to examine a broad range of opinions about this topic.

This study has several limitations, the first one being that over 90% of participants were female and recruited through social media alone. The cross-sectional design does not allow any inferences about causality and the measurement scale has not been validated. The authors also report a high dropout rate at the beginning of the survey, many did not even start the questionnaire after reading the first page, which may lead to selection bias and influence generalizability of the findings. Additionally, no data about political orientation, ethnic or cultural background, occupation was collected, and these are factors which might contribute to participant attitudes.

Relevance:
As C-L psychiatrists are often at the cusp of complex decision making and ethical considerations at the end-of-life/ life threatening situations due to severe medical or psychiatric illness, this study provides a compass to navigating sensitive and often painful discussions about death and dying with patients and their loved ones.