Educational inequalities in euthanasia use in Spain during the first three years after legalisation: a population-based study

Abstract Background In Spain, euthanasia has been legally recognised as a healthcare right since 2021. However, little is known about its socioeconomic distribution. This study examined educational inequalities in euthanasia use during the first three years after legalisation. This question is grounded in diffusion of innovations theory, which suggests that new practices may initially be adopted more by socially advantaged groups. Methods We conducted a national mortality study using individual-level data on all deaths in Spain between 2021 and 2023. Age-standardised death rates (ASDRs) and rate ratios (RRs) with 95% confidence intervals using Poisson regression with robust variance were estimated by educational attainment, sex and age group. Analyses compared euthanasia deaths with non-euthanasia deaths, both overall and from euthanasia-related conditions, followed by specific analyses of malignant neoplasms and diseases of the nervous system. Results We identified 643 euthanasia deaths and 1,342,700 non-euthanasia deaths. Euthanasia rates were higher among people with upper secondary and university education than among those with primary education, in both men (RR = 2.35[1.49–3.71]; RR = 2.14[1.29–3.55]) and women (RR = 2.32[1.72–3.13]; RR = 2.08[1.56–2.76]). The educational gradient was particularly pronounced among adults aged over 80 years. Conversely, all-cause mortality and mortality from euthanasia-related conditions showed the expected inverse educational gradient. Similar patterns were observed for malignant neoplasms and diseases of the nervous system. Conclusion During the early implementation of euthanasia in Spain, its use showed a clear educational gradient opposite to that observed in all-cause mortality, indicating unequal access to euthanasia. Monitoring systems should incorporate socioeconomic indicators across the entire euthanasia process to identify inequalities and inform policies aimed at ensuring equitable access to this right.