Does voluntary assisted dying (VAD) - or euthanasia and assisted suicide - have a negative impact upon other people? It's rare for this question to be raised in debates. If it is, supporters dismiss it - it's my life and it's none of their business, is their response.
And, to tell the truth, there is precious little reliable data on the intergenerational effects of VAD. However, a recent article in the British Journal of Psychiatry should ring alarm bells for supporters. A meta-analysis by German doctors of the impact of suicide on relatives claims that: "The experience of losing a parent to suicide is a strong and independent risk factor for suicidal behaviour in offspring."
They conclude that "children of parents who died by suicide should receive early attention, including identification of critical periods during which the loss is particularly harmful."
Suicide and suicide attempts are near the top of the list of causes of mortality globally. Nearly 800,000 people die by suicide every year. "Every suicide affects not only family and friends of the decedent, but also society as a whole," the authors point out - 135 people are exposed for every suicide death.
The data is cloudy; there is a correlation between the suicide of a parent and suicides of their children - but mechanism is far from clear. It could be genetic or environmental. It could be due to grief and shame.
Or it could be imitation: "Identification with one's caregivers plays a role in developing a sense of self, and a parent's self-harming behaviour and coping strategies are likely to be imitated. Offspring might thus replicate the parents' way of solving problems, including suicide when facing difficulties in life. Imitation may also desperately be driven by an urge to understand the suicidal parent's motives and state of mind."
As one might expect, age is a moderating factor. When children are older, the risk seems to be lower.
One response from the VAD lobby is that VAD has nothing whatsoever to do with suicide and data about suicide is irrelevant. Death With Dignity's New South Wales branch - where VAD is currently being debated in Parliament - tell readers of its website that suicide is what mad people do; VAD is what coolly rational people do:
Suicide is an irrational impulse, acted on in secret, in response to a problem that, with treatment, could most likely be fixed. Voluntary assisted dying is a rational response, taken in consultation with doctors and family, to a condition of suffering that cannot be fixed.
This is very tendentious. People who ask for VAD are often depressed or demoralised, even if they appear to in possession of their senses. But in any case, for a person's loved ones it's a distinction without a difference. From their point of view Mum or Dad took an early exit, whether they did it by jumping off a bridge or accepting a doctor's needle.
It's quite reasonable to speculate about the idea of an early exit seizing the imagination of grown-up children - to say nothing of teenage children - when they encounter one of life's roadblocks. Is there such a thing as inter-generational VAD? If parents ask for VAD, will their children be more disposed to do so?
This research suggests that it is imperative to collect data about life trajectory of the children and spouses or partners of people who request VAD. Without this vital information, if there is a correlation between VAD and family suicides, it could easily go quite unnoticed. This needs to be part of the conversation about voluntary assisted dying.