The argument according to which the poorest are over-represented among deaths by assisted suicide or euthanasia is swept aside by various international studies, which even tend to demonstrate the opposite.
This is one of the arguments of opponents of the bill on the end of life: assistance in dying would risk pushing the most precarious patients primarily to shorten their lives, due to lack of sufficient resources to overcome the ordeals linked to their pathology. “When you are poor, yes, the end of life is more difficult than when you are rich. And, yes, this can inspire ideas to end it”said LR deputy Philippe Juvin, Monday May 27, on the first day of examination of the text.
The head of emergency at the Parisian Georges-Pompidou hospital, who fears that this law will apply “mainly to vulnerable, poor and isolated people”challenged his parliamentary colleagues, from the podium of the National Assembly, on the subject of assisted suicides in the United States.
“Ask yourself: why, in Oregon, are the majority of suicides among the poorest?”
Philippe Juvin, LR deputy for Hauts-de-Seinein the National Assembly
That same morning, in the columns of FigaroMP Astrid Panosyan-Bouvet also cited the situation across the Atlantic. “In Canada and Oregon, it is patients with a modest standard of living who tend to request assistance with die”affirmed the elected Renaissance. The next day, on LCPthe turn of LR deputy Yannick Neuder: “When we look at the use of assisted suicide, we see that many people are in significant socio-economic difficulties.”
What is it really ? The data available in the United States, Canada and several European countries tend to demonstrate that there is no over-representation of the poorest among patients resorting to assisted suicide or euthanasia. On the contrary, certain studies suggest an over-representation of the wealthiest categories.
Head to Oregon, in the northwest of the United States, where assisted suicide has been authorized since 1997. Most of the patients who resort to it would be “among the poorest”, assures Philippe Juvin. Contacted by franceinfo, the Hauts-de-Seine elected official says he draws this conclusion from the annual report published by the local authorities (in PDF). According to this document, 78% of patients who ended their lives by assisted suicide in 2023 benefited from public health insurance (Medicare or Medicaid), while 22% had private insurance. “I don’t know the American insurance system well, but public insurance is for the poorest”says the MP.
The reality is more nuanced. The Medicaid system is intended for low-income people, but the Medicare program is open to all Americans aged at least 65, without means conditions. In Oregon, 96.3 percent of people in this age group have this insurance, according to public data. Given that a very large majority of patients who use assisted dying are over 65, it seems normal that they are largely covered by government health insurance.
Oregon’s annual report makes no mention of patients’ income, which would have allowed the question to be resolved. On the other hand, we learn that “close to half” deaths by assisted suicide in 2023 “had a bachelor’s degree or higher. For comparison, such a level of education is achieved by only about a third of the state’s general population, according to the official census. However, the most educated categories also turn out to be those with the highest incomes. We can therefore argue that it is the wealthiest, and not the poorest, who are turning more to assisted dying in Oregon, as the French think tank Terra Nova concludes.
Would Oregon be an exception? “In the United States, we have noted an over-representation of the poor in requests for active assistance in dying,” warned MoDem MP Maud Gatel on May 24 on the Le Journal website. However, a study published in 2022 on a national scale once again contradicts this assertion. In the nine American states with public data on beneficiaries of medical assistance in dying, “we discovered an overrepresentation of highly educated individuals, a variable that may be associated with socioeconomic status”underlines to franceinfo the main author, Elissa Kozlov, researcher at the Rutgers School of Public Health, in New Jersey.
In Canada, where assisted dying has been legal since 2016, work carried out over the period 2016-2018 in Ontario, the country’s most populous province, reached similar conclusions: “People in traditionally vulnerable categories (economically, linguistically, geographically or residentially) were significantly less likely to receive medical assistance in dying”. The following infographic, taken from their data, allows us to observe an under-representation of the poorest.
“People who benefit from medical assistance in dying (…) are generally well-off, privileged people”confirmed the lead author of this study, James Downar, during a hearing before Canadian MPs in 2022. According to this professor of palliative care in Ottawa, “there is absolutely no data allowing the conclusion that recourse to medical assistance in dying would be (…) the result, to any extent whatsoever, of insufficient access to palliative care, of deprivation socio-economic or any isolation”.
Across the Atlantic, however, stories of disadvantaged patients requesting assistance in dying have regularly been publicized, fueling concerns around deaths chosen due to lack of resources or housing suitable for the disease. In Oregon, the cost of medical treatment is cited by doctors as one of the factors that may have motivated their patient’s request for nearly one in ten assisted suicides. However, it is the least often mentioned factor, far behind dependence, loss of dignity or pain.
Faced with the conclusions of studies published across the Atlantic, French deputies and their teams plead “an honest mistake” or acknowledge not being “didn’t go to check” by themselves certain information. But are their fears justified in European countries where euthanasia and assisted suicide are accepted? Again, despite the absence of official data on the socio-economic profile of patients, several studies tend to refute the hypothesis of an over-representation of the most precarious.
In Switzerland, where almost all assisted suicides are carried out through specialized associations, a team of researchers used information collected between 2003 and 2008. The results published in 2014 confirm international trends: recourse rates the highest are observed “among more educated people, in urban areas (…) and in wealthier neighborhoods”. In Belgium, a survey conducted in 2013 also revealed an overwhelming proportion of higher education graduates among those requesting euthanasia.
Likewise, in the Netherlands, “we do not see more disadvantaged people, but rather a true mirror of Dutch society”assures franceinfo the spokesperson for the regional euthanasia control commissions, Jeroen Recourt. “The poorest and most vulnerable are not over-represented among those dying with medical assistance”confirms Margaret Pabst Battin, lead author of a cross-study on the Netherlands and Oregon in 2007. “It is the opposite”says this researcher.
“Those who obtain medical assistance in dying are relatively privileged people, who are sometimes said to be used to getting what they want.”
Margaret Pabst Battin, professor at the University of Utah (United States)at franceinfo
How can we explain that the first beneficiaries of assistance in dying are the most advantaged, and not the poorest, as feared? In Belgium, a 2013 study showed that cancer was the leading cause of death among the most educated, while the least educated were primarily exposed to other cardiovascular or respiratory conditions. However, cancer, because of its heavier symptoms and its greater predictability, is “strongly associated with euthanasia”, which could help to understand certain socio-economic gaps observed.
Several experts, however, see the under-representation of the poorest as a sign of unequal access to the medical world. The wealthiest would have a better mastery of the codes and would dare to assert themselves more. “In the United States, to use medical assistance in dying, you must have heard about it, find out who prescribes it, make appointments, identify the pharmacies that prepare the products…”reports researcher Elissa Kozlov.
“It requires a lot of resources, not just financial.”
Elissa Kozlov, assistant professor at Rutgers School of Public Healthat franceinfo
Added to this, according to her, is the fact that “most applicants must pay out of pocket for assisted dying orders”potentially dissuasive, with formulas “all-in” ranging from $500 to $5,000 in Oregon, reports The world. So many elements that can shed light on the debate in France, without prejudging the consequences that the introduction of assisted dying could have in the country.