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Suicide

Suicide

I. Social AspectsJack D. Douglas

BIBLIOGRAPHY

II. Psychological Aspects (1)Edwin S. Shneidman

BIBLIOGRAPHY

III. Psychological Aspects (2)Norman L. Farberow

BIBLIOGRAPHY

I. SOCIAL ASPECTS

Suicide has been an object of fundamental concern to Western men of all cultural periods, though the importance given to suicide itself, as well as the degree to which it has entered into other concerns, has varied greatly from one period to another. “Suicide,” said Goethe, “is an incident in human life which, however much disputed and discussed, demands the sympathy of every man, and in every age must be dealt with anew” ([1811-1833] 1908, vol. 2, p. 125).

This is not to say that suicide has failed to interest people in other cultures but, rather, that the reasons have usually been different. In feudal Japan, for instance, suicide was an ultimate act of honor, redemption, or union. In the Western world, however, suicide has always been regarded as fundamentally problematic. Possibly because suicide in the West has nearly always been interpreted as voluntary self-destruction, with no element of social constraint or obligation, philosophers from Plato to Camus have used it as a starting point for reflection on the eternal problems of human existence. Indeed, ambivalence toward the fact of his own existence is one of Western man’s most persistent characteristics; life and death, the relation of man to man, and the relation of man to himself have been subject to continual questioning, and suicide has been seen as relevant to all of these. In such a climate of thought, it is not surprising that neither settled opinion nor emotional consensus has ever been reached concerning the nature of suicide.

Early writings . Early Western writers on suicide were primarily concerned either with its desirability (including its honorability) or with its morality. But all of them, whether Greek, Roman, Jew, or Christian, were concerned to some degree with the particular facts of actual cases of suicide. Most importantly, from our point of view, they implicitly assumed that before one could properly judge the actor in the case, one had also to know his intentions, the situation in which he found himself, and the nature and outcome of his actions.

After the normative arguments against suicide by Augustine, the Council of Aries, and the Council of Bourges, there is little evidence that the normative evaluation of suicide was considered to be very problematic until the seventeenth century. But there remained the cognitive problem of deciding which set of facts concerning intentions, situations, and actions should be imputed to the category of suicide. Most important to Christian thinkers was the problem of categorizing “martyrs”: were they suicides or not? This cognitive problem was to be just as difficult for sociologists in the twentieth century as for theologians in the fifth century (see Halbwachs 1930).

The nineteenth century . The fundamental forms of thought about suicide, including the implicit assumptions that suicide must be studied as a form of normative action and that suicide is connected with the problem of man’s relation to God and man’s relation to man, were all part of the literary and common-sense background of sociological thought about suicide in the nineteenth century. But there were many other, more specific influences on these nineteenth-century works.

Almost all of the many works on suicide in the eighteenth and nineteenth centuries included extensive and detailed considerations of the historical cases, the literary examples, and the philosophical treatments of suicide. The works of Appiano Buona-fède, Louis F. Bourquelot, Carl F. Stäudlin, Albert des Étangs, Pierre J. C. Debreyne, Alexandre Brière de Boismont, and Alfred Legoyt, to mention but a few, were greatly concerned with such sources. Among the literary, philosophical, and historical influences on the developing sociology of suicide, three can be singled out as most important.

(1) Knowledge of the high frequency of suicide among the upper classes in ancient Rome, and of the honorableness of suicide among the Romans, led to the idea that suicide is fundamentally a matter of social custom. According to Voltaire and other thinkers of the Enlightenment, suicide in a society where suicide is neither the custom nor positively valued or expected was due to a failing, weakness, or disease. This background assumption helped to produce both the psychological theory that suicide is caused by insanity (or character weakness, or disequilibrium), a theory of great influence even today (Dahlgren 1945; Achille-Delmas 1932; Deshaies 1947), and the sociological theory that suicide is caused by a failure of the normative control of individuals by society (Brière de Boismont 1856; Morselli 1879; Durkheim 1897; Cavan 1928).

(2) In the eighteenth century, suicide became a focal point in the ethical argument between the philosophes and the church supporters. Largely as an outgrowth of this struggle, the relation of religion to suicide became a leading concern of the nineteenth-century sociologists. Specifically, this tradition of thought was largely responsible for the explanations of the great statistical increase in suicide in nineteenth-century Europe in terms of meaninglessness of life, lack of discipline, self-centeredness, moral disorganization, and materialism. These developments are dealt with more fully below.

(3) Death, especially death by suicide, was a favorite theme in the literature of the romantic movement. Indeed, the most important contribution of this literary tradition to the developing sociology of nineteenth-century Europe was probably that it helped to focus attention on suicide. Largely because of its treatment in literature, suicide was seen by the educated public as a fundamental social problem. Nineteenth-century Europeans, especially the French, were as frightened of la manie du suicide (as Tissot [1840] called it) as twentieth-century Americans are of juvenile delinquency and the Mafia. But the literary concern with suicide also provided the core of certain very important, specific “theoretical” explanations. Of fundamental importance was the prime romantic symbol of an isolated, lonely hero of a poetic (or intellectual) bent who wanders far from human society in search of the impossible and, failing of the impossible, becomes increasingly melancholy and enamored of eternity. The idea that self-imposed isolation produces “melancholy,” and thence suicide, was hardly novel; indeed, Robert Burton’s seventeenth-century treatise, The Anatomy of Melancholy, had carefully documented its classical sources. But this prime symbol of romanticism contained the most unclassical ideas of both egoism and anomie. Indeed, the romantic image of suicide seems to have been so much the mythical model which the sociologists of suicide had in mind that both Morselli ([1879] 1882, p. 297) and Durkheim (1897) had a strong tendency to treat egoism and anomie as almost identical. It is even possible to specify the work of Chateaubriand, especially as treated by Briére de Boismont (1856, pp. 39-40), as the major source of Durkheim’s idea of anomie suicide (Douglas 1965, pp. 20-26).

Some of the fundamental ideas about suicide which the sociologists inherited from history, philosophy, literature, and common sense became the cores of the various sociological theories of suicide. There were other influences on these theories which will be described later. But the sociologists of the period were dependent upon these nonscientific and, most importantly, nonempirical sources for their ideas about suicide as a specific phenomenon. Though this is somewhat less true today, the sociological study of suicide is in substantially the same condition.

The definition of suicide

A great number of different definitions of suicide have been proposed by the students of suicide during the first two hundred years of the term’s general use. Almost all of these definitions have included, to varying degrees and in various combinations, one or more of the following conceptual dimensions: (a) the initiation of an act that leads to the death of the initiator; (b) the willing of an act that leads to the death of the wilier; (c) the willing of self-destruction; (d) the loss of will; (e) the motivation to be dead (or to die, or to be killed) which leads to the initiation of an act that leads in turn to the death of the initiator; (f) the knowledge of an actor concerning the relations between his acts and the objective state of death; (g) the degree of central integration of the decisions of an actor who decides to initiate an action that leads to the death of the actor; (h) the degree of firmness or persistence of the decision to initiate an act that leads to the death of the initiator; (i) the degree of effectiveness of the act in producing death. (For a detailed presentation of the various definitions, see Schneider 1954, pp. 9-59; for an analysis of the definitions of suicide, see Douglas 1965.)

The great profusion and confusion of definitions of suicide have been very largely the result of combining an abstract, a priori approach to defining the concept with an assumption of “verbal realism” —i.e., the assumption that if the same name is in fact used to refer to a set of phenomena, then that set of phenomena must in fact have some shared property that is designated by the shared word. Durkheim and almost all other sociologists and psychologists who have attempted to carefully define suicide, have assumed that one should arbitrarily define the concept to fit his scientific methods and his theoretical purposes but that the definition should not differ too much from common usage (Durkheim [1897] 1951, pp. 41-42). Durkheim further assumed that the most common definition of suicide was that of death caused by an action initiated by the actor with the intention of causing his own death. Since, however, teleology is anathema to positivists, Durkheim decided that intentions are too “intimate” to yield valid information and that, consequently, “knowledge” by the actor of the deadly consequences of his actions should be the fundamental factor in deciding that a death is a suicide, even if the consequences are relatively uncertain (ibid., pp. 43-46).

Unfortunately, Durkheim’s definition of suicide was quite irrelevant to his work on suicide. As Maurice Halbwachs most astutely argued, Durkheim was almost totally dependent on the official suicide statistics for his data, so the only definition that really mattered was that (rather, those) which the officials had in mind when they categorized the causes of deaths. Since Halbwachs believed that one could not know what definitions these officials used, he concluded that sociologists must be satisfied with no definition at all (Halbwachs 1930). Actually, the coroners and doctors who do the categorizing seem generally to be firm believers in the common-sense theory of teleology. Moreover, the laws governing the certification of cause of death very generally specify “intention” as necessary for a classification of suicide. Benoit-Smullyan (1948) has also pointed out that since Europeans do not generally consider self-sacrifices to be suicides, Durkheim’s “altruistic suicides” would not be included in the official statistics on suicide. Consequently, it seems clear that Durkheim’s definition of suicide was not so much irrelevant to his data as it was a complete distortion of the meaning of the data.

With the exception of Halbwachs’ work, the published sociological works on suicide since Durkheim’s Suicide have generally assumed that Durkheim’s definition is best; they have even failed to note Halbwachs’ valid criticism of it. They have, however, also either implicitly assumed “intention” to be a necessary factor, or else they have totally avoided the problem. The result has been both confusion and a failure to recognize the problems involved in defining suicide. The sociology of suicide is in obvious need of a system of categories which will describe the observed phenomena that are significant in terms of a theory of suicide. Such descriptive categories must be worked out in partial independence of the theories in order to aid their development, but they must also be worked out in partial dependence on developing theories. However, the first critically important thing for sociologists to do is to make direct observations of the empirical phenomena which are called suicide in any society, so that definitions will be relevant and so that the meanings of the data will be known to the theorists.

Official statistics on suicide

Largely because of the rapid acceleration in statistics-keeping in eighteenth-century Europe, the systematic recording and tabulating of suicides had become standard practice in many of the governmental regions of Europe by the first quarter of the nineteenth century. The basic ideas of “moral statistics,” especially the fundamental idea that a given incidence of a phenomenon such as suicide is regularly associated with a given population, had been clearly formulated in the eighteenth century, certainly by 1741, when Johann Peter Süssmilch published his famous treatise on the “divine order” underlying demographic phenomena. The traditions of “political arithmetic,” of studying racial and national character, and of comparative studies of suicide rates were synthesized by Adolphe Quetelet (1835) in order to produce his “average man” theory of suicide rates. Quetelet’s fundamental idea was that each stable “social system” produces a stable, average personality type about which the individual personalities tend to cluster. The average man, therefore, has a given, stable probability of committing suicide in a given period of time.

Quetelet’s probabilistic theory was specifically intended to explain the observed regularity (or order) in the official suicide statistics. This regularity, which was first observed for the different nations of Europe, seemed to the moral statisticians to be a remarkable demonstration of the deterministic, lawlike nature of the actions of individuals. Since the seventeenth century, Europeans had believed suicide to be more frequent in some nations than in others. The French considered suicide to be as English as gambling (they seem to have believed that more Englishmen preferred death to life because the fog made living so unworthwhile), though Voltaire thought this impression was due to more newspaper coverage of suicide in England. But before the nineteenth century, the explanations of these (assumed) regular differences in suicide frequencies always involved the assumption that the individual will was the ultimate cause of the action. In the early nineteenth century both the psychiatric theory that all suicides are insane (and, therefore, do not cause their own actions) and the direct comparison of national suicide rates (without any real consideration of the individuals who committed the actions) combined to eliminate the individuals (or wills, or personalities) from consideration as possible causes of suicide. Quetelet’s early work on the comparisons of social rates of suicide (work that gained much support from the researches of Gustave F. Étoc-Demazy and Andre M. Guerry) was quickly given a metaphysical basis by the English positivists, especially by Henry Thomas Buckle. This largely eliminated Quetelet’s variable of average personality; the direct comparison of other external, objective data (such as geographical-ecological distributions and marriage rates) with suicide rates was now an established method with a metaphysical justification, that of positivistic determinism.

Largely because of the vast influence of Brière de Boismont’s great work on suicide (1856), based primarily on case studies of 4,595 suicides, including 1,328 suicide notes (a source of data first used by Guerry as early as 1833), and 265 attempted or planned suicides, the more important works on suicide by Wagner (1864) and Morselli (1879) did not deny causal significance to various individual factors, such as motives. They did, however, consider the comparative analysis of officially computed suicide rates to be necessary for establishing causes of suicide “. . . such as the most positive mode of psychological study would fail to discover in the individual” (Morselli [1879] 1882, p. 10). Durkheim’s sociologistic theory of suicide proposed that suicide rates are a sine qua non of the sociological study of suicide, and the great influence of his Suicide (the first edition of which appeared in 1897, although it was not translated into English until 1951) quickly made the statistical approach almost identical with the sociological approach, especially in the United States. Indeed, Kruijt (1960) and others have recently assumed the two to be totally identical.

Validity of official data . Since sociologists have relied almost exclusively on the official statistics and coroners’ reports on suicide for the data from which to develop and test theories of suicide, the question of the validity of the official data is absolutely critical in any evaluation of these sociological works. Throughout the nineteenth century most students of suicide were highly critical of the official statistics on suicide. Esquirol (1838), Brière de Boismont (1856), Legoyt (1881), Strahan (1893), and many others believed the official statistics grossly underestimated the actual number of suicides. Even Morselli (1879) most emphatically warned against the dangerous misuse of suicide statistics. But the sociologists, especially Durkheim (who included very little consideration of the value of his data in Suicide), consistently assumed that the evidence was good enough for the kinds of positivistic (i.e., objective, by definition) analyses they wanted to make. In general, they argued that (a) the stability of the statistics shows that there are no significant errors in them and (b) there are no good reasons to conclude that there are consistent biases in the data, i.e., the errors cancel each other out.

The first argument is based on the mistaken assumption that errors cannot be patterned or stable. Buckle (1857-1861, p. 18) even noted that the frequency of incorrectly addressed letters is extremely stable from year to year without noting the obvious implication for stable suicide statistics. Though contemporary sociologists (especially Americans) who have used the official records on suicide rarely have explicitly considered their value as evidence, they seem generally to have assumed that the second argument given above is correct. The most fundamental reasons for denying the validity of the argument, and therefore the adequate validity of the statistics, are as follows.

(1) It seems quite likely that the official categorizers of suicide in different nations, states, and cities have used different abstract and operational definitions of suicide. We have noted above that the formal definitions of suicide by the students of suicide have varied greatly and in a most complex fashion. But there have been some consistent differences in definitions between groups, such as those between the psychiatrists, the psychologists, and the sociologists. Why would one not expect to find similar consistent differences in the abstract and operational definitions of suicide used by different groups of official categorizers of causes of death? A coroner of a large city who will categorize a cause of death as suicide only if a suicide note is found clearly will produce results consistently different from those of a coroner in another city who uses a different rule-of-thumb definition, such as that there must be an eyewitness report, a clearly perceptible motive, etc. Only “verbal realism” can lead one to assure a priori that the coroner in Lapahaw, Georgia, applies the word “suicide” in a fashion substantially similar to the way the word is applied by the coroner in Los Angeles, California.

(2) It also seems most plausible to assume that there are consistent differences in the abstract and operational definitions of the terms of the different definitions, such as “cause,” “responsible,” “sane,” “death,” and “intention.” For example, some official agencies will not categorize the cause of death as suicide if death occurs three days after the injurious act; and it is worth observing here that all bureaucracies create ad hoc rules of thumb in order to effectively apply general policy to their own particular problems.

(3 ) A great deal of evidence has been presented by Herman Krose, Georg von Mayr, Halbwachs (1930, pp. 19-39), and Achille-Delmas (1932) which has shown both that (a) there are consistent differences in the administrative practices of dealing with suicide (and related categories) and that (b) changes (hence, differences) in administrative practices regarding suicide produce immediate and highly significant changes in suicide rates. Two brief examples are instructive. Halbwachs (1930, pp. 33-34) found that, though a ruling in 1866 made certification of cause of death by a doctor or public health official obligatory throughout France, in fact almost all rural deaths escaped certification; certification of cause of deaths in public places was made by police officials, and certification by family doctor was universally acceptable. He also found that a reform in the Prussian Bureau of Statistics in 1883 produced a 20 per cent stable increase in the suicide rate, beginning in 1884 (Douglas 1965, pp. 259-377).

These and other facts strongly suggest that the relationship between statistical organizations and the suicide rates they produce is subject to the following principle: other things being equal, suicide rates vary directly with the degree of professional medical training of the categorizers, the average rate of man-hours devoted to “cause of death” categorization, and the independence of the categorizers from “interested parties” (for which see below). This general principle leads us to expect, among other things, that (a) urbanization and suicide rates will vary directly; (b) both industrialization and the wealth of populations will vary directly with suicide rates (a possible explanation of the great increase in suicide rates of Europe in the nineteenth century and of developing nations today); and (c) periods of general disorganization or reorganization, such as wars, will produce decreases in suicide rates (because the officials are fewer and have more important things to do). And, in general, these predictions are strongly supported.

(4) The most important set of “other things” that are not equal, and which we must expect to cause great biases in official statistics on suicide, are the various social meanings of suicide, especially as they relate to approval or disapproval. Because of his positivist philosophy, his peculiar theory of “social pathology,” and his theory of “juridical norms,” Durkheim assumed that all groups in Europe were equally against suicide. With the partial exception of the works of Halbwachs (1930) and Cavan (1928), almost all sociological theories of suicide since Durkheim have implicitly assumed the normative definitions of suicide to be both invariant and highly negative. This is a totally fallacious and most unfortunate assumption. In his brilliant study of French attitudes toward suicide, Albert Bayet (1922) conclusively demonstrated that over a long period of time there was a consistently far more negative (even horrified) attitude toward suicide on the part of the “simple,” uneducated population (largely rural) than on the part of the more educated, upper-class population. Such patterned differences in the normative meanings of suicidal actions might produce different frequencies in actual (or real) suicidal actions, but they would seem far more likely to produce differences in the frequency and strength of attempts to conceal suicide both by the suicidal individual and by his significant others. Moreover, one would expect that the more a primary group has to lose from having one of its members socially categorized as a suicide, the greater will be the frequency and strength of attempts to conceal suicide. These two factors make up what can be called a group coefficient of attempted concealment of suicidal actions. We must also expect, however, that different groups will have different coefficients of success in such attempts, the major determinants of which would seem to be degree of social influence and degree of social integration of the group (or individual) making the attempt at concealment. Obviously, these two coefficients could produce many biasing effects on official statistics, the most likely of which seems to be that, given a certain degree of negative normative definition of suicidal action, the degree of social integration of the suicide’s primary group into the general community will vary directly with the coefficient of attempted concealment and with the coefficient of success in attempted concealment. This means, of course, that official statistics on suicide will tend to be biased in such a direction that they will support an integration theory of suicide, such as Durkheim’s.

(5) Over half a century before the publication of Durkheim’s Suicide, Jean-Étienne Esquirol (1838) had established that some methods of committing suicide make valid categorization of the cause of death more difficult. Since, moreover, there seem to be patterned variations between social categories in suicide methods, we must expect biases in official statistics from this source. For example, women use barbiturates and gas far more frequently than do men. Suicides by barbiturates and gas are very difficult to distinguish from accidents. Since such doubtful cases are almost always categorized as “accidental” or “accidental suicide,” we must expect bias in the direction of lower official suicide rates for women.

Two conclusions regarding the official statistics on suicide seem justified: (a) we have little specific, systematic knowledge about the means employed by different statistical bureaus to arrive at these figures; (b) what knowledge we do have about these figures and the means of arriving at them strongly supports our arguments that they are highly biased in certain directions. In general, at the present time there seems to be no adequate justification for using official statistics on suicide to build or test a scientific theory of suicide. There seems to be every reason for not using them (Douglas 1965, pp. 259-377).

Sociology and the official data . Almost every published theory of suicide that has been called sociological has depended on the official statistics on suicide for its testing. This means, of course, that the testing of these theories is subject to all of the biases of the official statistics and therefore cannot generally be accepted.

But this does not necessarily mean that the theories of suicide are themselves wrong. All the so-called sociological theories have been general abstract theories which the authors believed to be applicable to a great variety of social behavior—for instance, to all deviant behavior. These theorists have never derived their general theories from the official statistics, still less from any actual observations of cases of suicide. On the other hand, they have always known from the beginning most of the patterns of suicide shown by the official statistics, so that they have been able to select (no doubt unconsciously) just those patterns for consideration in the testing stage which their theories can “predict.” In spite of rhetorical disclaimers that any such bias exists, the fact remains that all published sociological theories of suicide have been supported at a high level of statistical significance by “tests” using the official statistics on suicide. Moreover, since all of these works after Durkheim’s Suicide have included only the most perfunctory consideration of alternative theories for explaining the same data, there is at present no justification for considering any one theory better than any other, unless one were to consider sophistication of argument an acceptable criterion, in which case Durkheim would hold the field unopposed (Douglas 1965, pp. 112-259).

Major theories of suicide

Durkheim’s sociologistic theory. In Suicide Durkheim was, of course, primarily concerned with proving by demonstration that sociology is a scientific discipline sui generis. The work was a polemic in a great ideological war; and as Halbwachs has said (1930, p. 3), its argumentative power has made it convincing (though, I would add, only to those already convinced of its general position). To achieve his goal of demonstration, Durkheim made use of the mass of published material on suicide statistics, the many statistical relations already established between suicide rates and social relations by the flourishing school of “moral statisticians,” and the methods of analysis developed by Bertillon and many others. Earlier sociologists, especially Morselli (1879), had considered “society,” and in particular the morals of a society, to be the most important cause of a given suicide rate. It was from these previous works that Durkheim took his specific ideas, such as “egoism” and “lack of moral restraint,” about what caused suicide rates to vary. But previous theorists, with the major exception of Quetelet, had proposed multifactored explanations; Durkheim proposed a general synthesis. In general, he took his notion of statistical relations and methods from the moral statisticians and, like many of the moral statisticians before him, turned to the romantics, and the psychologists whom they had influenced, for his fundamental causal variables. Durkheim’s own contribution was to translate “egoism,” “need for an external, moral authority,” and similar psychological variables into “social” (or cultural) variables which he finally reduced to the two opposing moral dimensions of egoism-altruism and anomie-fatalism.

Unfortunately for Durkheim’s ambitious program, Suicide (1897) is an extremely uneven work. The theory presented in Books 1 and 2 is for the most part extremely positivistic, relating external (or “objective”) variables to other external variables. In Book 3, however, the theory is radically different: internal variables are related both to each other and to external variables. The positivistic version is the one usually given primacy by American sociologists (see, for example, Gibbs & Martin 1964); but the later version is the more considered, developed, and tenable theory. The core of the latter is very simple, though its presentation is confused by Durkheim’s penchant for multiple terms (e.g., “disintegration,” “disorder,” “disequilibrium,” “lack of unity or cohesion”), petitio principii, and lack of conceptual clarity. He assumes that for all societies there is some optimal equilibrium or integration of egoism-altruism, on the one hand, and anomie-fatalism, on the other. Any change in the relative strengths of these ideas (or forces) will produce an increase in “social disintegration,” which will lead in turn to an increase in the suicide rate and in the particular type of social relation associated with the “force” that is on the increase. Hence, there is a statistical relation between suicide rates and the incidence of different types of social relations.

The critical flaw in the work is the lack of any means of measuring these forces of egoism, anomie, etc., either independently of each other or independently of a change in suicide rates. Yet Durkheim assumed that these were the fundamentally important variables: any change in suicide rates or social relations meant to him that one or more of the forces was increasing relative to the others. But how did he determine which force was increasing? We must conclude that he inferred it from the associated changes in social relations, and that, for the most part, he assumed he knew from common sense what these changes meant. Unfortunately, the concrete examples Durkheim gives us will not support the notion that his common sense was superior, as a scientific instrument, to anyone else’s (Douglas 1965, pp. 7-112).

The major contribution of Durkheim’s Suicide was its grand conception of the general nature of sociological theory. Durkheim’s intentions in this work went much too far beyond the possibilities of the theory and data of his day—and of ours.

Halbwachs’ theory of suicide. The work of Maurice Halbwachs (1930) began as a supplement to Durkheim’s Suicide but became a radical re-orientation of sociological theory. Halbwachs concluded that Durkheim, in spite of his extensive use of replicative analyses, had overlooked the high degree of overlap of the variables he found to be related to suicide rates. The only fundamentally significant independent relation, Halbwachs argued, is between suicide rates and the degree of complexity of a society: thus, the rural style of life (or sociocultural system) is simpler than the urban and therefore has a lower suicide rate. But Halbwachs also rejected Durkheim’s sociologism. He maintained that there is a complementary relation between the motives imputed to suicides and social situations of isolation. To support his theory, Halbwachs presented the most extensive and thorough analysis of official statistics in all of the sociological literature. As we have already said, however, it seems clear that there is a fundamental bias in the official statistics in the direction of underestimating rural rates (Douglas 1965, pp. 195-209).

Social disorganization theories . Unlike almost all other recent sociological works on suicide, the various “ecological” works on suicide have been done quite outside the tradition initiated by Durk-heim. Ruth Cavan’s Suicide (1928), the first of these works, was predominantly influenced by Morselli. Most ecological studies of suicide have relied heavily on some form of social disorganization theory. Various population variables, such as high mobility and complexity, are hypothesized as the causes of a relative lack of effect of social values on behavior (this being the meaning that “social disorganization” usually has for these writers), which in turn is hypothesized as the cause of suicide and similar deviant acts.

The social disorganization approach to suicide involved certain extreme assumptions which have more recently been shown to be clearly unacceptable. For one thing, it assumed cultural homogeneity of values and behavior patterns, that is, it was taken for granted that all of the many ethnic groups of cities like Chicago shared the same values and behavior practices with regard to any form of “deviance,” such as suicide was thought to be. An extensive literature has attacked this assumption when applied to delinquency, and Bayet (1922) has amassed enough evidence to prove that attitudes toward suicide may vary considerably even in a nation with a supposedly homogeneous culture. The social disorganization approach also assumed that cultural values are the only social meanings that determine rates of suicidal actions. But there is no evidence whatsoever in favor of this assumption—and, indeed, it was contradicted by Cavan’s own arguments concerning the importance of spite and other purely personal motives in causing suicide (Cavan 1928).

Cavan’s work, the earliest of the significant ecological works on suicide in America, did not involve the so-called ecological fallacy (for which see Robinson 1950). In fact, Cavan clearly recognized the fundamental principle involved in this fallacy, even to the extent of criticizing the statistical arguments of Morselli and Durkheim in terms of it (1928, p. 289). Realizing what was needed in order to avoid this fallacy, she did attempt to provide evidence regarding individual cases of suicide. In general, she argued that social disorganization causes individual disorganization, and that the latter manifests itself in patterns of increasing inability to cope with crisis situations. In an attempt to demonstrate the validity of this theory, she presented lengthy selections from the personal documents of two individuals who committed suicide. Though it seems clear now that the attempted demonstration involves an imposition of the general category of “individual disorganization” upon the statements of the individuals, it is also clear that Cavan’s work, which was followed in most important details by that of Schmid (1928), involved more consideration of real cases of suicide than any other sociological work to appear before the later 1960s. Moreover, her material on the case of Marion is still among the best available on real cases of suicide (see the discussion in Douglas 1965, pp. 140-167, 471-483).

Recent sociological theories . Most of the recent sociological theories of suicide have been formulated ostensibly within a Durkheimian content, yet most of them are psychosocial theories that are actually quite different from Durkheim’s.

The one theory that actually seems to be socio-logistic in the Durkheimian manner is that proposed by Gibbs and Martin (1964). This theory, although derived from far too simple an interpretation of Durkheim’s Suicide, is true to its positiv-istic aspect in rejecting any consideration of real cases of suicide and in attempting to relate official statistics on official categories (such as marriage) to official statistics on suicide. The basic idea of the theory is that the more socially integrated (or less “conflictful”) a set of statuses (such as age, race, marital status), the more frequently that set of statuses will be occupied by members of the society and the less frequently it will be associated with suicide. This whole approach suffers from all of the weaknesses already detected in Durkheim’s and from some important additional ones. Thus there is almost no consideration of the real-world (as opposed to official) social meanings of statuses, whereas Durkheim did at least make use of well-informed common sense to provide him with social meanings for the status categories he was interested in analyzing. In addition, the “testing” of the theory involved the analysis of only four of the truly immense number of statuses in our society, and all four of these are the standard categories used in analyses of official data on suicide, so that any sociologist making an analysis of the relations between these categories and suicide rates knows what the relations are before he begins (Douglas 1965, pp. 121-135).

Most of the other recent theories of suicide that purport to be sociological—the most significant is that of Henry and Short (1954)—include psychological variables. They almost all agree that socio-economic status change (or “reverse of fortune,” as Brière de Boismont called it) is the basic sociological cause of suicide, but each proposes a different personality theory (frustration-aggression theory, self theory, loss-of-meaning theory, etc.) to explain why some few individuals commit suicide when confronted with a given status change and almost all others do not. The basic problem is that status change is “significantly” related to an immense number of things. These statistical works never involve any demonstration that other factors are not causing both the supposed cause and the suicide. They rarely include consideration of the many alternative, conflicting theories that purport to explain the same official statistics. They generally involve careful arrangement and choice of data so that statistically “significant” results can be obtained. For example, in the work by Henry and Short (1954), social classes in America are dichotomized into high and low, an arrangement which completely obscures the U-functional relationship almost always found to exist between socioeconomic status and official suicide rates in the Western world. Moreover, theoretical argument in these works is frequently quite divorced from statistical analysis; in some cases, the two can be related only through the addition of many ad hoc assumptions (see, for instance, the analysis of Henry & Short 1954 in Douglas 1965, pp. 209-229). In some of these works, changes in the population bases for the official suicide statistics were actually not taken into consideration. For example, some of the most important analyses made by Henry and Short were for periods during which new states were being added almost each year to the U.S. Death Registration Area. This fact had led Dublin and Bunzel (1933) to use only the original Death Registration Area, but Henry and Short completely overlooked the whole problem.

However, a few of these psychosocial works, as this mingling of psychological and sociological approaches can be called, have introduced valuable new orientations into the study of suicide. Thus Breed’s interviews of the surviving families of individuals who committed suicide (1963) have finally introduced into sociology a research method long established in psychiatry. This method has moved sociologists one step further toward direct observation of real-world cases of suicidal events. Indeed, it has shown them that henceforth they must consider the effects of a suicide on others as part of the suicide phenomenon. The case studies reported by psychologists (Deshaies 1947; Schneider 1954) and the sociocultural studies of suicide made by a few anthropologists and psychiatrists (Devereux 1931; Hendin 1964) make clear what should have been obvious to sociologists long ago: suicidal actions are socially meaningful actions, and individuals commit them in order to communicate something to themselves and others about themselves and about others. Even an individual whose primary goal is a state of nonbeing will not commit suicide unless he can do so in such a way as to communicate, to himself and possibly to others as well, just the right meanings. The empirical study of suicidal actions as socially meaningful— cognitively, affectively, and normatively—opens new directions of highly fruitful research and theory (Douglas 1965, especially pp. 377-543).

Only the most comprehensive observation and description of the everyday actions and statements relevant to suicide are likely to result in scientifically useful empirical and theoretical generalizations concerning suicidal actions as socially meaningful actions. Systematic analyses of existing case studies have, however, already resulted in some very important generalizations concerning the social meanings of suicidal actions in the Western world. The best attempt to generalize about suicide in this way for a non-Western society is by Devereux (1931); there are some important contributions to such an approach in other works (see, for instance, Bohannan 1960).

Perhaps the most important high-level generalization about suicide that can be made at this time is that the situated meanings of suicidal acts are often very different from their abstract meanings. In other words, the meaning of a suicidal act for those who are directly involved with it will very rarely be the same as the meaning it has for those who are not so involved, and will certainly not be the same as for the individual who, by committing suicide, is trying to communicate something (Douglas 1965, pp. 406-440). This finding has two fundamental implications for all investigation of the social meanings of suicide and, perhaps, for all of sociology. First, it is not possible to predict or explain specific types of social events, such as suicide, in terms of abstract social meanings, such as values favoring suicide. Second, it is not possible to study the situated social meanings of suicide, which are most important in its causation, without reference to actual instances of suicidal acts with which the individuals to be questioned have been directly involved. This generalization leads one to question the value of any method for investigating any realm of social action if it attempts to abstract members of society from the involvements of their everyday lives.

This does not imply that there are no patterns of meanings common to all the events that members of a society call “suicide” or “suicidal.” When one looks at the meanings imputed to particular suicidal actions, one does find that certain general features tend to recur. Most importantly, any suicidal action is usually believed to mean something fundamental about the self of the individual committing it, or about the situation (especially the persons involved) in which he committed it, or about both of these. Whether the specific meanings realized will be directed to the actor’s self or to his situation will depend on the imputations of causality made by the various persons in the situation: will they see the individual as the cause of his own actions—that is, as “responsible” for them —or will they see him as having been caused (”driven”) to do them by circumstances (loss of job, family trouble, etc.)? The individual committing the suicidal action often attempts to place one of these two general constructions upon the action by pointing out in some way the external cause that is to be “blamed” for his suicide.

There is no one meaning or set of meanings that can be imputed to all (or even most) suicidal actions. Just what meanings are imputed in each case will depend on (1) the intentions of the various actors; (2) the socially perceived ways in which the actions are committed; (3) the specific patterns of suicidal meanings that are realized; (4) the argument processes before, during, and after the suicidal actions. It should be clearly noted that whether or not actions are socially categorized as “suicidal” depends on precisely the same sort of process. The obvious example is that of individuals who with various ends in mind (avoiding embarrassment to their families, loss of insurance money, or disgrace to themselves), arrange suicides that are designed to be taken for accidents.

It is probably not possible for individuals to construct any meanings they please for their actions, though individual creativity does extend the limits immensely, and all cases include imponderable idiosyncrasies. However, the limits remain. There are, first of all, various criteria of plausibility of motives, or rationality, though it is very likely that in some instances individuals intend their actions to be considered implausible or irrational. Second, a relatively few patterns of situated meaning play important parts in most interpretations of particular suicidal actions, and it therefore seems likely that individuals take these patterns into consideration when attempting to construct the meanings of their actions for others. The most common patterns of this sort in the Western world are those involving such motives as the search for help (Sacks 1966), sympathy, escape, repentance, expiation of guilt, self-punishment, and “seriousness” (Douglas 1965, pp. 440-511).

Much careful description and analysis in this area remain to be done (ibid, pp. 511-540). However, the basic problems and the most appropriate methods for solving them now seem clear, and there is great promise of rapid development in both the empirical and the theoretical study of suicide.

Jack D. Douglas

[See also Deviant behavior; Integration, article onsocial integration; Sociology, article onthe early history of social research; and the biographies ofDurkheim; Halbwachs; Quetelet.]

BIBLIOGRAPHY

Achille-Delmas, FranÇois 1932 Psychologie pathologique du suicide. Paris: Alean.

Bayet, Albert 1922 Le suicide et la morale. Paris: Alean.

BenoÎt-Smullyan, Émile 1948 The Sociologism of Émile Durkheim and His School. Pages 499-537 in Harry Elmer Barnes (editor), Introduction to the History of Sociology. Univ. of Chicago Press.

Bohannan, Paul (editor) 1960 African Homicide and Suicide. Princeton Univ. Press.

Breed, Warren 1963 Occupational Mobility and Suicide Among White Males. American Sociological Review 28:179-188.

BriÈre de Boismont, Alexandre 1856 Du suicide et de la folie suicide. Paris: Baillière.

Buckle, Henry Thomas (1857-1861) 1913 The History of Civilization in England. 2d ed. 2 vols. New York: Hearst.

Cavan, Ruth S. 1928 Suicide. Univ. of Chicago Press.

Dahlgren, Karl G. 1945 On Suicide and Attempted Suicide. Lund (Sweden): Universitets Bokhandel.

Deshaies, Gabriel 1947 La psychologie du suicide. Paris: Presses Universitaires de France.

Devereux, George 1931 Mohave Ethnopsychiatry and Suicide. Washington: Government Printing Office.

Douglas, Jack D. 1965 The Sociological Study of Suicide: Suicidal Actions as Socially Meaningful Actions. Ph.D dissertation, Princeton Univ.

Douglas, Jack D. 1966 The Sociological Analysis of Social Meanings of Suicide. Archives européennes de sociologie 7:249-275.

Douglas, Jack D. 1967 The Social Meanings of Suicide. Princeton Univ. Press.

Dublin, Leonard I.; and Bunzel, Bessie 1933 To Be or Not to Be: A Study of Suicide. New York: Smith & Haas.

Durkheim Émile (1897) 1951 Suicide: A Study in Sociology. Glencoe, 111.: Free Press. → First published in French.

Esquirol, Jean-ÉTIENNE D. (1838) 1845 Mental Maladies. Philadelphia: Lea & Blanchard. → First published as Des maladies mentales considérées sous les rapports médical-hygiéniques et médico-legal.

Gibbs, Jack P.; and Martin, Walter T. 1964 Status Integration and Suicide. Eugene: Univ. of Oregon.

Goethe, Johann Wolfgang Von (1811-1833) 1908 Poetry and Truth From My Life. 2 vols. London: Bell. → First published in German.

Guerry, AndrÉ M. 1833 Essai sur la statistique morale de la France. Paris: Crochard.

Halbwachs, Maurice 1930 Les causes du suicide. Paris: Alean.

Hendin, Herbert M. 1964 Suicide and Scandinavia: A Psychoanalytic Study of Culture and Character. New York: Grune.

Henry, Andrew F.; and Short, James F. JR. 1954 Suicide and Homicide: Some Economic, Sociological and Psychological Aspects of Aggression. Glencoe, 111.: Free Press.

Kruijt, Cornelius S. 1960 Zelfmoord: Statistich-sociologische verkenningen. Suicide: Sociological and Statistical Investigations. Assen (Netherlands): Van Gorcum. → Contains a summary in English.

Legoyt, Alfred 1881 Le suicide ancien et moderne. Paris: Droiun.

Morselli, Enrico (1879) 1882 Suicide. New York: Appleton. → First published in Italian.

Quetelet, Adolphe (1835) 1842 A Treatise on Man and the Development of His Faculties. 2 vols. Edinburgh: Chambers. → First published in French.

Robinson, W. S. 1950 Ecological Correlations and the Behavior of Individuals. American Sociological Review 15:351-357.

Sacks, Harvey 1966 The Search for Help: No One to Turn to. Unpublished manuscript.

Schmid, Calvin F. 1928 Suicides in Seattle, 1914 to 1925: An Ecological and Behavioristic Study. University of Washington, Publications in the Social Sciences, Vol. 5, no. 1. Seattle: Univ. of Washington Press.

Schneider, Pierre-B. 1954 La tentative de suicide. Neuchâtel (Switzerland): Delachaux & Niestlé.

Sthahan, Samuel 1893 Suicide and Insanity. London: Sonnenschein.

SÜssmilch, Johann P. (1741) 1788 Die göttliche Ordnung in den Veränderungen des menschlichen Geschlechts, aus der Geburt, dem Tode und der Fort-pflanzung. 3 vols. Berlin: Verlag der Buchhandlung der Realschule.

Tissot, Joseph 1840 De la manie du suicide et de l’esprit de révolte: De leur causes et de leur remèdes. Paris: Lagrange.

Wagner, Adolf H. G. 1864 Die Gesetzmässigkeit in den scheinbar willkuhrlichen menschlichen Handlungen vom Standpunkte der Statistik. Part 2. Statistik willkuhrlichen Handlungen. Hamburg (Germany): Boyes & Geisler.

II. PSYCHOLOGICAL ASPECTS (1)

The clear definition and meaningful classification of various suicidal phenomena are fundamental to advancements in the treatment, prevention, and investigation of self-destruction in man. The purpose of this article is to present some new conceptions of suicidal phenomena, first by identifying current confusions and then by proposing a taxonomic scheme that attempts to embrace many of the diverse aspects of self-destructive behavior.

Definition

As a beginning, a straightforward definition of suicide might read: “Suicide is the human act of self-inflicted, self-intentioned cessation.” At least five points are to be noted in this brief definition: (1) it states that suicide is a human act; (2) it combines both the decedent’s conscious wish to be dead and his actions to carry out that wish; (3) it implies that the motivations of the deceased may have to be inferred and his behaviors interpreted by others, using such evidence as a suicide note, spoken testimony, or retrospective reconstruction of the victim’s intention; (4) it states that the goal of the action relates to death, rather than to self-injury, self-mutilation, or inimical or self-reducing behaviors; and (5) it focuses on the concept of the cessation of the individual’s conscious introspective life. (An explication of the concept of “cessation” may be found in Shneidman 1964.)

Difficulties of definition. Assuming the validity of the definition of suicide cited above—that a human being, with the intention of stopping his life, inflicts upon himself the equivalent of a mortal wound—the meaning would seem clear enough if it were stated that a certain individual had “committed suicide.” On the other hand, confusions of meaning arise immediately if a specific individual is labeled as “suicidal.” Although suicide seems to be not too difficult to define, suicidal phenomena are, in fact, very complicated. Some of the current confusions relating to the term “suicidal” may be listed as follows.

(1) The word “suicidal” is used indiscriminately to cover different categories of behavior. For example, one cannot be sure whether it is being used to convey the idea that an individual has (a) committed suicide, (b) attempted suicide, (c) threatened suicide, (d) exhibited depressive behavior with or without suicidal ideation, or (e) manifested generally self-destructive or inimical patterns. Of recent writers, Stengel and Cook (1958) especially have emphasized the importance of differentiating specifically between data on attempted suicide and data regarding individuals who have committed suicide. But the fact remains that the classification of suicidal behavior currently most common in everyday clinical and research use is a rather homely, supposedly common-sense division: in its barest form it implies that all humanity can be divided into two groupings, suicidal and nonsuicidal; and then, with seeming meaningfulness, it divides the suicidal category into subgroups of committed, attempted, and threatened. Although this elaboration is more sophisticated than the suicidal-versus-nonsuicidal view of life, it remains neither theoretically nor practically adequate for understanding or treatment.

(2) There is constant confusion in respect to the temporal dimension of suicidal acts. One sees the word “suicidal” used to convey the information that an individual was self-destructive (or manifested behavior in any of the other categories listed immediately above), is currently self-destructive, or will be so. This obviously contains confusions among statements that are postdictive (relating to the past), “paridictive” (relating to the more-or-less present), and predictive (relating to the future). Most diagnoses of individual “suicidality” are post hoc definitions in that they refer to those cases in which an individual is labeled as “suicidal” only after he has committed suicide. Statistics on suicide are, of course, based primarily on post hoc definitions of suicide. The primary difficulty in all such cases lies in determining whether or not the individual actually intended to kill himself. The case of the individual who writes a suicide note and then shoots himself is fairly clear, but many cases of death are unclear or equivocal as to mode of death. For example, in the case of an individual who “jumps or falls” from a high place or who is found dead of barbiturate poisoning, the question is often raised whether the case was suicidal or accidental. The coroner’s traditional concern has been with assessing whether God (natural and accidental deaths) or man (suicidal or homicidal deaths) is responsible. The term “suicide” as used by coroners in the certification of death is a medicolegal term and includes, as a sine qua non, the concept that the person played a major role in bringing about his own demise, that is, that it was his intention to die. It should be obvious that statistics on suicide can be greatly influenced (in any city or country) by the manner in which these equivocal deaths are labeled.

(3) There are confusions relating to the characteristics of suicidal behaviors. In many past and current investigations of self-destructive behaviors, several different dimensions of behavior have unfortunately been thrown together. (If one were, for example, studying homicidal phenomena, it is unlikely that he would fail to differentiate among homicides committed on the highway, in the bedroom, during armed robberies, on the field of battle, etc.—and yet a comparable lack of discrimination has been characteristic of many studies of suicidal phenomena.) These issues also relate to the phenomenologic and semantic confusions in the use of the word “suicidal.” Some individuals who “die by their own hand” do not necessarily “commit suicide.” That is to say, they do not, in their own minds, kill themselves or seek death. Instead of fleeing into a vaguely conceptualized “death,” they behave so as to escape from aspects of life. For some the concept of death, or final cessation of being, does not enter into their thinking. They rather indulge in either a planned or a momentary impulsive act—and termination of life is the result. Then we say that they have “committed suicide,” whereas such an individual might conceivably have left a note which states that “. . . all I did was to swallow those pills ... I just wanted some relief at that moment. . . . The tension was so great I had to do something. ... I did not know what I was doing or what would happen. ... It was a gamble. ... I was desperate.. . .” Operationally, it would seem that the key characteristics of suicidal behaviors do not lie in the differences in method (shooting, sedation, cutting, hanging) but rather in the differences in the individual’s life phase, in the lethality of his acts, and in his intention vis-à-vis death, as indicated below in (4), (5), and (6), respectively. That is, it may very well be that the confusions listed above in (1), (2), and (3) might, in large measure, be avoided by making the very distinctions suggested in the subsequent paragraphs.

(4) Many confusions arise because each individual’s attitudes toward his own death are biphasic: that is, any adolescent or adult, at any given moment, has (a) more or less long-range, pervasive, relatively habitual orientations toward his own death. These characterological orientations are an integral part of his total psychological make-up and reflect his philosophy of life, need systems, aspirations, identifications, conscious beliefs, etc. And he is also capable of having (b) relatively short-lived, acute, fairly sudden shifts of his orientations toward his own death. Indeed, this is what is usually meant when one says that an individual has “become suicidal.” It is therefore crucial in any complete assessment of an individual’s orientations toward his own death to know both his habitual and his current (today’s) orientations. Failure to make this distinction is one reason why many current efforts to relate “suicidal state” to psychological test data or to case-history data have been barren and confusing. For individuals in their “normal” (usual for them) state, their habitual and their current orientations toward their own demise will be the same; for individuals who are acutely disturbed, their current orientations toward their demise will often reflect this perturbation. “Being suicidal” involves being disturbed, although not necessarily psychotic.

(5) Popular accounts of “suicidal” behaviors often focus on the method used (for example, wrist cutting) or on the precipitating cause (ill health, losing money) without regard for one of the key dimensions in the assessment of suicidal behavior, namely lethality. The primary clinical goal of any suicide prevention agency is to keep people out of the coroner’s department. Thus, an individual’s unhappiness, perturbation, loneliness, alcoholism, schizophrenia, homosexuality, depression, etc., are relevant in suicide prevention primarily as they bear on the assessment of his lethality potential. To say that an individual has “threatened” suicide or has “attempted” suicide is relatively uninformative without some indications of the potentialities of a lethal outcome with which the threat or attempt was made. Recently, at the Suicide Prevention Center in Los Angeles specific procedures have been evolved for the rapid assessment of the lethality of an individual’s suicidal potential (see Litman & Farberow 1961; Tabach-nick & Farberow 1961).

(6) The most obfuscating confusions relating to suicidal phenomena may occur if the individual’s intentions in relation to his own cessation are not considered. “Suicide” also has an administrative definition. In the United States (and most of the countries reporting to the World Health Organization), “suicide” defined from the point of view of the coroner or vital statistician is simply one of the four modes of death, the others being natural, accidental, and homicide (N-A-S-H). This traditional fourfold classification of all deaths leaves much to be desired. Its major deficiency is that it emphasizes relatively adventitious details in the death (that is, whether the individual was invaded by a lethal virus or a lethal bullet, which may make little difference to the deceased) and, more important, it erroneously treats the human being as a Cartesian biological machine rather than appropriately treating him as a psychosocial organism, thus obscuring the individual’s intentions in relation to his own cessation. Further, the traditional N-A-S-H classification of deaths completely neglects the concepts of contemporary psychology regarding intention and purpose, the multiple determination of behavior, unconscious motivation, etc.

Much of the problem arises because of a confusion between methods and purpose. Although it is true that the act of putting a shotgun in one’s mouth and pulling the trigger with one’s toe is almost always related to lethal self-intention, this particular isomorphic relationship between method and intent does not hold for most other means, such as ingesting barbiturates or cutting oneself with a razor. Individuals can attempt to attempt suicide, attempt to commit suicide, or attempt to be nonsuicidal. Cessation intentions may range all the way from deadly ones, through the wide variety of ambivalences, rescue fantasies, cries for help, and psychic indecisions, all the way to clearly formulated nonlethal intention in which a semantic usurpation of a “suicidal” mode has been consciously employed.

Deaths classified by intention. As a way out of this impasse it is suggested that all deaths—in addition to their being labeled as natural, accidental, suicide, or homicide—also be designated as intentioned, subintentioned, or unintentioned (Shneidman 1963).

Intentioned deaths. An intentioned cessation is one in which the deceased played a direct, conscious role in his own demise. The death was due primarily to the decedent’s conscious wish to stop his conscious life and to his actions in carrying out that wish. In this category would be individuals who seek their own demise, initiate or participate in their own demise, or take calculated risks where the odds are critically unfavorable to their survival, as in Russian roulette, where the individual bets his life on the objective probability of as few as five out of six chances that he will survive.

Subintentioned deaths. Subintentioned deaths are those in which the deceased played an important indirect, covert, partial, or unconscious role in his own demise. The death is suspected to be due in some part to the actions of the decedent which seemed to reflect his unconscious wishes to hasten his death, as evidenced by his own carelessness, foolhardiness, neglect of self, imprudence, resignation to death, mismanagement of alcohol or drugs, disregard of life-saving medical regimen, brink-of-death patterns, etc. This concept of subintentioned death is similar in some ways to Karl Menninger’s concepts (1938) of chronic suicide, focal suicide, and organic suicide, except that these relate to self-defeating ways of continuing to live, whereas the notion of subintentioned death relates to ways of stopping the process of living.

In terms of the traditional N-A-S-H classification of modes of death, it is important to note that some instances of all four types can be found in the category of subintentioned deaths, depending upon the particular details of each case. There is a growing literature on the role of the individual in his own natural, accidental, suicidal, or homicidal death. Subintentioned deaths involve what might be called the psychosomatics of death, that is, cases in which essentially psychological processes—like fear (including fear of voodoo), anxiety, derring-do, hostility, withdrawal, etc.—seem to play some role in exacerbating the catabolic or physiological processes which bring on termination, as well as those cases in which the individual seems to play an indirect, largely unconscious role in inviting or hastening his own demise [see Psychosomatic Illness; see also Gengerelli & Kirkner 1954; Macdonald 1961; Weisman & Hackett 1961; Weiss 1957; Wolfgang 1959].

It can be noted that the subintentioned death implies more than ambivalence toward wanting to be dead and wishing to be rescued (the to-be-or-not-to-be inner dialogue ) found in practically every suicide. It rather reflects the active indirect (largely unconscious) participation of the individual in hastening his own demise.

Unintentioned deaths. Unintentioned deaths are those in which the deceased played no significant psychological role in his own cessation. The death was due entirely to failures within the body or to assault from without (by a bullet, a blow, a steering wheel, etc.) in a decedent who, rather unambivalently, wished to continue to live. Such a person at the time of his death is, as it were, going about his business (even though he may be lying in the hospital) with no conscious intention or strong drive in the direction of effecting or hastening his demise. What happens is that something from the outside—outside of his mind— happens to him. This lethal “something” may be a cerebral vascular accident, a myocardial infarction, some malfunction, some catastrophic catabolism, some invasion—whether by bullet or by virus—which he did not, in any part, himself generate. “It” happens to “him.”

Practical applications. A practical application of the above schematization of death in terms of the individual’s intention has been made since 1960 in Los Angeles. This procedure, labeled the “psychological autopsy” (Curphey 1961; Litman et al. 1963), has been used in those cases that are equivocal as to mode of death. The procedure consists of the use of especially adapted interview techniques to generate psychological information about the deceased. Survivors, friends, and professional acquaintances of the deceased are interviewed. Clues are sought, especially in relation to the prodromal aspects of suicide. A judgment is made along traditional lines (for example, probable suicide, probable accident, probable natural cause, suicide-accident undetermined, suicide-natural undetermined, etc.). An additional judgment is also made in terms of the intentioned, subintentioned, and unintentioned categories. Although one would, a priori, expect all suicidal deaths to be intentioned and all natural, accidental, and homicidal deaths to be unintentioned, the findings in the Los Angeles procedures indicate that the relationship between traditional modes of death and types of intention is a complicated one, with the crucial role occupied by subintentioned deaths.

It might be protested, inasmuch as the assessments of these intentioned states involve the appraisal of unconscious factors, that some workers (especially lay coroners) cannot legitimately be expected to make the psychological judgments required for this type of classification. To this, one answer would be that medical examiners and lay coroners make judgments of this nature every day of the week. The fact is that in the situation of evaluating a possible suicide, the coroner often acts (sometimes without realizing it) as psychiatrist and psychologist and as both judge and jury in a quasi-judicial way. This is because certification of death as suicide does, in itself, imply some judgments of reconstruction of the victim’s motivation or intention. Making these judgments is an inexorable part of a coroner’s function. It might be much better for these psychological dimensions to be made explicit and for an attempt, albeit crude, to be made to use them, rather than for these psychological dimensions to operate on an unverbalized level.

Theoretical and taxonomic positions

We now turn from our consideration of the definitional problems of suicide to a brief historical resume of the major theoretical and taxonomic positions in relation to suicidal phenomena.

Durkheim and other sociological positions . In this century (or at least since 1897, the date of the publication of Durkheim’s Le suicide) there have been two major approaches to the definition and understanding of suicide: the sociological and the psychological. The former historically is identified primarily with Émile Durkheim, French sociologist (1897). Durkheim was interested not so much in suicidal phenomena per se as he was in the explication of his own sociological method. He used the analysis of suicidal phenomena as the occasion to work out four types of factors in suicide—altruistic, egoistic, anomic, and fatalistic—but discussed only the first three.

There are studies generally classified as “sociological” (in the sense that they present statistical or ecological data, but not in the sense that they follow Durkheim’s interest in explaining the variety of man’s moral commitments to his society) which are worthy of note, among them Sainsbury (1955) and Stengel and Cook (1958) in England, and Dublin (1963) in the United States. Dublin’s book, especially, furnishes the student with an encyclopedia of statistical information about suicide phenomena.

Freudian and other psychological positions . The psychological approach is identified primarily with Freud, who is generally acknowledged to have first stated comprehensive psychological insights into suicide. Freud’s conceptualization of suicide (1917a; 1917b) was that of a primarily intra-psychic phenomenon, stemming from within the mind, primarily the unconscious mind, of the individual. In one of his formulations Freud envisaged suicide as being the result of a process wherein feelings of love and affection which had originally been directed toward an internalized love object had become, as a result of rejection and frustration, angry, hostile feelings; however, because the object had become internalized and part of the self, the hostile feelings were then directed toward the self. Thus suicide, from a psychoanalytic point of view, might be described as murder in the 180th degree.

The classical Freudian approach not only tended rather systematically to ignore social factors but also tended to focus on a single complex or psychodynamic constellation. But we now know that individuals kill themselves for a number and variety of psychologically felt motives: not only hate and revenge, but also dependency, shame, guilt, fear, hopelessness, loyalty, fealty to self-image, pain, and even ennui. Just as no single formula or pattern can be found to explain all human homosexuality or prostitution, so no single psychological pattern is sufficient to contain all human self-destruction. (For a comprehensive review of this topic, see Litman 1967.)

Synthesis—the concept of self. The synthesis of the psychological position, with its clinical emphasis on the individual internal drama within the single mind, and the sociological position, discussed in the previous article, remains to be accomplished. A recent study bearing on this point (Shneidman & Farberow 1960) emphasized the interplay between both the social and psychological factors as mutually enhancing roles in each individual’s suicide. This finding is consistent with that of Halbwachs (1930), whose position—unlike that of his mentor, Durkheim—was that the “social” and “psychopathological” explanations of suicide are complementary rather than antithetical. A synthesis of these two lies in the area of the “self,” especially in the ways in which social forces are incorporated within the totality of the individual. In understanding suicide, one needs to know the thoughts and feelings and ego functionings and unconscious conflicts of an individual, as well as how he integrates with his fellow man and participates morally as a member of the groups within which he lives.

Taxonomic positions . Not many classifications of suicidal phenomena have been proposed. Durk-heim’s classification distinguished between anomic, egoistic, and altruistic suicide (1897). To this can be added Menninger’s classification of the sources of suicidal impulses, namely the wish to kill, the wish to be killed, and the wish to die (1938). Menninger also classified subsuicidal phenomena into chronic suicide (asceticism, martyrdom, addiction, invalidism, psychosis); focal suicide (self-mutilation, malingering, multiple accidents, impotence and frigidity); and organic suicide (involving the psychological factors in organic disease). A composite listing of other rubrics would include the following: suicide as communication; suicide as revenge; suicide as fantasy crime; suicide as unconscious flight; suicide as magical revival or reunion; suicide as rebirth and restitution. A classification of suicidal types in terms of cognitive or logical styles has been proposed (Shneidman 1961). This classification, which stemmed from the logical analysis of suicide notes, divides the thinking styles of suicides into three types: logical, catalogical, and paleological.

Thus, in general, we see that the term “suicidal” is a broad one, starting from a base line of the individual who consciously and advertently takes his own life, through those individuals who by virtue of their unconscious mechanisms hasten their demise, through those individuals who indulge in partial or focal or chronic suicide, and perhaps even to those many individuals who by their own daily inimical acts truncate and diminish the full scope of their potential self-actualizations.

A concluding note concerning the current professional status of suicide prevention: Since 1955 there has been a marked spurt in interest in suicide prevention activities. In the United States, in 1958, there were 3 suicide prevention centers; in 1960, there were 5; in 1964, 9; in 1965, 15; and in 1967, 40. A Center for Studies of Suicide Prevention was established within the National Institute of Mental Health (NIMH) in 1966. A new multidisciplinary profession, suicidology—the scientific and humane study of human self-destruction—has come into being; special training courses in suicidology are offered at Johns Hopkins University.

Edwin S. Shneidman

[See alsoDeath. Other relevant material may be found in Psychoanalysis; Self concept; Medical care; and in the biography of Durkheim.]

BIBLIOGRAPHY

The bibliography for this article is combined with the bibliography of the article that follows.

III. PSYCHOLOGICAL ASPECTS (2)

The continuum of suicidal activity comprises total self-destruction (death); self-injury (but non-lethal), including crippling, maiming, painful and nonpainful activities; threats and other verbalized indications of intention toward self-destruction or self-injury; feelings of despair, depression, and unhappiness (which may not include thoughts of self-injury, but frequently do); and thoughts of separation, departure, absence, and relief and release. Somewhere within this continuum the thought or impulse becomes translated into action. The clinical impression is that once the psychological defenses against suicidal activity have been breached and the action has occurred, the possibility for further future acting out when emotional tension and strain recur is facilitated. It seems likely also that increasingly serious behavior results, possibly because of feelings of guilt or of feelings that such behavior is necessary in order to communicate with equivalent impact. The factor that determines the behavior remains puzzling. Perhaps the controls developed through coping mechanisms and defense patterns, brought to bear at different levels of dysfunctioning (Menninger 1963), play a crucial role, and the intensive study of these might provide the understanding necessary for suicide prevention for different individuals in various suicidal situations.

Characteristics of the suicidal person . The identification of the suicidal person is not especially difficult once the process has begun. Most persons considering self-destruction will identify themselves by communicating this tendency either behaviorally or verbally long before any specific act occurs. The typical suicidal person will generally reveal all or most of the following characteristics: (1) ambivalence—the desire, either conscious or unconscious or both, to live and to die, present at the same time; (2) feelings of hopelessness and helplessness, futility, and inadequacy to handle problems; (3) feelings of either physical or psychological exhaustion, or both; (4) marked feelings of unrelieved anxiety or tension, depression, anger, and/or guilt; (5) feelings of chaos and disorganization with inability to restore order; (6) mood swings, for example, from agitation to apathy or withdrawal; (7) cognitive constriction, inability to see alternatives, limitation of potentialities; (8) loss of interest in usual activities, such as sex, hobbies, and work; (9) physical distress, such as insomnia, anorexia, psychasthenia, and psychosomatic symptoms.

Prediction of lethal behavior . The more difficult problem is the evaluation of the suicidal person in terms of the relatively immediate potentiality of lethal acting out. The suicidal crisis presents the professional person with the need for quick appraisal. A schedule, evolved from experiences in the Suicide Prevention Center in Los Angeles, lists the following criteria used in evaluation of the emergency situation (see Litman & Farberow 1961). (1) Age and sex: older white males generally have the highest suicidal potentiality; a young female, on the other hand, is usually less lethally suicidal. (2) Suicidal plans: specificity about time, place, and method, plus the means for carrying out a plan, indicate high suicidal danger; vague, diffuse talk by a nonpsychotic about dying indicates that the situation is less serious. (3) Resources: external sources of support and interest, such as family, relatives, friends, physician, or hospital, are helpful; when the patient’s resources are exhausted the suicidal potentiality rises. (4) Prior suicidal behavior: a past history of suicidal behavior indicates greater present danger, and the seriousness of the prior suicide attempt adds an additional important consideration. (5) Onset of suicidal behavior: the acute suicidal crisis may be more immediately serious but also more amenable to intervention. The chronically suicidal person, especially the alcoholic or borderline schizophrenic, who presents repeated feelings of depression, is the more serious long-term therapeutic problem. (6) The medical situation: many patients visit physicians with minor physical complaints which are in reality indications of severe depression. Studies (Motto & Greene 1958; Robins et al. 1959; Dorpat & Ripley I960; and Shneidman & Farberow 1961) have indicated that more than 50 per cent of the patients who had committed suicide had seen their physicians within three months prior to their deaths. (7) Loss of a loved one: where death, separation, quarrel, or divorce from someone close has recently occurred, the suicidal potentiality is increased. (8) Communication: if communication still exists between the patient and others the suicidal risk is lowered; when the communication breaks and the person withdraws the danger increases. (9) Reaction of the referring person: if interest and concern about the patient continue, this is helpful. If, however, the referring person is angry, rejecting, and attempting to rid himself of responsibility, the potentiality is increased.

Psychological theories

The psychological theories have been summarized by Jackson (1957), who divided them roughly into nonpsychoanalytic and psychoanalytic.

Nonpsychoanalytic formulations . The nonpsychoanalytic formulations refer to “exhaustion” causing restriction of the field of consciousness so that an “organic depression” occurs; failure of adaptation; a disturbance of balance of will to live from a dynamic fixation of infantile attachment; infantile protest and hostility against harsh, restraining figures; narcissism in a rigid personality; compensations for homicidal impulses against members of the immediate family; and spite in children.

Psychoanalytic formulations . Most of the psychoanalytic theories stern from two of Freud’s theoretical contributions: his elaboration of the dynamics of depression in Mourning and Melancholia (1917b) and his postulations of the death instinct in Beyond the Pleasure Principle (1920). Depression, and consequently suicide, occurs as a result of strong, aggressive urges directed against an introjected object formerly loved but now hated. Menninger (1938) adopts the concept of a death instinct and elaborates it by postulating three elements in suicide: a wish to kill, a wish to be killed, and a wish to die. Zilboorg (1936; 1937) considers suicide a way of thwarting outside forces and one method of gaining immortality. O’Connor (1948) adds the feeling that the person achieves omnipotence by a return to early power narcissism. Palmer (1941) suggests that arrested psychosexual development as a result of the unavailability of important figures at crucial stages is the basic mechanism. Garma (1943) stresses the loss of an important love object, suicide being used to recover it. Bergler (1946) describes the introjec-tion suicide, aggression against guilt feelings; hysteric suicide, unconscious dramatization of how one does not want to be treated; and the miscellaneous type, such as paranoid schizophrenics reacting to voices. Farberow (1961), in the collection The Cry for Help, summarizes his contributors’ several theoretical approaches to suicide. To the formulations already presented above, some of his contributors add frustrated dependency; longing for spiritual rebirth and seeking to re-establish contact with the self by destruction of the ego; strong inferiority feelings and veiled aggression in dependent individuals with “pampered life style”; a depressive, hateful type of personality structure developed from interpersonal experiences; alienation and feelings of disparity between idealized self and real self; and the person’s attempts to validate his self according to his own “constructions.”

Contributing factors

From the variety of theories and multitude of factors in suicide, it is apparent that suicidal phenomena are both widespread and complex. They reflect common sociological roots and influences and, at the same time, express singular personal experiences and impulses. A psychology of suicide must take as many such factors as possible into account if understanding is to be attained. A single schema encompassing the major factors which enter into the understanding of any suicidal event can, as yet, be only a desirable goal. The following factors are necessary considerations in any comprehensive overview of suicidal behavior.

Sociological background . It is obvious that any event needs to be viewed in the setting within which it occurs, but suicide especially has varying significance when it takes place in such widely different countries as, for example, Denmark, Italy, Japan, or the southern part of the United States. National differences are further compounded by racial, religious, and economic factors. Similarities and specific differences will be found. Studies of suicide in some of the tribes of east Africa (Bohannan 1960) and in aboriginal tribes of central India (Elwin 1943) have shown motives remarkably similar to those of Western cultures, for example, domestic strife or loss of social status, as well as features specific to these tribes, such as intervention by the gods or bewitchment by ghosts.

Fluctuations of economic status or the changing political scene influence suicide. For example, suicide has varied with economic depressions, as when the rate soared in the United States during the depression of the mid-1930s and dropped markedly during the war years of the 1940s. An investigation by Arkun (1963) of the suicide rates in Turkey during the periods from 1927 to 1946 (after sweeping social reforms) and 1950 to 1960 (after World War n) showed startling changes in rates which, during the earlier period, could be attributed to the upheavals in the culture of Turkey and especially to the change in the role of women because of the reforms of Ataturk. Japan’s suicide rate has always been high; but whereas in ancient times the traditions of hara-kiri and seppuku were prominent, today much of the suicide rate is contributed to by a younger age group, such as students in universities who are faced with failure or fear of it (Iga 1961).

Cultural background . Cultures often surround death with taboos and rituals which illustrate feelings about death and dying and which include attitudes toward suicide. Myths and folklore illustrate some of the attitudes, as in the history of the Vikings and the tales of Valhalla, and contribute to the condemnation or condoning of suicide.

The culture may also determine interpersonal relationships that influence the occurrence of suicide. Hendin (1964) examines the “Scandinavian suicide phenomenon” and arrives at an explanation for the high suicide rates in Denmark and Sweden in contrast to those in Norway by a determination of the “psychosocial characteristics.” Using psychoanalytic methods, he finds differences in the psychodynamic constellations of the three countries, such as in dependency aspects, attitudes toward performance and accomplishment, handling of aggression and guilt feelings, relationships between the sexes, methods of discipline, and other dynamic features.

Individual demographic characteristics . Epidemiological aspects of suicide, such as age, sex, nationality, race, religion, marital status, education, financial status, have all been studied exhaustively for various countries (Dublin 1963). Where the individual falls in respect to each of these provides immediately invaluable information about the suicidal person. Important to include here also is the physical and mental status of the individual. A chronic, debilitating, or possibly fatal illness such as emphysema, cardiac disease, or cancer, or a recurrent mental illness which hospitalizes the individual for several months every two or three years will obviously influence the individual suicide (Farberow et al. 1963; Shneidman et al. 1962).

Psychological factors . It is within the psychological factors that the core of the problem of understanding suicide is met. These factors include not only the current personality status and psycho-dynamic constellations of the individual in question but also the motivations for his suicidal behavior, the reasons why his actions, thoughts, or feelings lead him to suicide. The categorization of motivations into interpersonal and intrapersonal factors seems to offer a meaningful classification of many of the various phenomena. The distinction is arbitrary, of course, for it is practically impossible for a suicide to occur without both types of relationships being involved. Nevertheless, one or the other aspect will often predominate.

Interpersonal motivations in suicide occur when the suicidal person attempts by his behavior either to bring about an action on the part of another person or persons or to effect a change in attitude or feeling within another person or persons, or both. The suicidal behavior can thus be seen as a means to influence, persuade, force, manipulate, stimulate, change, dominate, reinstate, etc., feelings or behavior in someone else. The other person is most often someone who has been in a close relationship, such as spouse, fiancee, or member of the family. Infrequently, the object of the behavior is more generalized, and it may be society itself.

Interpersonal motivations can be found, of course, in all ages but are usually predominant in the younger and middle-aged groups. A typical example is that of the girl between the ages of 20 and 25 who is reacting with strong feelings of rejection to a quarrel with a loved one or to divorce or separation. Her emotional state is one of agitation, dependency, immaturity, poor judgment, and impulsivity. Her suicidal behavior is used to express anger or feelings of rejection and to force a change in the rebuffing person or to arouse guilt feelings in him. Much of the behavior is still verbal, some is impulsive acting out, and most of it contains an “appeal” element (Stengel & Cook 1958).

Less often the aim is the expiation of or the need to express the guilt the person feels for having done something either imaginary or real in the relationship with another person. Ambivalence about dying is relatively low, inasmuch as the person, despite the fact that he is engaging in suicidal behavior, does not usually wish to die.

Intrapersonal motivations appear most often in older persons and thus in situations in which ties with others have dissipated. The individual’s action seems aimed primarily at expressing the pressures and stresses from within and at fulfilling important needs in himself. The typical person is a male aged 60 or over who has recently suffered the death of a loved one, whose physical condition has deteriorated so that there is illness or pain, or whose children are married and so live their own separate lives. There are intense feelings of loneliness, feelings of not being needed any longer, of no longer being able to work effectively, perhaps because of physical condition, or of feeling that life has been lived and holds no more. The mood is often depressed, withdrawn, and physically and emotionally exhausted. There may be strong need for expiation and for atonement stemming from excessive feelings of guilt. An important dynamic is the need to maintain “psychological integrity” (Appelbaum 1963) or self-esteem or self-concept, even by the paradoxical act of self-destruction. Ambivalence is again low inasmuch as the person, if he embarks on a suicidal course, usually does so with full intent to die. [See Aging, article onpsychological aspects.]

Some cases of suicide occur in which it is difficult to distinguish whether interpersonal or intra-personal motivations are predominant. Rather it seems that each is equally present, although perhaps not always in the same strength at the same time. A typical example is a middle-aged person, the precipitating suicidal stimulus is the death of a loved one, separation, divorce, loss of job, loss of status, or sometimes a crippling, debilitating illness. Such a person is generally depressed, anxious, frustrated, and sometimes agitated, showing poor judgment and disorganization which will sometimes extend to psychotic or near-psychotic proportions. Marked symptoms of frustrated dependency, hostility, and aggression, perhaps because of rejection or masochism, and the two elements “appeal” and “ordeal” are readily seen (Stengel 1956). The ordeal element is especially apparent in the greater ambivalence about dying and the marked tendency to leave survival up to fate, destiny, or chance. Suicidal attempts are usually more lethal, but there are also more provisions for rescue, both conscious and unconscious.

Importance of work. Work takes on special significance for this group. Often with premature dissolution of relationships in the middle-aged group, work becomes the principal source of self-significance and self-esteem. The nonpersonal aspects of the work itself, rather than the people involved with whom interaction on the job occurs, become important. So long as the person is able to function in his job and to lose himself in its details, there is sufficient defense against suicidal impulses. For the very severely and chronically depressed person, work may provide a cover for the feeling of emptiness and void from which he is continually trying to escape. The routine of work keeps him busy and prevents him from thinking about himself. Not to work provides him with time during which he is free to think about himself and to feel useless and empty. Once the work is lost, perhaps through some personal difficulty, physical crisis, or enforced retirement, a crucial defense seems to be breached and suicidal impulses will burst through.

Can any suicide be entirely intrapersonal? One suggestion has been that this may occur only in the psychotic. However, the problem may well be only one of understanding on the part of the observer. The psychotic may be reacting entirely on an interpersonal basis but in a bizarre or devious process which simply is not comprehended by others.

Feelings about death and the afterlife. Most often the individual simply reflects the prevailing attitudes of his culture about suicide, death, or life after death. However, the individual may arrive at his own conceptualizations, which may vary markedly. Convictions of eternal peace after death, of the possibility of reunion with a deceased loved one, visions of hell-fire and brimstone, or of pain and unmitigated suffering, belief in the supernatural, or faith in magic may be key factors in an individual’s suicidal behavior.

Communication . Seen as a communication process, suicidal behavior often achieves clearer perspective. In most instances, the suicidal activity occurs at the end of a long train of events that have finally led the person to the decision that life is no longer worth living. Accompanied by many communications along this course, the suicidal act itself then becomes a communication which may have many meanings and much significance. The communication in suicidal behavior can be grouped under five headings. (1) Form: the communication may be verbal, including written, or nonverbal and behavioral. (2) Directness or indirectness: the communication may be straightforward and clear, or disguised and indirect. Withdrawal, giving away prized possessions, remarks about not needing articles, fantasies of death, burial, or rescue from dangerous situations may occur. (3) Substance or content: the communication may contain expressions of affect, either fixing or expiating guilt or blame, explanations of the suicidal act, or instructions and directions to survivors, as in wills and suicide notes (Shneidman & Farberow 1957a; Tuckman et al. 1959). (4) Object of the communication: in most interpersonal situations, the communication is directed to a specific person or persons; in intrapersonal motivations it is more often directed to society in general. (5) Purpose: the communication may be overt or indirect in aim. Sometimes it is a cry for help, a plea to be stopped or to be rescued, a means for expression of hostility and hate, a final fixing of blame, a way to cause shame or arouse guilt, or a way to assume blame, absolve others, and expiate one’s own guilt.

Countersuicidal controls

The factors that mitigate against suicide are as important as those that influence toward it. In many instances, the fact that self-destruction is not chosen as the way out of seemingly unbearable situations—as in the concentration camps of Germany, or when the individual is subject to continuous pain and discomfort in the terminal stages of cancer—impresses the observer. The controls may be external or internal.

External controls . External controls refer to all the controls that society may bring to bear on an individual to keep him conforming and alive, such as taboos, religion, myths, mores, group and subgroup identifications, marriage, family, children. Also significant are the actions of others toward the individual. Indications of support, understanding, interest, and concern, especially on the part of the “significant other” but also by hospital and professional personnel, may be the essential preventive factor.

Internal controls . Internal controls may stem from the ideals, standards, morality, conscience, or feelings of responsibility of the individual. In addition, the ego structure of the individual may provide him with flexibility, adaptability, independence, and feelings of self-esteem which will permit him to endure severe emotional stress. Or he may be more vulnerable because of rigidity, overdependence, and poor self-concept.

Psychology of the survivors

The suicide has great impact on the survivors, regardless of whether it had predominantly interpersonal or intrapersonal motives. These reactions generally vary directly in intensity with distance of relationship with the suicidal person. Among the group in a close relationship, the spouse, children, family, relatives, close friends, or therapist, a variety of feelings and reactions may be aroused. These may include (1) strong feelings of loss, accompanied by sorrow and mourning; (2) strong feelings of anger for (a) being made to feel responsible, or (b) being rejected in that what was offered was refused; (3) guilt, shame, or embarrassment with feelings of responsibility for the death; (4) feelings of failure or inadequacy that what was needed could not be supplied; (5) feelings of relief that the nagging, insistent demands have ceased; (6) feelings of having been deserted, especially true for children; (7) ambivalence, with a mixture of all the above; (8) reactions of doubt and self-questioning whether enough was attempted; (9) denial that a suicide has occurred, with a possible conspiracy of silence among all concerned; and (10) arousal of one’s own impulses toward suicide.

Among those in a more distant relationship, such as neighbors, employer or fellow employees, the hospital, or society, the reactions may also be those of (1) anger because of (a) a feeling that the suicidal person has rejected his social and moral responsibilities, or (b) being made to feel responsible, or (c) an implied accusation of not enough concern, interest, or caring about its members and fellow man; (2) guilt that not enough was offered to make the person want to live; (3) rejection, resulting from the suicidal person’s obvious choice to do without them; and (4) uneasiness, manifested by a vague need for self-examination to determine what was wrong or to rationalize the discomfort away.

Norman L. Farberow

[See alsoDeath. Other relevant material may be found in Depressive disorders; Medical care; and in the biography of Durkheim.]

BIBLIOGRAPHY

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Durkheim, ÉMILE (1897) 1951 Suicide: A Study in Sociology. Glencoe, 111.: Free Press. → First published in French.

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Farberow, Norman L.; and Shneidman, Edwin S. (editors) 1961 The Cry for Help. New York: McGraw-Hill. → Contains a bibliography on suicide, 1897-1957, on pages 325-388.

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Freud, Sigmund (1917b) 1959 Mourning and Melancholia. Volume 4, pages 152-170 in Sigmund Freud, Collected Papers. International Psycho-analytic Library, No. 10. London: Hogarth; New York: Basic Books. → Authorized translation from the German under the supervision of Joan Riviere. The first English edition was published in 1925.

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Suicide

Suicide

Definition

Suicide is defined as the intentional taking of one's own life. Prior to the late nineteenth century, suicide was legally defined as a criminal act in most Western countries. In the social climate of the early 2000s, however, suicidal behavior is most commonly regarded and responded to as a psychiatric emergency.

Description

Suicide is considered a major public health problem around the world as well as a personal tragedy. According to the National Institute of Mental Health (NIMH), suicide was the eleventh leading cause of death in the United States in 2000, and the third leading cause of death for people between the ages of 15 and 24. About 10.6 out of every 100,000 persons in the United States and Canada die by their own hands. There are five suicide victims for every three homicide deaths in North America as of the early 2000s. There are over 30,000 suicides per year in the United States, or about 86 per day; and each day about 1900 people attempt suicide.

The demographics of suicide vary considerably within Canada and the United States, due in part to differences among age groups and racial groups, and between men and women. Adult males are three to five times more likely to commit suicide than females, but females are more likely to attempt suicide. Most suicides occur in persons below the age of 40; however, elderly Caucasians are the sector of the population with the highest suicide rate. Americans over the age of 65 accounted for 18 percent of deaths by suicide in the United States in 2000. Geographical location is an additional factor; according to the Centers for Disease Control and Prevention (CDC), suicide rates in the United States are slightly higher than the national average in the western states, and somewhat lower than average in the East and the Midwest.

Race is also a factor in the demographics of suicide. Between 1979 and 1992, Native Americans had a suicide rate 1.5 times the national average, with young males between 15 and 24 accounting for 64% of Native American deaths by suicide. Asian American women have the highest suicide rate among all women over the age of 65. And between 1980 and 1996 the suicide rate more than doubled for black males between the ages of 15 and 19.

Causes & symptoms

Causes

Suicide is a complex act that represents the end result of a combination of factors in any individual. These factors include biological vulnerabilities, life history, occupation, present social circumstances, and the availability of means for committing suicide. While these factors do not "cause" suicide in the strict sense, some people are at greater risk of self-harm than others. Risk factors for suicide include:

  • Male sex.
  • Age over 75.
  • A family history of suicide.
  • A history of previous suicide attempts.
  • A history of abuse in childhood.
  • A local cluster of recent suicides or a local landmark associated with suicides. Examples of the latter include the Golden Gate Bridge in San Francisco; Sydney Harbor Bridge in Australia; St. Peter's Basilica in Rome; the Eiffel Tower in Paris; Prince Edward Viaduct in Toronto; and Mount Mihara, a volcano in Japan.
  • Recent stressful events: separation or divorce, job loss, bankruptcy, upsetting medical diagnosis, death of spouse.
  • Medical illness. Persons in treatment for such serious or incurable diseases as AIDS, Parkinson's disease, and certain types of cancer are at increased risk of suicide.
  • Employment as a police officer, firefighter, physician, dentist, or member of another high-stress occupation.
  • Presence of firearms in the house. Death by firearms is the most common method for women as well as men as of the early 2000s. In 2001, 55% of reported suicides in the United States were committed with guns.
  • Alcohol or substance abuse. Mood-altering substances are a factor in suicide because they weaken a person's impulse control.
  • Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a significant mental illness. Major depression accounts for 60% (especially in the elderly), followed by schizophrenia, alcoholism, substance abuse, borderline personality disorder, Huntington's disease, and epilepsy. The lifetime mortality due to suicide in psychiatric patients is 15% for major depression; 20% for bipolar disorder; 18% for alcoholism; 10% for schizophrenia; and 5-10% for borderline and certain other personality disorders.

Neurobiological factors may also influence a person's risk of suicide. Post-mortem studies of the brains of suicide victims indicate that the part of the brain associated with aggression and other impulsive behaviors (the frontal cortex) has a significantly lower level of serotonin, a neurotransmitter associated with mood disorders. Low serotonin levels are correlated with major depression. In addition, suicide victims have higher than normal levels of cortisol, a hormone produced in stressful situations, in the tissues of their central nervous system. Other research has indicated that abuse in childhood may have permanent effects on the level of serotonin in the brain, possibly "resetting" the level abnormally low. In addition, twin studies have suggested that there may be a genetic susceptibility to both suicidal ideation and suicide attempts which cannot be explained by inheritance of common psychiatric disorders.

Some psychiatrists propose psychodynamic explanations of suicide. According to one such theory, suicide is "murder in the 180th degree" that is, the suicidal person really wants to kill someone else but turns the anger against the self instead. Another version of this idea is that the suicidal person has incorporated the image of an abusive parent or other relative in their own psyche and then tries to eliminate the abuser by killing the self.

Diagnosis

When a person consults a doctor because they are thinking of committing suicide, or they are taken to a doctor's office or emergency room after a suicide attempt, the doctor will evaluate the patient's potential for acting on their thoughts or making another attempt. The physician's assessment will be based on several different sources of information:

  • The patient's history, including a history of previous attempts or a family history of suicide.
  • A clinical interview in which the physician will ask whether the patient is presently thinking of suicide; whether they have made actual plans to do so; whether they have thought about the means; and what they think their suicide will accomplish. These questions help in evaluating the seriousness of the patient's intentions.
  • A suicide note, if any.
  • Information from friends, relatives, or first responders who may have accompanied the patient.
  • Short self-administered psychiatric tests that screen people for depression and suicidal ideation. The most commonly used screeners are the Beck Depression Inventory (BDI), the Depression Screening Questionnaire, and the Hamilton Depression Rating Scale.
  • The doctor's own instinctive reaction to the patient's mood, appearance, vocal tone, and similar factors.

Treatment of attempted suicide

Suicide attempts range from well-planned attempts involving a highly lethal method (guns, certain types of poison, jumping from high places, throwing oneself in front of trains or subway cars) that fail by good fortune to impulsive or poorly planned attempts using a less lethal method (medication overdoses, cutting the wrists). Suicide attempts at the less lethal end of the spectrum are sometimes referred to as suicide gestures or pseudocide. These terms should not be taken to indicate that suicide gestures are only forms of attention-seeking; they should rather be understood as evidence of serious emotional and mental distress.

A suicide attempt of any kind is treated as a psychiatric emergency by the police and other rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation; a mental status examination ; blood or urine tests if alcohol or drug abuse is suspected; and a detailed assessment of the patient's personal circumstances (occupation, living situation, family or friends nearby, etc.). The patient will be kept under observation while decisions are made about the need for hospitalization.

A person who has attempted suicide can be legally hospitalized against his or her will if he or she seems to be a danger to the self or others. The doctor will base decisions about hospitalization on the severity of the patient's depression; the availability of friends, relatives, or other social support; and the presence of other suicide risk factors, including a history of previous suicide attempts, substance abuse, and psychosis (loss of contact with reality, often marked by delusions and hallucinations ). If the attempt is judged to be a nonlethal suicide gesture, the patient may be released after the psychiatric assessment is completed. According to CDC figures, 132,353 Americans were hospitalized in 2002 following suicide attempts while 116,639 were released following emergency room treatment.

Related issues

Survivors of suicide

One group of people that is often overlooked in discussions of suicide is the friends and family left behind by the suicide. It is estimated that each person who kills him- or herself leaves six survivors to deal with the aftermath; thus there are at least 4.5 million survivors of suicide in the United States. In addition to the grief that ordinarily accompanies death, survivors of suicide often struggle with feelings of guilt and shame as well. They often benefit from group or individual psychotherapy in order to work through such issues as wondering whether they could have prevented the suicide or whether they are likely to commit suicide themselves. The American Foundation for Suicide Prevention (AFSP) has a number of online resources available for survivors of suicide.

Assisted suicide

One question that has been raised in developed countries as the average life expectancy increases is the legalization of assisted suicide for persons suffering from a painful terminal illness. Physician-assisted suicide has become a topic of concern since it was legalized in the Netherlands in 2001 and in the state of Oregon in 1997. It is important to distinguish between physician-assisted suicide and euthanasia, or "mercy killing.". Assisted suicide, which is often called "self-deliverance" in Britain, refers to a person's bringing about his or her own death with the help of another person. Because the other person is often a physician, the act is often called "doctor-assisted suicide." Euthanasia strictly speaking means that the physician or other person is the one who performs the last act that causes death. For example, if a physician injects a patient with a lethal overdose of a pain-killing medication, he or she is performing euthanasia. If the physician leaves the patient with a loaded syringe and the patient injects himself or herself with it, the act is an assisted suicide. As of early 2005 assisted suicide is illegal everywhere in the United States except for Oregon, and euthanasia is illegal in all fifty states.

Media treatment of suicide

The Centers for Disease Control and Prevention (CDC) sponsored a national workshop in April 1994 that addressed the connection between sensationalized media treatments of suicide and the rising rate of suicide among American youth. The CDC and the American Association of Suicidology subsequently adopted a set of guidelines for media coverage of suicide intended to reduce the risk of suicide by contagion.

The CDC guidelines point out that the following types of reporting may increase the risk of "copycat" suicides:

  • Presenting oversimplified explanations of suicide, when in fact many factors usually contribute to a person's decision to take their own life.
  • Excessive or repetitive local news coverage.
  • Sensationalizing the suicide by inclusion of morbid details or dramatic photographs.
  • Giving "how-to" descriptions of the method of suicide.
  • Describing suicide as an effective coping strategy or as a way to achieve certain goals.
  • Glorifying the act of suicide or the person who commits suicide.

Alternative treatment

Some alternative treatments may help to prevent suicide by preventing or relieving depression. Meditation practice or religious faith and worship have been shown to lower a person's risk of suicide. In addition, any activity that brings people together in groups and encourages them to form friendships helps to lower the risk of suicide, as people with strong social networks are less likely to give up on life.

Prognosis

The prognosis for a person who has attempted suicide is generally favorable, although further research needs to be done. A 1978 follow-up study of 515 people who had attempted suicide between 1937 and 1971 reported that 94% were either still alive or had died of natural causes. This finding has been taken to indicate that suicidal behavior is more likely to be a passing response to an acute crisis than a reflection of a permanent state of mind.

Prevention

One reason that suicide is such a tragedy is that most self-inflicted deaths are potentially preventable. Many suicidal people change their minds if they can be helped through their immediate crisis; Dr. Richard Seiden, a specialist in treating survivors of suicide attempts, puts the high-risk period at 90 days after the crisis. Some potential suicides change their minds during the actual attempt; for example, a number of people who survived jumping off the Golden Gate Bridge told interviewers afterward that they regretted their action even as they were falling and that they were grateful they survived.

Brain research is another important aspect of suicide prevention. Since major depression is the single most common psychiatric diagnosis in suicidal people, earlier and more effective recognition of depression is a necessary preventive measure. Known biological markers for an increased risk of suicide can now be correlated with personality profiles linked to suicidal behavior under stress to help identify individuals at risk. In addition, brain imaging studies using positron emission tomography (PET) are presently in use to detect abnormal patterns of serotonin uptake in specific regions of the brain. Genetic studies are also yielding new information about inherited predispositions to suicide.

Another major preventive measure is education of clinicians, media people, and the general public. In 2002 the CDC, the National Institutes of Health (NIH), and several other government agencies joined together to form the National Strategy for Suicide Prevention, or NSSP. Education of the general public includes a growing number of medical and government websites posting information about suicide, publications available for downloading, lists of books for further reading, tips for identifying symptoms of depressed and suicidal thinking, and advice about helping friends or loved ones who may be at risk. Many of these websites also have direct connections to suicide hotlines.

The National Institute of Mental Health (NIMH) recommends the following action steps for anyone dealing with a suicidal person:

  • Make sure that someone is with them at all times; do not leave them alone even for a short period of time.
  • Persuade them to call their family doctor or the nearest hospital emergency room.
  • Call 911 yourself.
  • Keep the person away from firearms, drugs, or other potential means of suicide.

KEY TERMS

Assisted suicide A form of self-inflicted death in which a person voluntarily brings about his or her own death with the help of another, usually a physician, relative, or friend.

Cortisol A hormone released by the cortex (outer portion) of the adrenal gland when a person is under stress. Cortisol levels are now considered a biological marker of suicide risk.

Euthanasia The act of putting a person or animal to death painlessly or allowing them to die by withholding medical services, usually because of a painful and incurable disease. Mercy killing is another term for euthanasia.

Frontal cortex The part of the human brain associated with aggressiveness and impulse control. Abnormalities in the frontal cortex are associated with an increased risk of suicide.

Psychodynamic A type of explanation of human behavior that regards it as the outcome of interactions between conscious and unconscious factors.

Serotonin A chemical that occurs in the blood and nervous tissue and functions to transmit signals across the gaps between neurons in the central nervous system. Abnormally low levels of serotonin are associated with depression and an increased risk of suicide.

Suicide gesture Attempted suicide characterized by a low-lethality method, low level of intent or planning, and little physical damage. Pseudocide is another term for a suicide gesture.

Resources

BOOKS

Alvarez, A. The Savage God: A Study of Suicide. New York: Random House, Inc., 1972. A now-classic study of suicide written for general readers. The author includes a historical overview of suicide along with accounts of his own suicide attempt and the suicide of his friend, the poet Sylvia Plath.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

"Depression." In The Merck Manual of Geriatrics, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

"Psychiatric Emergencies." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

"Suicidal Behavior." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

"Suicide in Children and Adolescents." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Friend, Tad "Letter from California: Jumpers." New Yorker, 10 November 2003. http://newyorker.com/printable/?fact/031013fa_fact. A journalist's account of the Golden Gate Bridge in San Francisco, the world's leading location for suicide.

Fu, Q., A. C. Heath, K. K. Bucholz, et al. "A Twin Study of Genetic and Environmental Influences on Suicidality in Men." Psychology in Medicine 32 (January 2002): 11-24.

Plunkett, A., B. O'Toole, H. Swanston, et al. "Suicide Risk Following Child Sexual Abuse." Ambulatory Pediatrics 1 (September-October 2001): 262-266.

Soreff, Stephen, MD. "Suicide." eMedicine, 3 September 2004. http://www.emedicine.com/med/topic3004.htm.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. http://www.aacap.org..

American Association of Suicidology. Suite 408, 4201 Connecticut Avenue, NW, Washington, DC 20008. (202) 237-2280. Fax: (202) 237-2282. http://www.suicidology.org.

American Foundation for Suicide Prevention (AFSP). 120 Wall Street, 22nd Floor, New York, NY 10005. (888) 333-2377 or (212)

Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC). Mailstop K60, 4770 Buford Highway, Atlanta, GA 30341-3724. (770) 488-4362. Fax: (770) 488-4349. http://www.cdc.gov/ncipc.htm.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (886) 615-NIMH. www.nimh.nih.gov.

OTHER

American Academy of Child and Adolescent Psychiatry (AACAP). Teen Suicide. AACAP Facts for Families #10. Washington, DC: AACAP, 2004.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. "Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop." Morbidity and Mortality Weekly Report 43 (22 April 1994): 9-18. http://www.cdc.gov/mmwr/preview/mmwrhtml/00031539.htm.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Suicide: Fact Sheet. http://www.cdc.gov/ncipc/factsheets/suifacts.htm.

National Institute of Mental Health (NIMH). In Harm's Way: Suicide in America. NIH Publication No. 03-4594. Bethesda, MD: NIMH, 2003. http://www.nimh.nih.gov/publicat/NIMHharmsway.pdf.

National Suicide Hotline: (800) 273-TALK (1-800-273-8255).

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Suicide

Suicide


The word suicide covers a wide range of behaviors, including (1) completed suicide; in which the individual dies as a result of the self-destructive act; (2) attempted suicide, in which the individual survives the act; and (3) suicidal ideation, which refers to the individual thinking about and planning suicidal behavior, but not putting these thoughts into action.

A controversy exists over the term attempted suicide. Because many of the individuals who survive a suicidal action did not intend to die (for example, they may have intentionally taken only half of a lethal dose of a medication), some scholars object to the term. Europeans suggested parasuicide as an alternative, especially for suicide attempts of low lethality, but in recent years the terms self-injury and self-poisoning have become popular.


The Epidemiology of Suicide

Completed suicide rates vary widely by nation. According to the latest figures available from the World Health Organization, rates in the 1990s ranged from thirty to forty per 100,000 per year for Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Russia, Slovenia, and the Ukraine to zero to five per 100,000 per year for Armenia, Greece, and Thailand. National rates of attempted suicide are not available, but it is estimated that there may be eight to ten attempts at suicide for every completed suicide.

Completed suicide rates are higher in men than in women in every country except for mainland China, where the female suicide rate exceeds the male suicide rate (Phillips, Liu, and Zhang 1999). However, in every nation, female rates of attempted suicide exceed those for men in the small samples that have been studied.

Completed suicide rates rise with age in men, but in women the peak age for suicide varies with the level of economic development in the nation. Female suicide rates peak in middle age in the most developed nations, but in young women in the least developed nations (Girard 1993). In general, attempted suicides are younger than completed suicides.

In the United States, whites and American Indians have the highest completed suicide rates, whereas Filipino Americans have the lowest rates. African Americans, Chinese Americans and Japanese Americans have intermediate rates (Lester 1998). These ethnic differences in the United States match those in other nations. For example, in Zimbabwe and South Africa, whites have higher completed suicide rates than blacks, and Philippine suicide rates are lower than the rates in China and Japan.


Theories of Suicide

Research into why individuals become suicidal has identified psychiatric disturbance as the strongest predictor of future suicidality. In particular, depression, both unipolar and bipolar, is associated with the greatest suicidal risk, and even in schizophrenics and substances abusers, both groups with high rates of suicide, depression is the strongest predictor of which individuals in those groups will complete suicide (Maris, Berman, and Silverman 2000). Among the components of depression, the cognitive component, which has been called pessimism and hopelessness by Aaron Beck and his colleagues (1979), is a more powerful predictor than the somatic components of depression (such as loss of appetite) or the mood symptoms (such as guilt).

Suicidal individuals are found to have experienced a high level of stress for a long period of time, and often have an increasing level in the time leading up to their suicidal action. In addition, suicidal individuals are found to have few resources, and the resources that they have are often unavailable (Lester 2000). For example, the people available to turn to for help may be resented by the suicidal person, or the resources may be hostile toward the suicidal person.

The family plays a critical role in each of these factors. Physiological and psychological theories of psychiatric disorder stress the role of the parents, either in passing on the genes for the disorder (in physiological theories) or in creating a pathological home environment (in psychological theories) (Maris, Berman, Silverman 2000). Family members are often the cause of much of the stress that suicidal individuals experience, and they are the resources that may be unavailable to the suicidal individual.

Sociological theories of suicide attempt to explain the suicide rates of cultures or regions. They have focused on the role of social disorganization (social integration and social regulation in Durkheim's theory—see below) or in the opportunity to blame others for one's misfortunes rather than oneself (Henry and Short 1954). For example, African Americans have been oppressed by the racism in U.S. society and so have a clear source of blame for their misery, whereas white Euro Americans have been the oppressors. African Americans have higher murder rates whereas whites have higher suicide rates, in line with this argument.


Marital Status and the Family

Marital status has a strong association with rates of completed suicide. Suicide rates are higher in the divorced and widowed than in single people, who in turn have higher suicide rates than married people. This protective effect of marriage on suicide is stronger for men than for women, although it is found for both men and women (Gove 1972).

The strong association of divorce with suicide is found at the societal level as well as at the individual level. For example, nations with higher divorce rates have higher suicide rates, U.S. states with higher divorce rates have higher suicide rates and, within nations, years with higher divorce rates have higher suicide rates. This association is probably the most robust association found in suicidology. The associations between marriage rates and suicide rates and between birth rates and suicide rates are not as consistent, although they do tend to be negative associations more often than positive associations.

These associations fit well with the classic sociological theory of suicide proposed by Emile Durkheim (1897). Durkheim proposed that suicide would be common where the level of social integration—the extent to which the members of a society are bound together in social networks—was high (leading to altruistic suicide) or low (leading to egoistic suicide), and where the level of social regulation—the extent to which the behaviors and desires of the members of the society conform to social rules and norms—was high (leading to fatalistic suicide) or low (leading to anomic suicide).

Modern sociologists have argued that altruistic and fatalistic suicide are rare in modern societies and that it is hard to measure social integration separately from social regulation ( Johnson 1965). Thus, they propose that suicide varies inversely with the level of social integration/regulation.

The association between divorce rates and suicide rates has two interpretations. Composition theory argues that because suicide rates are higher in divorced individuals, societies with a greater proportion of divorced people will necessarily have a higher suicide rate.

However, looking at the United States, divorce rates are strongly associated over the states with interstate migration rates, alcohol consumption, and low church attendance. Thus, these variables form a cluster of related social indicators, and they perhaps tap some broad, abstract quality of society: perhaps social disorganization is an appropriate term. This broad social characteristic has an effect on all of the members of the society, not just the divorced, the alcohol abusers, or the migrants.

Christopher Cantor and Penelope Slater (1995) found that the suicide rate in Queensland, Australia, was highest for men who were separated, as opposed to men who were single, married, divorced, or widowed. For women, the divorced had the highest suicide rate. The increase in the suicide rate in separated men was greater in those who were younger (age 15–19) than in those who were older (over the age of 55). These results suggest that the time during the breakdown in the marriage may be more stressful for men than for women, whereas the state of divorce may be stressful for both men and women.

The higher rate of suicide in widows as compared to those married of the same may be because bereavement increases the risk of suicide or because widows and widowers who are prone to suicide are less likely to get remarried. Some old data from Brian MacMahon and Thomas Pugh (1965) indicate that it is bereavement—and not differential remarriage rates—that is the factor responsible. However, research (for example, a study by Arne Mastekaasa [1993] in Norway) also indicates that, once age is taken into account, the higher suicide rate in the widowed as compared to the divorced is no longer found.

Even though those who are married have lower suicide rates than those in other marital statuses, Walter Gove (1972) has documented that marriage is more beneficial for men than for women, in that the reduction in the suicide rate (and also in rates of psychiatric disturbance) is greater for married men than for married women.


The Protective Effect of Children

The presence of children appears to have a protective effect with regard to suicide. In a study of a large sample of women in Norway, Georg Hoyer and Eiliv Lund (1993) obtained a sample of almost one million single and married women in Norway in 1970 and identified which of them had completed suicide by 1985. They found that unmarried women had a higher suicide rate than married women without children for those aged twenty-five to sixty-four, but not for those over the age of sixty-four. Thus, marriage appeared to reduce the suicide rate in women.

Hoyer and Lund also found that married women with children had lower suicide rates than married women with no children for all age groups. Thus, the presence of children further reduces the risk of suicide in women above and beyond the protective impact of marriage per se. Furthermore, the more children, the lower the suicide rate of the married women.

This study is the best study on the topic reported hitherto, but it confirms the results of earlier studies on smaller samples and without such detailed analyses. For example, in Portugal women with children were found to have a lower suicide rate than childless women, and those with more than five children had the lowest suicide rate (de Castro and Martins 1987).

There is also some evidence that the presence of children reduces the severity of suicidality in suicidal women, for example, making attempted suicide relatively less common and suicidal ideation relatively more common.


The Disturbing Effects of Families

Although the presence of children may protect their parents from suicide, the parents may increase the risk of suicide in the children. Even sibling position may play a role, as Alfred Adler (1958) suggested, with completed suicide being less common in last-borns and attempted suicide less common in first borns (Lester 2000).

Although in general, having a spouse and children reduces the risk of suicide, family members can play a role in precipitating suicide. For example, often family members feel and express a great deal of hostility toward one another. In psychic homicide, an individual commits suicide in response to the conscious or unconscious murderous impulses for them (Meerloo 1962). The role of murderous desires of parents toward their offspring may play a greater role in adolescent suicides than in the suicides of older adults. Transactional analysis has proposed that suicidal individuals had parents who experienced these desires (such as "I wish you had never been born") during the baby's first year of life.

It is difficult to show these effects with research, but the hostility has been observed at the time of the suicidal behavior. For example, Milton Rosenbaum and Joseph Richman (1970) in their study of attempted suicides reported a mother's first statement to her 24-year-old son in the hospital, "Next time pick a higher bridge." Or a wife whose 70-year-old husband said to her, "If I had a gun, I'd shoot myself," replied, "I'll buy you a gun." He used pills a few days later instead. A father said to his 17-year-old daughter, "We'd all be better off if you were dead. At least we'd know where you are."

There are many features of family life that impact on suicidal behavior. Abuse of children, both physically and sexually, appears to result in an increase in later suicidal behavior as well as other psychiatric disorders and symptoms.

Loss of parents during childhood, especially between the ages of six and sixteen, increases the risk of suicide. David Lester (1989) found that exactly half of a sample of famous suicides, for whom detailed biographies were available, had experienced such loss, such as the poet Sylvia Plath whose father died of natural causes when she was eight. If the parent dies from suicide, then suicide is even more likely in the children.

In general, research finds that married couples in which one partner attempts suicide have poorer communication between each other and more destructive conflicts (such as avoiding discussion and fleeing the home), and that the suicidal partner is more psychiatrically disturbed (Lester 2000).

Suicidal behavior in family members increases the risk of suicide in other family members, perhaps because this indicates a greater acceptance of suicidal behavior as a solution to problems in that family, or perhaps because the occurrence of suicide in many family members indicates the presence of an inherited psychiatric disorder. In the Hemingway family, for example, Ernest's father completed suicide, and so did three of his six children (including Ernest, of course). It is likely that an affective disorder was passed down in this family, but also completing suicide in middle age when suffering from severe medical problems appears to have become a learned strategy in the family.

However, this copycat (or contagion) effect is also found in social groups. A suicide in an adolescent is occasionally followed by "imitation" suicides among his or her peers (Maris, Berman, and Silverman 2000), and in these cases inheritance does not play a role.


Helping Suicidal Individuals

The most common tactic for suicidal individuals is to treat the underlying psychiatric disturbance using medication and psychotherapy. In recent years, the increasing prescribing of antidepressants appears to have resulted in a decline in suicide rates (Isacsson 2000). In addition, effective psychotherapies have been devised for suicidal individuals (Linehan 1993), and many countries now have networks of telephone crisis centers, functioning twenty-four hours a day, seven days a week, for individuals to call during times when they are most distressed (Mishara and Daigle 2001).

However, because interpersonal factors are often involved in precipitating and maintaining the suicidality of people, family therapy is perhaps the most appropriate format for psychotherapy for suicidal individuals. Joseph Richman (1986) has been the leading advocate of this approach.


Problems for Survivors

Those who experience the suicide of a significant other are known as survivors. Survivors have great difficulty coping with the death, perhaps more so than those whose significant others die of natural causes. In some cases, it is the family members who discover the body of the suicide, often greatly disfigured by the suicide. For example, Leicester Hemingway, Ernest's brother, was only thirteen when he found his father dead from a firearm wound. Leicester was one of the three children who later completed suicide.

Furthermore, the grieving process after a suicide is different in significant ways from the grieving after natural deaths. There is more anger felt toward the suicide and guilt over what the survivors might have done to prevent the suicide. Group therapy is particularly helpful for survivors whether led by peers or by professionals (Farberow 2001).

In recent years, survivors have banded together to form organizations to help one another and to work for the prevention of suicide in general. There are survivor groups in many countries and, in some countries, in every region. In the United States, the American Association of Suicidology maintains a directory of these services and, inter-nationally, Befrienders International has services (usually under the name The Samaritans) in more than forty countries.


See also:Childhood, Stages of: Adolescence; Death and Dying; Depression: Adults; Depression: Children and Adolescents; Euthanasia; Grief, Loss, and Bereavement; Rape; Self-Esteem; Widowhood

Bibliography

adler, a. (1958). "suicide." journal of individual psychology 14:57–61.beck, a. t.; rush, a. j.; shaw, b. f.; and emery, g. (1979).cognitive therapy of depression. new york: guilford.

cantor, c. h., and slater, p. j. (1995). "marital breakdown,parenthood, and suicide." journal of family studies 1:91–102.

de castro, e. f., and martins, i. (1987). "the role of female autonomy in suicide among portuguese women." acta psychiatrica scandinavica 75:337–343.

durkheim, e. (1897). le suicide. paris: felix alcan.

farberow, n. l. (2001). "helping suicide survivors." insuicide prevention: resources for the millennium, ed. d. lester. philadelphia: brunner-routledge.

girard, c. (1993). "age, gender, and suicide." americansociological review 58:553–574.

gove, w. (1972). "sex, marital status and suicide." journal of health and social behavior 13:204–213.

henry, a. f., and short, j. f. (1954). suicide and homicide. new york: free press.

hoyer, g., and lund, e. (1993). "suicide among womenrelated to number of children in marriage." archives of general psychiatry 50:134–137.

isacsson, g. (2000). "suicide prevention: a medical breakthrough?" acta psychiatrica scandinavica 102: 113–117.

johnson, b. d. (1965). "durkheim's one cause of suicide." american sociological review 30:875–886.

lester, d. (1989). "experience of personal loss and latersuicide." acta psychiatrica scandinavica 79:450–452.

lester, d. (1998). suicide in african americans. commack, ny: nova science.

lester, d. (2000). why people kill themselves, 4th edition.springfield, il: charles c. thomas.

linehan, m. m. (1993). cognitive-behavioral therapy ofborderline personality disorder. new york: guilford.

macmahon, b., and pugh, t. f. (1965). "suicide in the widowed." american journal of epidemiology 81:23–31.

maris, r. w.; berman, a. l.; and silverman, m. m. (2000).comprehensive textbook of suicidology. new york: guilford.

mastekaasa, a. (1993). "marital status and subjective well-being." social indicators research 29:249–276.

meerloo, j. a. m. (1962). suicide and mass suicide. newyork: grune and stratton.

mishara, b., and daigle, m. (2001). "helplines and crisisintervention services." in suicide prevention: resources for the millennium, ed. d. lester. philadelphia: brunner-routledge.

phillips, m. r.; liu, h. q.; and zhang, y. p. (1999). suicide and social change in china. culture, medicine and psychiatry 23:25–50.

richman, j. (1986). family therapy for suicidal people.new york: springer.

rosenbaum, m., and richman, j. (1970). "suicide: therole of hostility and death wishes from the family and significant others." american journal of psychiatry 126:1652–1655.

other resources

american association of suicidology. (2002). available from http://www.suicidology.org.

world health organization. (2002). available from www.who.int.

DAVID LESTER

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Suicide

Suicide

Definition

Suicide is defined as the intentional taking of one's own life. In some European languages, the word for suicide translates into English as "self-murder " Until the end of the twentieth century, approximately, suicide was considered a criminal act; legal terminology used the Latin phrase felo-de-se, which means "a crime against the self." Much of the social stigma that is still associated with suicide derives from its former connection with legal judgment, as well as with religious condemnation.

In the social climate of 2002, suicidal behavior is most commonly regarded and responded to as a psychiatric emergency.

Demographics of suicide

In the United States, the rate of suicide has continued to rise since the 1950s. More people die from suicide than from homicide in North America. Suicide is the eighth leading cause of death in the U.S., and the third leading cause of death for people aged 15 to 24. There are over 30,000 suicides per year in the U.S., or about 86 per day; each day about 1,500 people attempt suicide.

The demographics of suicide vary considerably from state to state. Some states, like Pennsylvania, have suicide rates that are very close to the national average; others, such as Connecticut, have significantly lower rates. However, other states have much higher rates than the national average. These variations are due in part to differences among age groups and racial groups, and between men and women. Males are three to five times more likely to succeed in their suicide attempts than females, but females are more likely to attempt suicide. Most suicides occur in persons below the age of 40; however, elderly Caucasians are the sector of the population with the highest suicide rate.

Race is also a factor in the demographics of suicide. Between 1979 and 1992, the suicide rate of Native Americans was 1.5 times the national average, with young males between the ages of 15 and 24 accounted for 64% of Native American deaths by suicide. Asian-American women have the highest suicide rate among all women over the age of 65. Further, between 1980 and 1996 the suicide rate more than doubled for African-American males between the ages of 15 and 19.

High-risk factors

Research indicates that the following factors increase a person's risk of suicide:

  • Male sex.
  • Age over 75.
  • A family history of suicide.
  • A history of suicide attempts.
  • A history of abuse in childhood.
  • Traumatic experiences after childhood
  • Recent stressful events, such as separation or divorce, job loss, or death of spouse.
  • Chronic medical illness. Patients with AIDS have a rate of suicide 20 times that of the general population.
  • Access to a gun. Death by firearms is now the fastestgrowing method of suicide among men and women. Nearly 57% of deaths caused by guns in the U.S. are suicides.
  • Alcohol or substance abuse. While mood-altering substances do not cause a person to kill himself/herself, they weaken impulse control.
  • High blood cholesterol levels.
  • Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a mental illness. Major depression accounts for 60% of suicides, followed by schizophrenia , alcoholism, substance abuse, borderline personality disorder , Huntington's disease, and epilepsy. The lifetime mortality due to suicide in psychiatric patients is 15% for major depression; 20% for bipolar disorder ; 18% for alcoholism; 10% for schizophrenia; and 510% for borderline and certain other personality disorders.

Low-risk factors

Factors that lower a person's risk of suicide include:

  • a significant friendship network outside the workplace
  • religious faith and practice
  • a stable marriage
  • a close-knit extended family
  • a strong interest in or commitment to a project or cause that brings people together, including community service, environmental concerns, neighborhood associations, animal rescue groups, etc.

Suicide in other countries

Suicide has become a major social and medical problem around the world. The World Health Organization (WHO) reported that one million people worldwide died from suicide in the year 2000. That is a global mortality rate of 16:100,000or one death by suicide every 40 seconds. Since the mid-1950s, suicide rates around the world have risen by 60%. Rates among young people have risen even faster, to the point where they are now the age group at highest risk in 35% of the world's countries.

The specific demographics, however, vary from country to country. China's pattern, for example, is very different from that of most other countries. China has a suicide mortality rate of 23:100,000, with a total of 287,000 deaths by suicide each year. The rate for women is 25% higher than that for men, and rates in rural areas are three times higher than in cities. The means also vary; In China, Sri Lanka, and Turkey the primary means of suicide is ingestion of pesticides, rather than using guns.

Suicide in children and adolescents

The suicide rate among children and adolescents in the U.S. has risen faster than that of the world population as a whole. The suicide rate for Caucasian males aged 15 to 24 years has tripled since 1950; and it has more than doubled for Caucasian females in the same age bracket. In 1999, a survey of high school students found that 20% had seriously considered suicide or attempted it in the previous year. Of adolescents who do commit suicide, 90% have at least one diagnosable psychiatric disorder at the time of their death. Most frequently it is major depression, substance abuse disorder, or conduct disorder . Adolescents are particularly susceptible to dramatic or glamorized portrayals of suicide in the mass media.

Causes

Suicide is an act that represents the end result of a combination of factors in any individual. One model that has been used by clinicians to explain why people suffering under the same life stresses respond differently is known as the stress/diathesis model. Diathesis is a medical term for a predisposition that makes some people more vulnerable to thoughts of suicide. Components of a person's diathesis may include:

Neurobiological and genetic factors

Post-mortem studies of the brains of suicide victims indicate that the part of the brain associated with controlling agression and other impulsive behaviors (the frontal cortex) has a significantly lower level of serotonin, a neurotransmitter associated with mood disorders. Low serotonin levels are correlated with major depression. In addition, suicide victims have higher than normal levels of cortisol, a hormone produced in stressful situations, in the tissues of their central nervous system. Studies of the levels of other neurotransmitters in brain tissue are underway.

Other research has indicated that abuse in childhood may have permanent effects on the level of serotonin in the brain, possibly "resetting" the level abnormally low. In addition, twin studies have suggested that there may be genetic susceptibility in males to both suicidal ideation and suicide attempts which cannot be explained by inheritance of common psychiatric disorders. No twin studies of susceptibility to suicide in women have yet been reported.

History and lifestyle

Other components of a diathesis include:

  • Chronic illness
  • Traumatic experiences after childhood
  • Alcohol or substance abuse
  • High blood cholesterol levels.

Factors in the wider society

In addition to factors at the individual level, factors in the wider society have been identified as contributing to the rising rate of suicide in the United States:

  • Stresses on the nuclear family, including divorce and economic hardship.
  • The loss of a set of moral values held in common by the entire society.
  • The weakening of churches, synagogues, and other mid range social groups outside the family. In the past, these institutions often provided a sense of belonging for people from troubled or emotionally distant families.
  • Frequent geographical moves, which makes it hard for people to make and keep long-term friendships outside their immediate family.
  • Sensationalized treatment of suicide in the mass media. A number of research studies have shown that there is a definite risk of "contagion" suicides from irresponsible reporting, particularly among impressionable adolescents.
  • The development over the past century of medications that allow relatively painless suicide. For most of human history, the available means of suicide were uncertain, painful, or both.
  • The easy availability of firearms in the United States.

Treatment of attempted suicide

Researchers estimate that 825 people attempt suicide for every person who completes the act. Suicide attempts can be broadly categorized along a continuum that ranges from seriously planned attempts involving a highly lethal method that fail by good fortune, to impulsive or poorly planned attempts using a less lethal method. Suicide attempts at the lower end of the spectrum are sometimes referred to as suicide gestures or pseudocide.

A suicide attempt of any kind, however, is treated as a psychiatric emergency by rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation, a mental status examination, and a detailed assessment of the circumstances surrounding the attempt. The physician will interview relatives or anyone else who accompanied the patient in order to obtain as much information as possible. As a rule, suicide attempts requiring advance planning, including precautions taken against discovery, and the use of violent or highly lethal methods are regarded as the most serious. The patient will be kept under observation while decisions are made about the need for hospitalization .

A person who has attempted suicide and who is considered a serious danger to him- or herself or to others can be hospitalized against their will. The doctor will base the decision on the severity of the patient's depression or agitation; availability of friends, relatives, or other social support; and the presence of other suicide risk factors, including a history of previous suicide attempts, substance abuse, recent stressful events, and symptoms of psychosis . If the attempt is judged to be a nonlethal suicide gesture, the patient may be released after the psychiatric assessment is completed.

Related issues

Survivors of suicide

One group of people that is often overlooked in discussions of suicide is the friends and family bereaved by the suicide. It is estimated that each person who kills him- or herself leaves six survivors to deal with the aftermath. On the basis of this figure, there are at least 4.5 million survivors of suicide in the United States. In addition to the grief that ordinarily accompanies death, survivors of suicide often struggle with feelings of guilt and shame as well. In spite of a general liberalization of social attitudes since World War II, suicide is still stigmatized in many parts of Europe and the United States. Survivors often benefit from group or individual psychotherapy in order to work through such issues as wondering whether they could have prevented the suicide or whether they are likely to commit suicide themselves. Increasing numbers of clergy as well as mental health professionals are taking advanced training in counseling survivors of suicide.

Assisted suicide

One question that has been raised in developed countries as the average life expectancy increases is the legalization of assisted suicide for persons suffering from a painful terminal illness. Physician-assisted suicide has become a topic of concern since it was legalized by recent legislation in the Netherlands (in April 2001) and in the state of Oregon. It is important to distinguish between physician-assisted suicide and euthanasia, or "mercy killing." Assisted suicide, which is often called "self-deliverance" in Britain, refers to a person's bringing about his or her own death with the help of another person. Because the other person is often a physician, the act is often called "doctor-assisted suicide." Euthanasia strictly speaking means that the physician or other person is the one who performs the last act that causes death. For example, if a physician injects a patient with a lethal overdose of a pain-killing medication, he or she is performing euthanasia. If the physician leaves the patient with a loaded syringe and the patient injects himself or herself with it, the act is an assisted suicide. As of 2002, assisted suicide is illegal every where in the United States except for Oregon, and euthanasia is illegal in all fifty states.

Media treatment of suicide

In 1989, the Centers for Disease Control (CDC) sponsored a national workshop to address the issue of the connection between sensationalized media treatments of suicide and the rising rate of suicide among American youth. The CDC and the American Association of Suicidology subsequently adopted a set of guidelines for media coverage of suicide intended to reduce the risk of suicide by contagion.

The CDC guidelines point out that the following types of reporting may increase the risk of "copycat" suicides:

  • Presenting oversimplified explanations of suicide, when in fact many factors usually contribute to it. One example concerns the suicide of the widow of a man who was killed in the collapse of the World Trade Center on September 11, 2001. Most newspapers that covered the story described her death as due solely to the act of terrorism, even though she had a history of depressive illness.
  • Excessive, ongoing, or repetitive coverage of the suicide.
  • Sensationalizing the suicide by inclusion of morbid details or dramatic photographs. Some news accounts of the suicide of an Enron executive in January 2002 are examples of this problem.
  • Giving "how-to" descriptions of the method of suicide.
  • Referring to suicide as an effective coping strategy or as a way to achieve certain goals.
  • Glorifying the act of suicide or the person who commits suicide.
  • Focusing on the person's positive traits without mentioning his or her problems.

Prevention

Brain research is an important aspect of suicide prevention as of 2002. Since major depression is the single most common diagnosis in suicidal people, earlier and more effective recognition of depression is a necessary preventive measure. Known biological markers for an increased risk of suicide can now be correlated with personality profiles linked to suicidal behavior under stress to help identify individuals at risk. In addition, brain imaging studies using positron emission tomography (PET) are presently in use to detect abnormal patterns of serotonin uptake in specific regions of the brain. Genetic studies are also yielding new information about inherited predispositions to suicide.

A second major preventive measure is education of clinicians, media people, and the general public. Public health studies carried out in Sweden have shown that seminars for primary care physicians in the recognition and treatment of depression resulted in a rise in the number of prescriptions for antidepressants and a drop in suicide rates. Education of the general public includes a growing number of CDC, NIMH, and other web sites posting information about suicide, tips for identifying symptoms of depressed and suicidal thinking, and advice about helping friends or loved ones who may be at risk. Many of these web sites have direct connections to suicide hotlines.

An additional preventive strategy is restricting access to firearms in the developed countries and to pesticides and other poisons in countries where these are the preferred method of suicide.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. "Psychiatric Disorders." In Current Medical Diagnosis & Treatment 2001, edited by L. M. Tierney, Jr., MD, and others. 40th edition. New York: Lange Medical Books/McGraw-Hill, 2001.

"Psychiatric Emergencies." Section 15, Chapter 194 in The Merck Manual of Diagnosis and Therapy, edited by MarkH. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

"Suicidal Behavior." Section 15, Chapter 190 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

"Suicide in Children and Adolescents." Section 19, Chapter 264 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories,1999.

PERIODICALS

Byard, R. W., and J. D. Gilbert. "Cervical Fracture, Decapitation, and Vehicle-Assisted Suicide." Journal of Forensic Science 47 (March 2002): 392-394.

Fu, Q., A. C. Heath, K. K. Bucholz, and others. "A Twin Study of Genetic and Environmental Influences on Suicidality in Men." Psychology in Medicine 32 (January 2002): 11-24.

Gibb, Brandon E., Lauren B. Alloy, Lyn Y. Abramson, and others. "Childhood Maltreatment and College Students' Current Suicidal Ideation: A Test of the Hopelessness Theory." Suicide and Life-Threatening Behavior 31(2001): 405-415.

Kara, I. H., and others. "Sociodemographic, Clinical, and Laboratory Features of Cases of Organic Phosphorus Intoxication in the Southeast Anatolian Region of Turkey." Environmental Research 88 (February 2002): 82-88.

Mancinelli, Iginia, MD, and others. "Mass Suicide: Historical and Psychodynamic Considerations." Suicide and Life-Threatening Behavior 32 (2002): 91-100.

Phillips, M. R., X Li, and Y. Zhang. "Suicide Rates in China, 1995-99." Lancet 359 (March 9, 2002): 835-840.

Plunkett, A., B. O'Toole, H. Swanston, and others. "Suicide Risk Following Child Sexual Abuse." Ambulatory Pediatrics 1 (September-October 2001): 262-266.

Vieta, E., F. Colom, B. Corbella, and others. "Clinical Correlates of Psychiatric Comorbidity in Bipolar I Patients." Bipolar Disorders 3 (October 2001): 253-258.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007.(202) 966-7300. Fax: (202) 966-2891. <www.aacap.org>.

American Association of Suicidology. Suite 310, 4201 Connecticut Avenue, NW, Washington, DC 20008. (202) 237-2280. Fax: (202) 237-2282. <www.suicidology.org>.

National Institutes of Mental Health (NIMH). NIMH Public Inquiries: (800) 421-4211. <www.nimh.nih.gov>.

OTHER

Befrienders International. <www.befrienders.org>.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Programs for the Prevention of Suicide Among Adolescents and Young Adults; and Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop. MMWR 1994; 43 (No. RR-6). <www.cdc.gov/ncipc>.

Mann, J. John, MD. "The Neurobiology of Suicide." Mental Health Clinical Research Center for the Study of Suicidal Behavior, Columbia-Presbyterian Medical Center, New York. <www.afsp.org>.

National Suicide Hotline: (800) SUICIDE (800-784-2433).

Rebecca J. Frey, Ph.D.

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Suicide

SUICIDE

Among industrialized countries that provide statistics on suicide, nearly all report that suicide rates rise progressively with age, with the highest rates occurring for men age seventy-five and older. In the United States in 1997, older white males age eighty-five and older had a rate of 65.4 per 100,000. This latter rate is almost six times the rate of all ages combined. Reviewed here is the available research evidence on correlates and risk factors in later life suicidal behavior, and suggested opportunities for prevention.

Demographic correlates and methods of later life suicide

U.S. data on completed suicides by sex, age, race, marital status, and method are based on vital statistics information gathered by the Centers for Disease Control and Preventions National Center for Health Statistics, with each state reporting from death certificates. From this data source we know that increased age among persons sixty-five and older is associated with higher rates of suicide. Also, older adults as a group are more likely to use a firearm as a suicide method compared to the total U.S. rate; 70 versus 60 percent. In terms of demographic correlates of suicide deaths, male sex, white race, older age, and unmarried status are associated with higher rates of suicide.

Older suicide victims are more likely to have lived alone than younger suicides. However, older adults are also likely to be those members of the population who live alone, so the potency of living arrangement as a risk factor for suicide is not clear. A correlate associated with living arrangement is marital status. The suicide rate for unmarried older adults is higher than the suicide rate for married older adults. For older men, the suicide rate for those who are divorced or widowed is much higher when compared with older females or with their married counterparts (Buda and Tsuang).

Psychological status and life events associated with later life suicide

In the absence of adequate prospective studies, the psychological autopsy (PA) method has been used to reconstruct a detailed picture of the victims psychological state prior to death, including psychiatric symptomatology, behavior, and life circumstances during the weeks or months before death. This includes interviewing knowledgeable informants, reviewing available clinical records, and comprehensive case formulation by one or more mental health professionals with expertise in postmortem studies. The PA method has been used to provide an inclusive, well-defined sample of all persons who die by suicide within a defined catchment area, region, or population. One of the most striking and consistent findings of the PA method is that psychiatric disorder and/or substance use is present in about 90 percent of all suicides, with affective disorder as the most common psychopathology, followed by substance use and schizophrenia (Conwell and Brent).

When compared to younger suicide victims, older victims are more likely to have had a physical illness, and to have suffered from depression that is not comorbid with a substance disorder (Conwell and Brent). The type of depression found in the majority of later life suicides is usually a first episode of depression, uncomplicated by psychoses or other comorbid psychiatric disorders, and, ironically, is the most treatable type of late-life depression. Such age-related patterns have appeared in reports from a number of countries including the United States, Finland, and the United Kingdom.

Although substance use is less frequent among elderly suicides, there is some evidence that among the young old, alcohol may be a correlate. For men with early onset alcoholism who have survived to their fifties and sixties, the combination of continued alcohol abuse and burn out among their social support network may be lethal. Murphy and his associates described that for older male alcoholics, loss of the last social support can be a pivotal event in suicide risk (Murphy, Wetzel, Robins, and McEvoy). How current, as well as past alcohol abuse, lowers the threshold for suicidal behavior in later life requires further systematic examination. Although it is often assumed that medication misuse (e.g., benzodiazepine dependence, psychotropic medication with alcohol abuse) is a risk for late life suicide, there is little published information on this topic.

Despite high rates of dementia and delirium in later life, few studies have found these diagnoses to be risk factors for suicide (Conwell and Brent). Controlled PA studies are needed to determine what other factors in combination with mental and physical disorders are related to risk for later life suicide.

The PA has been used to explore possible personality traits that may increase risk for later life suicide (Duberstein). Duberstein used an informant-based personality inventory measure to examine possible personality traits among older and younger suicides, relative to age- and sex-matched controls. The inventory measured five general personality traits: neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness. Suicides were found to have higher neuroticism scores than normal controls, and older suicide victims had lower openness to experience scores than both younger suicides and normal controls.

Hopelessness, a set of beliefs related to lack of anticipated positive outcomes about the future, has also been examined in the context of later life suicide. A prospective investigation of a retirement community found a single item asking about hopelessness was related to later completed suicides (Ross, Bernstein, Trent, Henderson, and Paganini-Hill).

Suicide intent has also been examined in older adult suicide victims. Using the PA method, older adults were found to be more intent compared to younger suicide victims (Conwell, Duberstein, Cox, Herrmann, Forbes, and Caine). That is, older adults were more likely to have avoided intervention, taken precautions against discovery, and were less likely to communicate their intent to others. Moreover, older men, in particular, were less likely to have had a history of previous attempts.

The PA method has also been used to examine patterns of health services use among suicide victims. Health services for older adults who later suicided was typically available, and used. A number of reports indicate that approximately 70 percent of older suicide victims had seen a primary health care provider within a month (Conwell). In contrast, few older adult suicide victims have had a history of mental health care.

Neurobiological correlates of late life suicide

Postmortem brain tissue studies of suicide victims have found that the sertonergic systems (presynaptic and nontransporter nerve terminal binding sites) had reduced activity (Mann). Although there is optimism about new refinements and applications of neurobiological, brain imaging, and candidate gene markers to identify high risk individuals, there are currently no specific biological markers for suicidal behavior. With regard to older adults, it is conceivable that a neurobiological vulnerability to suicide might be modulated by age-related changes in neurobiological systems (Schneider). The consistency of increased suicide risk with age and male sex across nations also suggests a possible neurobiological process. Decreased brain concentrations of serotonin, dopamine, norepinephrine and their metabolites (HVA, 5-HIAA); increased brain MAO-B activity; increased hypothalamic-pituitary-adrenal (HPA) activity; and increased sympathetic nervous system activity are associated with both depression and normal aging (Schneider). Although several reviews have examined the evidence for neurobiologic abnormalities among older suicide victims relative to controls, there are too few studies that included sufficient older subjects (older than sixty years) to draw any conclusions (Conwell and Brent). This is particularly true of the subgroup of the older adults most at risk: those eighty-five and older.

Suicide attempts in later life

There are currently no national surveillance data of suicide attempts in the United States. Using data from the National Institute of Mental Health Epidemiologic Catchment Area study of five communities, Moscicki and her associates found a much lower prevalence of lifetime suicide attempts for older adults than younger populations. For persons age sixty-five and older, the lifetime prevalence for suicide attempts was 1.1 percent. By comparison, the rate was 4 percent for persons age twenty-five to forty-four. Other community-based studies have estimated lower attempt to completion ratios for older, compared to younger, adults (e.g., Nordentoft et al.). These findings support Conwell and colleaguess 1998 report that older adults are more intent in their efforts to commit suicide.

Other information about attempted suicide in late life comes from studying the characteristics of older persons recently admitted to a hospital due to the attempt. Draper reviewed twelve studies of later life suicide attempts published between 1985 and 1994. Despite variation in sampling contexts and approaches to measurement, and lack of adequate control groups, he reported several consistent factors associated with attempted suicide in late life: depression, social isolation, and being unmarried. The degree to which physical health was a risk factor was unclear. In some studies it appeared to play a major role, while in another only about one-third of the patients identified health as a salient factor.

The relationship between hopelessness and suicide attempts in later life was examined by studying the course of hopelessness in depressed patients (Rifai et al., 1994). Patients who had attempted suicide in the past had significantly higher hopelessness scores than nonattempters during both the acute and continuation phases of psychiatric treatment. Moreover, a high degree of hopelessness persisting after the remission of depression in older patients appeared to be associated with a history of suicidal behavior. This study by Rifai and her associates also suggested that a high degree of hopelessness may increase the likelihood of premature discontinuation of treatment and lead to future attempts or suicide. One prospective study of older depressed inpatients followed over a year found that 8.7 percent attempted suicide (Zweig and Hinrichsen). Patients who attempted suicide were more likely to have an incomplete remission of depression, history of suicide attempts, and familial interpersonal strain compared to those who did not attempt within the one year follow-up.

Prevention strategies

Prevention strategies should follow the most potent risk factor findings. Since the majority of older adults use firearms as a means of suicide, some have proposed that reduction in access to firearms may be an effective, preventive measure. However, others have argued that substitution in suicide methods may minimize the potency of this prevention approach (1990).

Research findings of increases in intent with age suggest that older persons who are at risk for suicide may be more difficult to identify as being at imminent risk than is the case for younger persons. Thus, clinical intervention strategies that target individuals who are at high risk for suicide, as indicated by a variety of demographic and psychiatric variables, may be more effective for preventing suicide than interventions that solely target individuals with suicide ideation or behavior. The fact that the majority of older adults are seen in primary care settings within the month of their deaths, coupled with the finding that most later life suicide victims have had a late onset, depressive episode, suggests that detecting and treating depression in primary care may be an efficient way to prevent later life suicides.

Although the identification and adequate treatment of depression is proposed as the most promising research avenue when considering preventive interventions in late life suicide, there are a number of factors that work against these prevention efforts. Ageism works against out-reach efforts. Many health providers, family members, and older adults themselves believe that depression and suicidal ideation are part of the normal aging process. Prevention efforts will need to consider these issues in public education and provider training to advance efforts in increased detection and treatment of depression.

Jane L. Pearson

See also Depression; Euthanasia and Senicide; Suicide and Assisted Suicide, Ethical Aspects.

BIBLIOGRAPHY

Buda, M., and Tsuang, M. T. The Epidemiology of Suicide: Implications for Clinical Practice. In Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. Edited by S. J. Blumenthal and D. J. Kupfer. Washington, D.C.: American Psychiatric Press, Inc., 1990. Pages 1737.

Conwell, Y. (1994). Suicide in Elderly Patients. In Diagnosis and Treatment of Depression in Late-Life. Edited by L. S. Schneider, C. F. Reynolds, B. D. Lebowitz, and A. J. Friedhoff. Washington, D.C.: American Psychiatric Association, 1994. Pages 397418.

Conwell, Y., and Brent, D. Suicide and Aging I: Patterns of Psychiatric Diagnosis. International Psychogeriatrics 7 (1995): 149181.

Conwell, Y.; Duberstein, P. R.; Cox, C.; Herrmann, J. H.; Forbes, N. T.; and Caine, E. D. Age Differences in Behaviors Leading to Completed Suicide. American Journal of Geriatric Psychiatry 6 (1998): 122126.

Draper, B. Attempted Suicide in Old Age. International Journal of Geriatric Psychiatry 11 (1996): 577587.

Duberstein, P. R. Openness to Experience and Completed Suicide across the Second Half of Life. International Psychogeriatrics 7 (1995): 183198.

Mann, J. J. The Neurobiology of Suicide. Nature Medicine 4 (1998): 2530.

Moscicki, E. K.; OCarroll, P.; Rae, D. S.; Locke, B. Z.; Roy, A.; and Regier, D. A. Suicide Attempts in the Epidemiologic Catchment Area Study. Yale Journal of Biology and Medicine 61 (1988) 259268.

Murphy, G. E.; Wetzel, R. D.; Robins, E.; and McEvoy, L. Multiple Risk Factors Predict Suicide in Alcoholism. Archives of General Psychiatry 49 (1992): 459463.

Nordentoft, M.; Breum, L.; Munck, L.; Nordestgaard, A. G.; Hunding, A.; and BjÆldager, P. A. L. High Mortality by Natural and Unnatural Causes: A 10 Year Follow Up Study of Patients Admitted to a Poisoning Treatment Centre after Suicide Attempts. British Medical Journal 306 (1993): 1637-1641.

Rifai, A. H.; George, C. J.; Stack, J. A.; Mann, J. J.; and Reynolds, C. F. Hopelessness in Suicide Attempters After Acute Treatment of Major Depression in Late-Life. American Journal of Psychiatry 151 (1994): 16871690.

Ross, R. K.; Bernstein, L.; Trent, L.; Henderson, B. E.; and Paganini-Hill, A. A Prospective Study of Risk Factors for Traumatic Death in the Retirement Community. Preventive Medicine 19 (1990): 323334.

Schneider, L. S. Biological Commonalities among Aging, Depression, and Suicidal Behavior. In Suicide and Depression in Late-Life: Critical Issues in Treatment, Research and Public Policy. Edited by G. J. Kennedy. New York: John Wiley & Sons, Inc., 1996. Pages 3950.

Szanto, K.; Reynolds, C. F., 3d; Conwell, Y.; Begley, A. E.; and Houck, P. High Levels of Hopelessness Persist in Geriatric Patients with Remitted Depression and a History of Attempted Suicide. Journal of the American Geriatrics Society 46 (1998): 14011406.

Zweig, R. A., and Hinrichsen, G. A. Factors Associated with Suicide Attempts by Depressed Older Adults: A Prospective Study. American Journal of Psychiatry 150 (1993): 16871692.

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Suicide

Suicide

DURKHEIMS STUDIES

AMERICAN DEMOGRAPHIC DATA

SUICIDE AMONG THE ELDERLY

TEEN SUICIDE AND THE FAMILY

PHYSICIAN-ASSISTED SUICIDE

INTERNATIONAL DEMOGRAPHIC DATA

OTHER MANIFESTATIONS OF SUICIDE

BIBLIOGRAPHY

Suicide can be the outcome of an individuals difficult and stressful experiences or a response to an unbearable situation. Sometimes suicide is complicated by drug and/or alcohol use. The scope of suicide includes all ages, classes, races, and sexes, although some groups are at more risk than others. Children or family members of those who have attempted or completed suicide are more likely themselves to attempt or complete suicide, as suicide has a ripple effect and can convey the idea that self-destruction is an acceptable solution to distress. Casualties of suicide, or those left behind, experience traumatic grief, guilt, shame, stress, and self-doubtsometimes keeping them from speaking of the event at all. Statistics of suicide are underrepresented and not always reliable because the action can be classified in some other way; legally, suicidal components must be established beyond a doubt. Additionally, it is sometimes difficult to categorize the intentionality of death.

Suicide rates are higher for those who suffer from depression or other psychiatric problems; use drugs or alcohol when depressed; suffer from physical, especially irreversible, illness; are divorced; have lost an important relationship through death or breakup; and live in certain areas. War combatants also face a high rate of suicide because of post-traumatic stress disorders. People with HIV/AIDS are at risk, with the decision of suicide based on the fear of loss of function or increase in suffering and the feeling of being isolated. In suicide by cop incidents, an armed suicidal individual forces a law officer to use deadly force resulting in death. Individuals name various other reasons for suicide, including as a means to reunite with the dead, a means to ensure rest and refuge, a way to take revenge, and a penalty for failure.

DURKHEIMS STUDIES

In 1897 the French sociologist Émile Durkheim (18581917) conducted a study of suicide in France. He found lower suicide rates among women, Catholics, Jews, and married people and higher rates among men, Protestants, wealthy people, and unmarried individuals. Based on the data, he argued that categories of people with strong social ties had low suicide rates, and that categories of people with the lowest social integration had the highest suicide rates. Durkheim believed that too much or too little integration or regulation (cohesion) was unhealthy for society and accordingly established four conditions that can lead to suicide: (1) altruism, or too much integration, a willingness to sacrifice the self for the groups ostensible interest (e.g., suicide bombers); (2) egoism, or too little integration (e.g., those not bound to social groups left with little guidance); (3) fatalism, or too much regulation with no perceived way out of a situation (e.g., slaves); and (4) anomie, or too little regulation and no fulfillment of needs (e.g., those coping with the death of a spouse, economic depression, institutional failure, or wealth insufficient to provide happiness). Durkheim focused on anomie as an unhealthy and destructive pathological state for society, resulting in a milky-way-galaxy of choices for normative behavior (read normlessness) and a lack of social regulation.

AMERICAN DEMOGRAPHIC DATA

In the United States, suicide ranks eleventh on the list of causes of death. Suicides occur most often among white males, and the rate increases with age; older white males have the highest suicide rates in the nation. Females and nonwhite males reach their peak for suicide vulnerability earlier in adult life. Suicide is the third leading cause of death in the age group fifteen to twenty-four. Bad economic times are usually associated with an increase of suicide rates. Rates for Native Americans are the highest of any ethnic population in the nation.

Suicide rates tend to be higher in areas where people live far apart from each other; more densely populated states have lower suicide rates. Accordingly, the highest suicide rates are in the western states, with Wyoming and Alaska at the top of the list, although California is ranked as having one of the lowest rates. The middle and eastern states are ranked lower in suicide rates than the western states (with the District of Columbia and Massachusetts as the lowest), although Vermont, West Virginia, and Oklahoma are ranked as high. Most of the New England states are ranked as having the lowest rates of suicide.

SUICIDE AMONG THE ELDERLY

Since 1990, in the United States there has been an increase in suicide rates in individuals eighty-five years or older, although suicide in the elderly does not elicit the same response as it does in younger individuals. Elderly individuals are more likely to be socially isolated for a longer time before death and are more likely to experience physical illness, other sources of distress and depression, and loss of relationships, making them at higher risk for suicide. Elders are less likely to give warning signs of suicide.

TEEN SUICIDE AND THE FAMILY

Since the 1980s the general incidence of suicide has increased in the United States; the rate for those between the ages of fifteen and twenty-four has tripled. Although suicide among adolescents is seriously underreported, researchers generally consider it to be the second- or third-most common cause of death in that group. More than eight out of ten kids who threaten suicide attempt it; females make more suicide attempts, although more males complete suicide, with firearms or explosives the most common method of self-destruction. Half of all children who have made one suicide attempt will make another, sometimes as many as two a year until they succeed. The majority of suicide attempts are expressions of extreme distress and not merely bids for attention; this distress is often related to others prior to suicide. Additionally, some children who take their own lives are indeed the opposite of the rebellious teen. They are anxious, insecure kids who have a desperate desire to be liked, to fit in, and do well. Their expectations are so high that they demand too much of themselves, thereby condemning themselves to constant disappointment. A traumatic event (such as the loss of a valued relationship or a change of residence), which can seem minor viewed from an adult perspective, is enough to push children and adolescents over the edge into a severe depression. Alcohol and drug use are associated with heightened suicide risk in youth.

The role of the family is also a variable in teen suicide. Two-thirds of suicidal teens report poor relationships with their parents. Increased levels of suicidal behavior in adolescents is associated with certain family characteristics: rigid rules, poor communication, overbearing parents, and long-term patterns of family dysfunction such as alcoholism and mental illness.

PHYSICIAN-ASSISTED SUICIDE

In some cases an individual may be too incapacitated by illness to end his or her life without assistance. The ethics of physician-assisted suicide, or euthanasia, has been the subject of vigorous debate. Active euthanasia refers to direct action being used to end a life; passive euthanasia refers to not taking steps to prolong life or letting die. Some argue that active euthanasia respects the principle of individual autonomy and the right to self-determination, that its foremost concert is the patients well-being, and that it adheres to the physicians Hippocratic Oath to do no harm, where doing no harm means alleviating pain and respecting the wishes of a rational person. Many argue that a decision to kill oneself with the assistance of a physician is a private choice that society has no right to regulate; others argue that assisted suicide threatens the moral foundations of society.

INTERNATIONAL DEMOGRAPHIC DATA

Suicide rates vary from nation to nation, with Belarus, Estonia, Hungary, Kazakhstan, and the Russian Federation having the highest suicide rates in the world. Suicide rates for men are substantially higher in all countries and are also high for indigenous populations who have been exploited, discriminated against, and deprived of their previous cultural existence. China is undergoing a national suicide crisis, with 21 percent of the worlds population, 44 percent of the worlds suicides, and 56 percent of the worlds female suicides. Those in China at a higher risk of suicide live in rural areas or areas where the government has policies that have increased stress through the disruption of traditional family patterns. Some argue that this level of suicidal behavior has changed attitudes in China about suicide, with self-destruction coming to be seen as an acceptable action.

OTHER MANIFESTATIONS OF SUICIDE

Suicide can also occur as a group response to extreme situations, notable examples being the mass suicide at the Masada fortress in 73 CE by besieged Jews choosing death over defeat by the Romans; the Jonestown cults mass murder-suicides in Guyana in 1978; and the Heavens Gate cult suicides in southern California in 1997.

Suicide bombings by terrorist groups became a phenomenon in the late twentieth century. Terrorism constitutes random acts of violence or the threat of such violence as a political or religious strategy, and suicide bombing is one of these strategies. The attacks of September 11, 2001, show how self-destruction can be used as a weapon.

The act of suicide has been interpreted in many ways and given various meanings. In Christianity and Judaism, suicide is sinful and forbidden. Historically, many societies have viewed suicide as a crime and have enacted laws to regulate the act and punish those who attempt it. Those who attempt or commit suicide have often been seen as psychotic or mentally ill; by contrast, in some cultures suicide is viewed as an honorable and glorious death. Some approve of suicide when it is seen as the only option left to alleviate pain and suffering from severe illness. Freud understood suicide as a drive or death instinct; from an existentialist standpoint, suicide removes the necessary choice for authentic existence.

SEE ALSO Alienation; Alienation-Anomie; Assisted Death; Death and Dying; Depression, Psychological; Durkheim, Émile; Euthanasia and Assisted Suicide; Morbidity and Mortality; Native Americans; Suicide Bombers

BIBLIOGRAPHY

Beckerman, N. L. 1995. Suicide in Relation to AIDS. Death Studies 19 (3): 223234.

Brock, Dan W. 1994. Voluntary Active Euthanasia. In Contemporary Issues in Bioethics, 4th ed., eds. Tom L. Beauchamp and LeRoy Walters. Belmont, CA: Wadsworth.

Colt, George Holt. 1991. The Enigma of Suicide. New York: Summit.

Conwell, Y. 2001. Suicide in Later Life: A Review and Recommendation for Prevention. Suicide and Life-Threatening Behavior 31 (Suppl.): 3247.

Crosby, A. E., M. P. Cheltenham, and J. J. Sacks. 1999. Incidence of Suicide Ideation and Behavior in the United States, 1994. Suicide and Life-Threatening Behavior 29 (2): 131140.

Durkheim, Émile. 1951. Suicide. Trans. John A. Spaulding and George Simpson, ed. George Simpson. Glencoe, IL: Free Press.

Freud, Sigmund. [1917] 1959. Mourning and Melancholia. In Collected Papers. Trans. Joan Riviere, Vol. 4, 152172. New York: Basic Books.

Hendin, Herbert. 1995. Suicide in America, expanded ed. New York: Norton.

Kastenbaum, Robert. 2000. The Psychology of Death. 3rd ed. New York: Springer.

Kochanek, Kenneth D., et al. 2004. Deaths: Final Data for 2002. National Vital Statistics Report 53 (5). Hyattsville, MD: National Center for Health Statistics.

Leenaars, Anton A., and Susanne Wenckstern. 1991. Suicide Prevention in Schools. New York: Hemisphere.

Mancinelli, I., A. Comparelli, P. Girardi, and R. Tatarelli. 2002. Mass Suicide: Historical and Psychodynamic Considerations. Suicide and Life-Threatening Behavior 32 (1): 91100.

Minois, Georges. 1999. History of Suicide: Voluntary Death in Western Culture. Trans. Lydia G. Cochrane. Baltimore, MD: Johns Hopkins University Press.

Murray, Alexander. 19982000. Suicide in the Middle Ages. 2 vols. Oxford and New York: Oxford University Press.

National Household Survey on Drug Abuse. 2002. Substance Use and the Risk of Suicide Among Youths. http://www.oas.samhsa.gov/2k2/suicide/suicide.htm.

National Vital Statistics Reports: Deaths (2002). http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_10.pdf.

Osgood, Nancy J. 1992. Suicide in Later Life. New York: Lexington.

Pedahzur, Ami. 2004. Suicide Terrorism. Cambridge, U.K.: Polity Press.

Pellegrino, Edmund D. 1994. The Virtuous Physician and the Ethics of Medicine. In Contemporary Issues in Bioethics, 4th ed., eds. To m L. Beauchamp and LeRoy Walters. Belmont, CA: Wadsworth, 1994.

Phillips, M. R., H. Liu, and Y. Zhang. 1999. Suicide and Social Change in China. Medicine and Psychiatry 23 (1): 2550.

Rachels, James. 1994. The Distinction between Active Killing and Allowing to Die. In Contemporary Issues in Bioethics, 4th ed., eds. To m L. Beauchamp and LeRoy Walters. Belmont, CA: Wadsworth.

Reisman, David. [1961] 2000. The Lonely Crowd. New Haven, CT: Yale University Press.

Reuter, Christoph. 2002. My Life Is a Weapon: A Modern History of Suicide Bombing. Trans. Helena Ragg-Kirkby. Princeton, NJ: Princeton University Press.

Ryan Ashley Caldwell

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Suicide

SUICIDE

SUICIDE. When early modern authors and intellectuals considered the topic of suicide, they started out with one salient contrast in mind: Whereas the ancient Greeks and Romans had often approved of suicide, Christians did not. For many, this contrast illustrated the superiority of Christian thinking, but throughout the Renaissance and into the seventeenth century, some who admired the ancients drew a more nuanced set of conclusions. Thomas More's Utopia (1516), for example, presents voluntary euthanasia for the terminally ill in a favorable light, although More condemned suicide vigorously in other works. The bishop of Guadix, Antonio de Guevara, took inspiration from the heroic suicides of classical antiquity (for example, Cato, Diogenes, Zeno, Lucretia, Seneca) and praised the nobility of barbarians who did not overvalue life in this world. Similarly, Michel de Montaigne touched on the question of suicide repeatedly and in "A Custom of the Island of Cea" considered the topic at considerable length, thoughtfully assembling moral, religious, social, and legal views. Although he admired the deaths of the noble ancients, he was reluctant to give his blanket approval to all who sought to escape shame or pain through suicide, and in the end he thought one might kill oneself only as a last resort to avoid intense pain or torture.

Shakespeare's characters commit suicide with remarkable frequency (there are fifty-two cases in his plays), and Hamlet's soliloquy ("To be or not to be") dwells on the topic, presenting arguments both for and against (although ignoring specifically Christian objections), before concluding, famously, that the future was too murky to make self-murder a safe option. In other plays Shakespeare presents suicide as the result of tragic misunderstanding (Romeo and Juliet) or as grand examples of freedom or despair (Julius Caesar, Antony and Cleopatra, and Othello). In 1610 John Donne went further, arguing in Biathanatos that sometimes suicide was justified or at least excusable. He did not proceed, as others had, from the example of ancient worthies but specifically considered the Christian grounds for condemning suicide. In a nutshell, he concluded that suicide did not necessarily and always violate the laws of nature, reason, or God. Despite the daring independence of this view, Donne forbade the publication of his book, and it only appeared in print in 1647, sixteen years after his death. This fact illustrates the ongoing and deep anxiety early modern Christians felt about suicide as both a crime and as the result of despair, the ultimate sin. Usually Protestants and Catholics united to condemn "self-murder" and to depict the devil as the prime mover or inspiration for most cases of self-destruction. As a result, throughout early modern Europe, suicides were denied burial in hallowed ground and often suffered desecration of their corpses. The worldly goods of suicides were sometimes confiscated by the crown, as was the case in England and Scotland.

In the seventeenth and eighteenth centuries, however, this legal and moral position decayed, not so much because suicide became positively defensible but more commonly because it seemed increasingly to be the result of melancholy madness. Moralists and theologians had regularly made provision for a sort of insanity defense of suicide. They viewed both sin and crime as actions that proceeded from free and voluntary decisions; condemning actions one could not prevent or avoid did not seem to make moral sense. Indeed, Martin Luther had carried this point so far that he thought suicides were driven to their deaths by the devil, thus extinguishing human responsibility: "I have known many cases of this kind, and I have had reason to think in most of them, that the parties were killed, directly and immediately killed by the devil, in the same way that a traveler is killed by a brigand." Most theologians, however, understood the role of the devil as that of a tempter or seducer, and therefore left ample room for the harsh condemnation of suicide, as long as it seemed clear that the victim had acted deliberately, intentionally, or voluntarily.

THE SECULARIZATION OF SUICIDE

By the late seventeenth century, suicide began to seem so alien to right reason, so much the product of melancholy or delusion (what we might call acute depression), that coroners, villagers, pastors, and magistrates were prepared to grant decent (even if quiet) burials inside the churchyard. Townsmen and villagers alike might also (as in England and Scotland) unite to portray a suspicious death as the result of illness or accident in order to circumvent the crown's efforts to confiscate a victim's estate, a move that usually added to the burdens on local poor relief. Thus from about 1650 onwards, we can mark the "secularization of suicide," that is, the development of medical or other naturalizing explanations and excuses for suicide. This evolution of public sentiment was supplemented during the eighteenth century by the moral philosophizing of the Enlightenment. Montesquieu's Persian Letters (1721), for example, sharply criticized the condemnation of suicide. Voltaire went further and saw suicide as a question of liberty. It could not harm God or society, in his view, to exit the world when one could no longer enjoy life or contribute to the welfare of others. David Hume also defended an individual's absolute right to suicide. Despite hesitations and equivocations, however, many philosophes were drawn to the medical conclusion that suicide was usually the result of madness or bodily disturbances.

THE SOCIAL HISTORY OF SUICIDE

Broadly speaking, this array of opinions on suicide has been well known and well described for several generations. In recent years, scholars have renewed their attention to suicide and have made several noteworthy contributions, not so much to high religious or intellectual history, but to the sociology or social distribution and cultural understandings of suicide. In this work they have often taken inspiration from the foundational work of Émile Durkheim, Le suicide (1897), which tried to demonstrate that social dynamics account for almost all the statistical variations in suicide found in modern countries. Roughly stated, Durkheim held that higher rates of suicide were prompted by increasing conditions of social isolation, so that tight webs of social support served to protect populations from the effects of urbanization, individualism, migration, and other conditions of modernity. It seemed to make sense, from this point of view, that Protestants (as part of a "modern," "secularizing," and "individualizing" movement) should always and everywhere have higher rates of suicide than presumably more traditional and more socially cohesive Catholics. This schema has inspired a great deal of modern sociological investigation, and recently scholars have extended these efforts to the early modern period. However, one supreme difficulty has been that neither the numbers of suicides nor early modern populations were reliably recorded, making the calculation of a suicide rate (the number of suicides per 100,000 population) doubly problematic.

Suicide in Britain and Germany. After an extraordinary and energetic attempt to count the number of suicides in early modern England, for example, Terence Murphy and Michael MacDonald abandon the task of calculating the varying suicide rate from place to place and from time to time, turning instead to an examination of the varying meanings of suicide. In an excellent study of suicide in far northern Germany, Vera Lind draws similar conclusions, heaping criticism on those who have imagined that medieval or early modern rates of self-murder could be calculated unproblematically. In a vast and complex survey, Alexander Murray draws the same conclusion with respect to medieval Europe, but then curiously hazards the guess that whatever the medieval rate may have been, suicide became far more common in the sixteenth century.

Suicide in Switzerland. The most impressive recent attempt to scrutinize all the suicides in a fairly controlled population is Jeffrey Watt's study of early modern Geneva, where suicide remained rare until the end of the seventeenth century and then increased slowly in the early eighteenth century. After 1750, however, the rate jumped up by a factor of five or more, and it went even higher after 1780. Watt has been careful to count not only those cases regarded as suicide by the Genevan authorities, but to look for "disguised" suicides as well, deaths from falls or from drowning that may well have been self-inflicted even if contemporaries declined to label them self-murder. Watt's evidence is so rich and so complete that, at least for this city, a genuine suicide rate can probably be calculated. Recognizing a dramatic escalation after 1750 seems unavoidable. Rejecting an easy equation of Calvinism with higher rates of suicide, however, Watt points out that Geneva during the Reformation had promoted just as tight an integration of society as in any Catholic city or principality. Yet by the late eighteenth century, Genevans from top to bottom had grown more secular in their attitudes, abandoning belief in the devil and often in hell as well. These processes may have developed more quickly or more profoundly for men than for women, which might explain why the disproportion of male suicides became even more pronounced after 1750. On this reading, growing secularization accomplished more than just the decriminalization or medicalization of suicide; increasingly a more secular society relaxed its supportive web as well as its sanctions against self-killing. Taking one's own life became far easier to contemplate.

This finding runs counter to the conclusion of a study of suicide in Zurich, in which Markus Schär connects the rapidly escalating numbers of self-inflicted deaths in the eighteenth century not with increasingly secular attitudes but with the growth of acute religious despair among people who doubted that they could ever gain God's mercy. Oddly enough, however, both Watt and Schär agree in emphasizing the importance of religious and cultural changes, rather than social changes (such as demography, economy, and urbanization), as crucial stimulants to suicide.

THE EIGHTEENTH CENTURY

As far as eighteenth-century Europeans were concerned, England was the classic land of melancholy and suicide. In the absence of reliable comparative studies, it is not clear that this stereotype was fully deserved. It does seem certain, however, that suicide notes and newspaper publicity about recent suicides first proliferated in England, for reasons well explored by Murphy and MacDonald. In Germany, the popularity of Goethe's Sorrows of Young Werther (1774) led to a wave of widely publicized suicides supposedly inspired by the romantic death of that lovelorn protagonist. By the late eighteenth century suicide had been common enough that it seemed symptomatic of the cultural and social disruptions endured by nations undergoing rapid urbanization, industrialization, or secularization.

See also Death and Dying ; Madness and Melancholy ; Religious Piety .

BIBLIOGRAPHY

Bernardini, Paolo. Literature on Suicide, 15161815: A Bibliographical Essay. Lewiston, N.Y., 1996.

Donne, John. Biathanatos. Edited by Ernest W. Sullivan II. Newark, Del., and London, 1984.

Jansson, Arne. From Swords to Sorrow: Homicide and Suicide in Early Modern Stockholm. Stockholm, 1998.

Lind, Vera. Selbstmord in der frühen Neuzeit: Diskurs, Lebenswelt und kultureller Wandel am Beispiel der Herzogtümer Schleswig und Holstein. Göttingen, 1999.

Minois, Georges. The History of Suicide. Translated by L. Cochrane. Baltimore, 1999.

Murphy, Terence R., and Michael MacDonald. Sleepless Souls: Suicide in Early Modern England. Oxford, 1990.

Murray, Alexander. Suicide in the Middle Ages. 2 vols. Oxford, 1998, 2000.

Schär, Markus. Seelennöte der Untertanen: Selbstmord, Melancholie und Religion im Alten Zürich, 15001800. Zurich, 1985.

Watt, Jeffrey R. Choosing Death: Suicide and Calvinism in Early Modern Geneva. Kirksville, Mo., 2001.

H. C. Erik Midelfort

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Suicide and Suicidal Behavior

Suicide and suicidal behavior

Definition

Suicide is the act of ending one's own life. Suicidal behavior are thoughts or tendencies that put a person at risk for committing suicide.

Description

Suicide, attempted suicide, and thoughts of committing suicide are, as of the early 2000s, growing problems among adolescents in the United States and much of the world. It is the third leading cause of death among 15 to 19 year olds in the United States and the sixth leading cause of death among 10 to 14 year olds. About 2 percent of adolescent girls and 1 percent of adolescent boys attempt suicide each year in the United States. Another 5 to 10 percent of children and teens each year come up with a plan to commit suicide.

Psychologists have identified the teenage years as one of the most difficult phases of human life. Although they are often seen as a time in which to enjoy life, hang out with friends, and perform other activities that adults would not usually do, the teenage period can be difficult. Many changes in the human mind take place during puberty . Apart from facing the onset of sexual maturity, teenagers must also make key decisions about their future, develop their identities, change schools, and meet new friends. They may have to cope with a wide range of personal and social challenges. Many young people have difficulty dealing with stress these experiences may elicit.

The most common reasons for suicide or suicidal behavior among children and adolescents involve personal conflict or loss, most frequently with parents or romantic attachments. Family discord, physical or sexual abuse, and an upcoming legal or disciplinary crisis are also commonly associated with completed and attempted suicide. Adolescents who complete suicide show relatively high suicidal intent, and many are intoxicated at the time of death. The most serious suicide attempters leave suicide notes, show evidence of planning, and use an irreversible method, such as a gunshot to the head. Most adolescent suicide attempts, though, are of relatively low intent and lethality, and only a small number of these individuals actually want to die. Usually, suicide attempters want to escape psychological pain or unbearable circumstances, gain attention, influence others, or communicate strong feelings, such as anger or love.

Suicidal behavior is rare in children prior to puberty, probably because of their relative inability to plan and execute a suicide attempt. Psychiatric risk factors, such as depression and substance abuse, become more frequent in adolescence , contributing to the increase in the frequency of suicidal behavior in older children. Some view the transition from primary to middle school as particularly stressful, especially for girls. Also, parental monitoring and supervision decrease with increasing age, so that adolescents may be more likely to experience emotional difficulties without their parents' knowledge.

Repeated suicide attempts are common, but rates vary. Follow-up studies ranging from one to 12 years found a re-attempt rate among adolescents of 5 to 6 percent per year, with the greatest risk within the first three months after the initial attempt. Factors associated with a higher re-attempt rate included chronic and severe psychiatric disorders, such as depression and substance abuse; hostility and aggression; non-compliance with treatment; poor levels of social skills; family discord, neglect, or abuse; and parental psychiatric disorders.

Highest risk

Four out of five teenagers who successfully commit suicide are male, but the average female teenager is prone to attempt suicide four more times during her teen years than the average male. White teenage males are more likely to commit suicide than other ethnic groups, but as of the early 2000s teenage suicide among blacks is also increasing. Teenagers who have unsuccessfully tried to commit suicide in the past are more likely to attempt suicide in the future. The odds increase after each failed attempt. There are two groups of teens that are at a particularly high risk for committing suicide: Native Americans, and gay, lesbian, bisexual, and transgendered teens.

In Native American, including Native Alaskan, youth ages 15 to 24 years, suicide is the second leading cause of death, according to a 2001 survey by the Bureau of Indian Affairs. The survey also showed that 16 percent of Native American youth attempted suicide in the preceding year. Among Native American high school students, suicide attempts were most associated with poor school performance, poor physical health, a history of family or friends who committed or attempted suicide, family problems, and physical and sexual abuse.

Gay and bisexual male teens, which represent about 10 percent of the male teen population, are six to seven times more at risk for attempting suicide than their heterosexual peers. Several surveys show gay and lesbian youth account for 30 percent of all suicides among teens, according to the U.S. Department of Health and Human Services. Yet most studies of teen suicide have not been concerned with identifying sexual orientation.

A 1997 study by the Massachusetts Department of Education found that 46 percent of high school students who identified themselves as gay, lesbian, or bisexual, had attempted suicide in the past year compared to 8.8 percent of their heterosexual peers. Of the gay, lesbian, and bisexual teens, 23.5 percent required medical care as a result of their suicide attempt compared to 3.3 percent of heterosexual students who attempted suicide.

Common problems

The following are common risk factors for teenage suicide:

  • Psychological problems: Depression, previous attempts at suicide, and having received psychiatric care in the past.
  • Personal failure: Unmet high standards set by the teen or parents, including failing grades in school or poor performance in sports.
  • Recent loss: Death of a close friend or family member, divorce , abandonment by a parent, pregnancy, and the breakup with a boyfriend or girlfriend.
  • Substance abuse: Abuse of alcohol and other drugs as forms of self-medication for overwhelming depression. A combination of depression, substance abuse, and lowered impulse control can lead to suicide or attempted suicide. Substance abuse in other family members can also lead to suicide.
  • Household guns: Easy access to a gun. Children of law enforcement officers have a much higher suicide rate because of the accessibility of guns in their houses. The most common method of suicide among teens is gunshot.
  • Violence: Violence against the teen either at home or outside the home, including physical, emotional, or sexual abuse, or bullying. Violence at home or against the youth teaches teens that the way to resolve conflict is through violence, and suicide is the ultimate act of self-violence.
  • Communication problems: The inability to discuss anger or other uncomfortable feelings with family members or friends. These feelings can include loneliness, rejection, and awareness of one's gay or bisexual sexual orientation.

Parental concerns

Parents who are concerned that their child is or may be suicidal should seek help immediately, such as from a psychiatrist, psychologist, or counselor. Therapists and counselors can listen to the child talk about his or her problems and may be able to suggest ways to cope which the teen will find useful.

There are a number of ways parents can help children and teens deal with loneliness, depression, and suicidal feelings. First, they can let the child do the talking, and listen carefully. They can let the child know they take his or her feelings and thoughts seriously. They can try to identify the root of the problem. Second, they can ask direct questions, such as "Are you thinking of committing suicide?" or "Are you thinking of ending your life?" Third, they can stay with the child. Parents should not leave their child alone if the child says he or she wants to commit suicide. By staying with the child, the parent may be protecting the child's life.

When to call the doctor

Many doctors recommend that teenagers be taken to a hospital immediately after they express the desire to commit suicide. At the least, immediate psychological help should be sought. There are many methods, both medical and psychological, of helping teenagers who consider committing suicide. Most teenagers who think of suicide believe their problems are too hard to solve or too embarrassing to talk about, so it is important for their helpers to show they are trustworthy and able to listen. Seeing a psychologist is widely recommended as well. A psychologist may be able to improve a teenager's vision of life by listening to the young person and conveying optimism regarding the future.

Doctors recommend that helpers not ask the teenager's reason for thinking of suicide; rather, helpers should listen and wait for the teenager to trust enough to talk openly about the problem. Helpers should, however, be understanding of the teenager's situation. Doctors also recommend that helpers not mention "reasons for living," as doing so might generate more depressing thoughts in the teenager.

There are many telephone hot lines available, on national, state, and local levels, to help teenagers who are considering suicide. Two national, 24-hour, toll-free suicide hotlines are: 8007842433 and 8009999999. Gay, lesbian, bisexual, or transgendered teens thinking of suicide can get help at 8008508078.

KEY TERMS

Puberty The point in development when the ability to reproduce begins. The gonads begin to function and secondary sexual characteristics begin to appear.

Transgendered Any person who feels their assigned gender does not completely or adequately reflect their internal gender, such as a biological male who perceives himself to be female.

Resources

BOOKS

Empfield, Maureen, and Nicholas Bakalar. Understanding Teenage Depression: A Guide to Diagnosis, Treatment, and Management. New York: Owl Books, 2001.

King, Robert A., et al. Suicide in Children and Adolescents. Cambridge, UK: Cambridge University Press, 2003.

Spirito, Anthony, and James C. Overholser. Evaluating and Treating Adolescent Suicide Attempters: From Research to Practice. New York: Academic Press, 2002.

Wallerstein, Claire. Need to Know: Teenage Suicide. Portsmouth, NH: Heinemann Educational Books, 2003.

PERIODICALS

Eckert, Tanya L., et al. "Adolescent Suicide Prevention: School Psychologists' Acceptability of School-based Programs." School Psychology Review (Winter 2003): 5776.

Fritz, Gregory K. "Prevention of Child and Adolescent Suicide." The Brown University Child and Adolescent Behavior Letter (September 2001): 8.

Norton, Patrice G. W. "Prevention Plan Reduces Teen Suicide Attempts." Clinical Psychiatry News (May 2004): 44.

Perlstein, Steve. "TeenScreen Flags Adolescents at Risk of Suicide." Clinical Psychiatry News (April 2004): 43.

Portes, Pedro R., et al. "Understanding Adolescent Suicide: A Psycho-social Interpretation of Developmental and Contextual Factors." Adolescence (Winter 2002): 805814.

ORGANIZATIONS

American Association of Suicidology. 4201 Connecticut Ave. NW, Suite 408, Washington, DC 20008. Web site: <www.suicidology.org>.

Suicide Awareness Voices of Education. 7317 Cahill Road, Suite 207, Minneapolis, MN 55424. Web site: <www.save.org>.

Yellow Ribbon International Suicide Prevention Program. PO Box 644, Westminster, CO 80036. Web site: <www.yellowribbon.org>.

WEB SITES

Columbia University. TeenScreen, 2003. Available online at <www.teenscreen.org> (accessed August 12, 2004).

"Depression and Suicide Page," 2004. Available online at <www.teenlineonline.org/helparchives/depression.htm> (accessed August 12, 2004).

Screening for Mental Health, Inc. "SOS High School Suicide Prevention Program", 2004. Available online at <www.mentalhealthscreening.org/sos_highschool/> (accessed August 12, 2004).

Ken R. Wells

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Suicide

SUICIDE.

The word suicide is a seventeenth-century English invention put together from Latin elements and meaning literally "self-slaughter," and from English the word spread to other European languages. An isolated scholar around 1179 had in fact coined a Latin word suicida, but it had not gained currency, and that fact highlights the question why so ancient an act should have had to wait so long for a name.

Taboo

One reason was taboo. People did not want to talk about suicide and, when they had to, used composite expressions like the medieval lawyers' "homicide (or felony) of oneself," or others, tinged with euphemism, like "to hasten death," "to die by one's own hand" (to quote from over a dozen expressions in classical Latin). A second reason, linked with the first, was an enduring difficulty in understanding the character of suicide. This is best seen in the history of a much older word, the Greek biaiothanatos. It literally meant "violent death" and included suicide along with deaths we would classify as accidents, like falling from a bridge, all of which were thought polluting, and had consequences for burial and for the dead person's status as a ghost. Although the Latinized successor-word, biothanatos, came increasingly to be confined to suicide, it still carried the old ambiguity as late as the twelfth century. The slowness of that discovery is confirmed by early legal texts, where rabbis, Christian canon lawyers, and commentators on the Koran all, in their turn, insist that it is intention that distinguishes suicideas if people did not know.

So the mere linguistic history of suicide already reveals a lot about how it was conceived. It suggests, further, that the taboo extended beyond the topic to the act of suicide, however vaguely distinguished. Religion absorbed the taboo, and in time gave it force and rationale. Already in Greek antiquity we find indignities attached to the burial of suicides, so understood. Similarly, as ideas of hell became better defined, we find suicides assigned to it, first (this time) in India.

Rationale

As for rationale, it drew on two kinds of source, divine and social. Around the sixth century b.c.e., Pythagoreans taught that we mortals are on sentry duty and bound to stay at our watch until relieved, an image that clearly implied man's obligation to superior powers, sovereign beyond death. The image would be absorbed by Plato and his innumerable readers, who in the later Roman Empire included Neoplatonists and Christians, both of whom used it, with other borrowings, to fortify their faintly equivocal traditions. For the Christian tradition had until then itself been uncertain. In the Bible, keen eyesight is needed to find suicide expressly forbidden (as perhaps in Gen. 9:5 or Exod. 20:13). And although most suicides in the BibleJudas the most notoriousare manifest villains, a "suicide guerilla" had slipped in among biblical heroes around the tenth century b.c.e., in the person of Samson (Judg. 16:1830), and was joined around 70 b.c.e. by another hero, Razias, who had killed himself after military defeat, in the Roman manner (2 Macc. 14:4346). The early church furthermore revered as saints certain women who had killed themselves to avoid rape. In the fourth century c.e., Christian opinion formers set about closing these loopholes, notably Pachomius (in respect of burial ritual) and Augustine (in argument). A few centuries later, Muslim commentators would do the same for the Koran, whose deficiencies in this particular were amply supplied by the Hadith (tradition).

A second main source for an antisuicide rationale was social. Aristotle had explained the Athenians' mutilation of suicides' corpses on the ground that a suicide had injured his polis (an argument to be seized on gratefully by Christian theologians in the later Middle Ages, when Aristotle became available in Latin). The Jews, for their part, told sympathetically (in Tobit, c. 200 b.c.e.) of a woman restrained from suicide by the thought that it would hurt her father. Even suicide-prone Roman Stoics could be restrained by consideration for their friends. Illiterates meanwhile expressed their social feelings on the subject by ideas about pollution of the community cemetery and bad weather. Finally, social considerations could express themselves on the vertical plane, from master to dependent. A Roman slave who killed himself robbed his owner, who might make him an example by maltreating the corpse. In early medieval Europewhen nearly everyone was someone else's dependentlords would punish an underling's suicide by confiscating the property. That prerogative gradually passed to monarchs. That suicide was in England classed as a felony until 1961 probably owed its origin to the defiance it had represented, in the early Middle Ages, to the king qua lord.

Justifications of Suicide

Condemnation of suicide, though widespread, has been far from universal. In all kinds of society, including preliterate kinds in Africa and America, communities with a suicide taboo can sometimes be found alongside others without. At least in more advanced cultures, two kinds of milieu have bred acceptance of suicide. One is military. In 1897 Émile Durkheim's classic, Suicide, recorded abnormally high rates among military officers. Durkheim ascribed this to the military ethos, on grounds that soldiers are familiar with weapons and death and set a high premium on honor. The same factors have operated throughout history. Greek and Roman warrior-heroes like Ajax or Brutusnot to mention their opposite numbers among Germanic opponents of Romewere remembered honorably as falling on their swords after defeat. Off the battlefield, in a political climate similarly based on honor, members of the same class might kill themselves to vindicate their honor, as Lucretia and Cato did, winning post-humous glory as martyrs, respectively to chastity and republicanism. In the most intensely militarized cultures, suicide can become an institution, as with the hara-kiri ("belly-cutting") ritualized by samurai in twelfth-century Japan, and the kamikaze of their twentieth-century successors, who piloted torpedoes and bombs. A more complex case is that of warriors fighting for Semitic monotheisms, which frown on suicide. That Jewish warrior-suicide Razias would set a dilemma for Christian commentators, while Muhammad's condemnation of suicide came to sit uneasily with the martial ethos of early Islam, which could at its most extreme produce an offshoot like the Shurat ("sellers of their lives for God"), who plunged into battle against patently overwhelming odds.

The second tolerant milieu has been philosophy. The classical Greek kind of philosophy, still thriving, tends to resist taboos unjustified by reason; and reason alone cannot easily justify the taboo on suicide, as Hamlet found. It may indeed resent it, since, lacking unquestionable evidence of sensation beyond death, reason suggests that an unhappy life with no prospects is best ended. This train of thought was formally inaugurated by the Cynic Diogenes in the fourth century b.c.e. and survived under the capacious blanket of Roman Stoicism, whose philosophers argued that, just as we may quit a banquet if it becomes tedious, so, under the same condition, we mayindeed must, to be rationalquit the banquet of life; what we do is in any case up to us and no cause for disgrace or punishment. Among lasting effects of this view was the systematic erasure from classical Roman law of any stigma on suicide as such. Around the fourth century c.e. came a change of mood, of which Augustine's arguments were less a cause than a symptom. The philosophical current only began reemerging in the Renaissance, and more fully in the eighteenth-century Enlightenment, when it targeted, in particular, ancient rituals that aimed to disgrace a suicide's memory, usually to the prejudice of his family. After a series of skirmishesincluding a pan-European scandal at the romanticization of suicide in Goethe's novel Die Leiden des jungen Werthers (1774; The sufferings of young Werther)philosophical tolerance completed its conquest of European law during the twentieth century.

Quite a different philosophical tradition has meanwhile recommended suicide of a very strictly defined type. The same ancient Sanskrit texts that condemned suicide done through passion have allowed those ascetics who have overcome passion to sever its last roots by parting from their bodies, by the least passionate method available (say, by drowning in a sacred river or by starvation). Traces of this view have been present in Mediterranean history, and condemnation of suicide by the Semitic religions may owe some of its force to a defensive reaction, against the doctrine of what one early Koran commentator calls the "Indian fools."

While suicides form a minute proportion of the population (0.03 percent per annum is a fairly high figure), a study of their circumstances, as Durkheim and his successors have demonstrated, throws otherwise inaccessible light on the lives of everyone else. In the same way, while suicide commands only a small proportion of moral and legal theory, it raises inexhaustible questions, both of the casuistical kind about suicide as such and also, through those, about life itself.

See also Christianity ; Cynicism ; Judaism ; Stoicism .

bibliography

Bohannan, Paul, ed. African Homicide and Suicide. Princeton, N.J.: Princeton University Press, 1960.

Durkheim, Émile. Suicide: A Study in Sociology. Translated by John A. Spaulding and George Simpson. 1952. Reprint, New York: Free Press, 1989.

Halbwachs, Maurice. The Causes of Suicide. Translated by Harold Goldblatt. London: Routledge and Kegan Paul, 1978.

McManners, John. Death and the Enlightenment: Changing Attitudes to Death among Christians and Unbelievers in Eighteenth-Century France. Oxford: Oxford University Press, 1981.

Murray, Alexander. Suicide in the Middle Ages. 2 vols. Oxford: Oxford University Press, 1998, 2000.

Stack, Steven. "Suicide: A Decade Review of the Sociological Literature." Deviant Behaviour 4 (1982): 4166.

Thakur, Upendra. A History of Suicide in India. Delhi: Munshi Ram Manoharlal, 1963.

Alexander Murray

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Suicide

SUICIDE

Suicide is defined as the act of deliberately taking one's own life. It occurs most often in response to a crisis such as a death or the loss of a relationship or job. During a crisis people experience a wide range of feelings, and each person's response to crisis is different. It is normal to feel frightened or anxious or depressed. If a person feels overwhelmed or unable to cope, he or she may try to commit suicide.

Almost all people who kill themselves either suffered from depression or had substance abuse problems. People who are lonely and isolated or who have histories of previous suicide attempts are also at greater risk for attempting suicide.

In 1996, approximately 31,000 people died of suicide in the United States. Suicide is the eighth leading cause of death overall, and the third leading cause of death among American teenagers. In Canada, suicide is second only to motor-vehicle accidents as a cause of death among adolescents.

The suicide rate is twice the murder rate among those aged 15 to 24, and it has increased dramatically in recent years. Each year, two thousand adolescents commit suicide in the United States. The highest suicide rates in the United States are found in white men over age 85. Men are more than four times as likely as women to die by suicide, yet women are more likely to make a nonlethal suicide attempt.

Suicide is a major public health problem. The need for a public health approach to suicide can be found in the African-American community, where the suicide rate among youths more than doubled between 1980 and 1995. Further, the number of suicides in the United States outnumbered homicides in 1995. Each year, firearms are used as many times for suicide as they are for murder. In some other countries, 71 percent of all firearm deaths are suicide.

Attempted and completed suicides result in enormous social, economic, and medical costs. Suicide is very disruptive to the quality of life of survivors and their families and friends. In 1995 it was estimated that in the United States each suicide attempt costs approximately $33,000. The cost of a completed suicide has been estimated at almost $400,000. These estimates were derived from factors including the expense of hospitalization, medication, and more general social costs.

Public health professionals have a major role to play in addressing the problem of suicide. Public health programs and policies can play a part before, during, and after completed or attempted suicides. First, public health programs are an important aspect of the prevention of suicide. Education campaigns can be used to increase knowledge and to change people's attitudes, beliefs, and values about suicide, and about people who may have attempted suicide. People may have distorted ideas about suicidal persons. For example, it is a myth that people who commit suicide never talk about it first. Most people provide important warning signs that can help to reduce the risk of suicide.

Health education can be combined with counseling or support programs. These programs can be provided by trained public health professionals or by peer counselors. For example, teenagers can be trained to provide counseling and support for other teens. Suicide awareness or prevention programs can be delivered in a variety of settings such as schools, churches, or in the community as a whole. They can also be delivered in psychiatric settings.

A second aspect of the prevention of suicide lies in judging or assessing a person's risk for suicide. Public health professionals such as nurses or doctors can help to prevent completed suicides by identifying people who may be thinking about or planning to try to commit suicide. They can also provide support through crisis or suicide-prevention counseling.

Public health can also play a valuable role during a suicide attempt. A suicide attempt is often a person's response to a crisis, or to a time when they feel overwhelmed or hopeless. Public health professionals can help during a suicide attempt through suicide-prevention counseling. This type of short-term counseling involves providing support and guidance to an individual who is suicidal. Its purpose is to decrease the person's emotional pain, to make sure that the person is safe, and to help develop a plan for coping. Sometimes suicide-prevention counseling includes connecting a person to community or health services. These services can then provide longer-term support.

Suicide prevention counseling is a valuable tool for public health. It is relatively low-cost, flexible, and simple to provide. A wide variety of health professionals, including doctors, nurses, psychologists, and social workers, can be taught to help people with suicide-prevention counseling techniques. These services can be provided in a wide variety of places or settings, including hospitals, community clinics, and telephone-based crisis centers or helplines. Suicide-prevention services provide an important link between the community and the formal health care system.

Public health professionals who work in suicide prevention and counseling are faced with a growing variety of issues and clients. Most communities are home to an increased number of people from a wide variety of cultural and ethnic backgrounds. There are also more older people in society. New issues that might trigger a suicide attempt include elder abuse, racism or discrimination, bullying, or gay bashing. Police officers, firemen, paramedics, and others are being trained to deliver on-the-spot suicide prevention counseling.

There is also a role for public health following a completed or attempted suicide. A suicide attempt or death can have a traumatic effect on the quality of life of survivors and their families and friends. Public health programs can provide important support services to survivors of a suicide attempt and their families.

Public health is only one important part of society's response to suicide as a health and social problem. There is also a role for law enforcement, the education system, the government, and the formal health care system in prevention, treatment, and follow-up to a suicide attempt.

Law enforcement (police officers) and public health professionals can cooperate to help suicidal persons. Police officers are often the first ones on the scene of a suicide attempt. They may act to prevent a suicidal person from hurting themselves (or someone else) through suicide prevention counseling. The may detain someone who is at high risk for suicide and refer him or her to appropriate public health resources.

Legislators can also help to address the challenges of suicide by creating policies or laws to support the development of public health programs and the training of public health professionals. They can also work to change society's attitude toward suicide and suicidal people. One example of this type of work is the fact that in many countries suicide is no longer illegal. Attempting suicide is seen as a mental health issue, not a crime. In 1999 the United States Public Health Service issued the first-ever Surgeon General's Report on Mental Health, as well as a Call to Action on Suicide Prevention, charting out this new approach to suicide.

The educational and health care systems also have a role to play in the prevention, treatment, and follow-up to a suicide attempt. Schools provide access to most young people and provide a place for delivering suicide prevention or awareness programs. They can also teach young people to recognize the warning signs of a potential suicide attempt in their friends, to provide peer counseling, and how to get immediate help and support. This is important because young people are at higher risk of attempting suicide than most adults.

The formal health care system (hospitals, clinics, doctor's offices) can play an important role in two main ways. First, people who are suicidal may come to an emergency room or a physician's office. In these cases, the health system serves as a "first-response" and crisis service. Second, once a person has been identified by a public health or law enforcement professional as suicidal, they may need to be hospitalized for a period of time. Health professionals can provide medications and further counseling or support to a suicidal person and their family.

Once a suicidal person is released from a hospital, public health professionals may make home visits or provide follow-up support through a community-based clinic. The prevention of suicide and the provision of support to people who are suicidal play an important and increasing role in the health of individuals, families, and communities. The most comprehensive national strategies on suicide have been developed by Finland, Norway, Australia, New Zealand, and Sweden.

C. James Frankish

Robbin Jeffereys

(see also: Crisis Counseling; Gun Control; Hotlines, Helplines, Telephone Counseling; Mental Health; School Health; Social Work; Violence )

Bibliography

Carter, C., and Baume, P. (1999). "Suicide Prevention: A Public Health Approach." Australian and New Zealand Journal of Mental Health Nursing 8:4550.

Harwitz, D., and Ravizza, L. (2000). "Suicide and Depression." Emergency Medical Clinics of North America 18:263271.

Lester, D. "Estimating the True Economic Cost of Suicide." Perceptual and Master Skills 80:746.

Office of the Surgeon General (1999). Mental Health: A Report of the Surgeon General. Washington, DC: U.S. Public Health Service.

Potter, L. B.; Powell, K. P.; and Kachur, S. P. (1995). "Suicide Prevention from a Public Health Respective." Suicide and Life Threatening Behavior 25:8291.

U.S. Public Health Service (1999). The Surgeon General's Call to Action to Prevent Suicide. Washington, DC: U.S. Public Health Service.

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Suicide

Suicide


Suicide rarely occurs before age ten, and although suicide rates for ten to fourteen year olds and adolescents greatly increased in the United States between the mid-1970s and the mid-1980s, suicide rates for children and adolescents are lower than for other age groups. Nevertheless, by the end of the twentieth century, suicide was the second greatest cause of death in adolescents, after (mainly automobile-related) accidents. In children age ten to fourteen suicide is the third leading cause of death, following unintentional injuries and malignant neoplasms. In the United States, males age ten to fourteen die by suicide three times more than females, and males age fifteen to nineteen have five times more suicides than females. The difference between male and female suicide rates may be explained by males being more vulnerable, or it may be due to their preferences for more lethal methods, particularly firearms: gunshot wounds are the leading cause of suicide deaths in the United States for all age groups. For each person who dies by suicide (a "completed suicide") there are an estimated 50 to 100 suicide attempts. When people under age eighteen are asked if they have ever seriously attempted suicide, at least one out of twenty say that they have.

The Historical Problem

The contemporary concern about adolescent suicide raises a complex historical problem. First, how new is the pattern? We know that adolescents and very young adults committed suicide in the past. In Germany in the late 1700s, the publication of Die Leiden des jungen Werthers (The Sorrows of Werter ), a novel by Johann Wolfgang von Goethe, presumably spurred some suicides in young men who were attracted to death by the prevailing romantic culture. Studies of suicide in England in the late nineteenth century also reveal some adolescent suicides. It is unclear how much the current patterns reflect new developments, as opposed to new levels of attention and concern.

To the extent that there is change, the question then arises: what might the causes be? A culture permeated with images of violence, but in which children rarely experience death directly, is sometimes held accountable. New tensions at school and in peer groups may be involved, sometimes complemented by drug use. Suicide is closely linked, of course, to psychological depression, which also seems to be on the rise among young people.

Children's Understanding of Suicide

Although young children (less than ten to twelve years) rarely die by suicide, contemporary children develop an understanding of suicide at an early age, and their conceptions of suicide may influence their behaviors later in life, when they experience the vulnerabilities of adolescence.

Research indicates that by age seven or eight most children understand the concept of suicide, can use the word suicide, and can name several common methods of committing suicide. Young children, as young as age five and six, can understand and talk about killing themselves, even if they do not understand the word suicide. Children by age seven or eight report that they have talked about suicide with other children, and most have seen at least one fictional suicide on television. These suicides usually occur in cartoons in which the villain takes his or her own life when he or she has lost an important battle and has no way to escape. Children also experience suicide attempts and threats in adult television programs, including soap operas and the news. Despite children's knowledge of and exposure to the subject, they receive little guidance about it from adults.

Children age five to twelve generally have quite negative attitudes toward suicide; they consider suicide something that one should not do and generally feel that people do not have a right to kill themselves. When there is a suicide in the family or in the family of their friends, children usually know about the suicide, despite parents' attempts to hide the facts by avoiding talking about it or explaining that the death was an accident. For example, in studies conducted in Quebec, Canada, by Brian L. Mishara, 8 percent of children said that they knew someone who committed suicide, but none of the children said that they were told about the suicide by an adult. Surveys of parents found that 4 percent of children have threatened to kill themselves at some time but these threats are rarely taken seriously or discussed.

Children at a young age are curious about understanding death, and although they know that one can commit suicide, their view of what occurs when someone dies may be very different from an adult's understanding of death. However, children learn fairly early (generally by age seven or eight) that death is finalthat someone who dies may not come back to life. Younger children often believe that people who have died are able to see, hear, feel, and be aware of what living people are doing.

Suicidal Behavior in Children and Adolescents

Suicide is a relatively rare event that results from a combination of risk factors, usually a precipitating event combined with access to a means of committing suicide and a lack of appropriate help. Suicide is generally understood to be the result of complex interactions between developmental, individual, environmental, and biological circumstances. Despite the complexity of factors that may result in suicidal behavior, it is possible to identify children at risk.

Depression is a major risk factor for suicide, although depression symptoms in children may be difficult to recognize and diagnose. In prepubescent children, symptoms may include long-lasting sadness, frequent crying for no apparent reason or, conversely, inexpressive and unemotional behavior, including speaking in a monotone voice. Other signs include difficulty concentrating on schoolwork, lack of energy, social withdrawal, and isolation. Children and adolescents who threaten suicide or become interested in the means of killing themselves, such as tying nooses or playing suicide games or trying to acquire a firearm, should be considered as potential suicide risks.

The best way to verify the risk of suicide is to ask direct questions of the child. They might include the following: "Are you thinking of killing yourself?"; "have you thought about how you would kill yourself?"; "do you think you might really commit suicide?" Many adults hesitate to ask such questions because they are afraid they might "put ideas" in a child's head. However, decades of experience indicate that talking about suicide cannot suggest suicidal behavior to children and can only help children express their concerns to an adult.

It is also important to ask suicidal children what they think will happen when a person dies. If the child indicates that they think someone can return from the dead or that being dead is like being alive, it may be useful to correct that impression and describe with some details what it means to die.

Children who have symptoms of depression or threaten suicide may benefit from help from a mental-health professional. It is also important to talk with a child or adolescent when there is a suicide in the family or in the school environment. Most children already have a good understanding of what occurred and do not feel that this is appropriate behavior. However, in the event that the child glorifies or trivializes a death by suicide or feels that the suicide victim is "better off" after dying, it is important to clarify what occurred and, if necessary, seek counseling or professional help. It is also important to help children express their feelings about a loss by suicide, even if they include "unacceptable" feelings such as being angry at the suicide victim for having abandoned them. It is important to communicate that suicide is a tragic event that is usually generally avoidable and certainly is not beneficial for anyone.

See also: Drugs; Emotional Life; Mental Illness.

bibliography

Bailey, Victor. 1998. This Rash Act: Suicide across the Life Cycle in the Victorian City. Stanford, CA: Stanford University Press.

Kushner, Howard I. 1989. Self-Destruction in the Promised Land: A Psychocultural Biology of American Suicide. New Brunswick, NJ: Rutgers University Press.

Maris, Ronald W., Alan L. Berman, and Morton M. Silverman, eds. 2000. Contemporary Textbook of Suicidology. New York: Guilford Press.

Mishara, Brian L. 1999. "Conceptions of Death and Suicide: Empirical Investigations and Implications for Suicide Prevention." Suicide and Life-Threatening Behavior 29, no. 2: 105108.

World Health Organization. 2001. Preventing Suicide: A Resource for Primary Health Care Workers. Geneva: World Health Organization.

Brian L. Mishara

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Suicide

SUICIDE

The deliberate taking of one's own life.

Under common law, suicide, or the intentional taking of one's own life, was a felony that was punished by forfeiture of all the goods and chattels of the offender. Under modern U.S. law, suicide is no longer a crime. Some states, however, classify attempted suicide as a criminal act, but prosecutions are rare, especially when the offender is terminally ill. Instead, some jurisdictions

require a person who attempts suicide to undergo temporary hospitalization and psychological observation. A person who causes the death of an innocent bystander or would-be rescuer while in the process of attempting suicide may be guilty of murder or manslaughter.

More problematic is the situation in which someone helps another to commit suicide. Aiding or abetting a suicide or an attempted suicide is a crime in all states, but prosecutions are rare. Since the 1980s the question of whether physician-assisted suicide should be permitted for persons with terminal illnesses has been the subject of much debate, but as yet this issue has not been resolved.

The debate over physician-assisted suicide concerns persons with debilitating and painful terminal illnesses. Under current laws a doctor who assists a person's suicide could be charged with aiding and abetting suicide. Opponents of decriminalizing assisted suicide argue that decriminalization would lead to a "slippery slope" that would eventually result in doctors being allowed to assist persons who are not terminally ill to commit suicide.

The debate on physician-assisted suicide intensified after 1990 when Dr. jack kevorkian, a retired Michigan pathologist, began to attend many suicides. Kevorkian admitted to obtaining carbon monoxide and instructing persons who suffered from terminal or degenerative diseases on how to administer the gas so they would die. Despite the efforts of Michigan legislators and prosecutors to convict Kevorkian of murder, the pathologist, who was dubbed "Doctor Death," successfully fought the charges. Three murder charges were dismissed by Michigan courts, and in 1994 Kevorkian was acquitted of violating Michigan's assisted suicide law (Mich. Comp. Laws § 752.1021 et seq.). Despite Kevorkian's acquittals other assisted suicide advocates believe his methods have actually hurt the cause. In 1997 the U.S. Supreme Court held that neither the due process clause (washington v. glucksberg, 521 U.S. 702, 117 S. Ct. 2258, 138 L. Ed. 2d 772) nor the equal protection clause (Vacco v. Quill, 521 U.S. 743, 117 S. Ct. 2293, 138 L. Ed. 2d 834) of the fourteenth amendment includes a right to assisted suicide.

After four acquittals, Kevorkian was convicted in March 1999 of second-degree murder and delivery of a controlled substance by a jury in Pontiac, Michigan. Kevorkian administered a lethal injection in September 1998 to Thomas Youk, a 52-year-old man who suffered from amyotrophic lateral sclerosis, or Lou Gehrig's disease, a fatal neurological disorder that slowly disables its victims. Kevorkian performed the procedure on the CBS television program 60 Minutes amid great controversy.

At the time of his trial, Kevorkian represented himself, insisting that only he could explain to the jury that he did not intend to kill Youk but to end his suffering. The jury nevertheless reached a guilty verdict. Although he could have been sentenced to life in prison, he was sentenced to ten to 25 years in prison. He sought unsuccessfully for three years to appeal his conviction.

Kevorkian was not entirely alone in his crusade to legalize assisted suicide. In 1994, Oregon voters passed the Oregon Death with Dignity Act (DWDA), which allows physicians to prescribe lethal medication to Oregon residents who request it. The statute requires that the patient must be 18 years or older, must be able to make and communicate healthcare decisions, and have been diagnosed with a terminal illness that likely will result in death within six months. While physicians may make the prescription, patients must self-administer it, since the DWDA specifically prohibits "lethal injection, mercy killing, or active euthanasia." Oregon is the only jurisdiction in the world that has legalized physician-assisted suicide.

The Oregon legislature enacted the DWDA after residents voted in favor of the law twice, 51 percent in favor in 1994, then 60 percent in 1997. The law originally went into effect in 1994 but immediately was suspended by court injunctions pending legal challenges. After the Supreme Court rendered its decisions in Glucksberg and Vacco, the Ninth Circuit Court of Appeals lifted the injunction. The Oregon law went into effect on October 27, 1997.

Between 1998 and 2001, between 70 and 96 patients—the exact numbers are disputed—committed suicide under the act. In November 2001, U.S. attorney general john ashcroft issued a directive stating that physicians who prescribe lethal doses of drugs to end the lives of terminally ill patients would be subjected to criminal charges and have their medical licenses revoked or suspended. Ashcroft issued this directive pursuant to the Controlled Substances Act and reversed the position previously taken by former attorney general janet reno, who determined that the Oregon statute was outside the scope of the Controlled Substances Act. Members of Congress, including Senator Orrin Hatch (R-Utah) and Representative Henry Hyde (R-IL), also unsuccessfully sought to pass federal legislation that would have revoked the registration of Oregon physicians who participated in assisted suicide efforts.

In response to Ashcroft's order, the state of Oregon brought suit against the attorney general, seeking a permanent injunction to prevent him and the u.s. justice department from enforcing the directive. In April 2002, U.S. District Court Judge Robert E. Jones issued the injunction and also criticized Ashcroft for his handling of the directive. According to Jones, the Controlled Substances Act was not intended to override a state's decision concerning what constitutes legitimate medical practice, at least in the absence of federal law prohibiting such a practice. The judge also found that Congress never intended, through the Controlled Substances Act or other federal law, to grant blanket authority to the attorney general or the Drug Enforcement Agency to define what constitutes the legitimate practice of medicine.

The DWDA has strict requirements that are designed to prevent abuse of the act. Patients must make two verbal requests for lethal medication separated by at least 15 days, plus a written request. Two physicians must independently confirm that the patient has a terminal illness likely to result in death within six months and that the patient is capable to make and communicate healthcare decisions. If either physician believes the patient suffers from depression or any other psychiatric disorder, he or she must refer the patient for counseling. The prescribing physician must request, but not require, the patient to inform his or her next of kin of the suicide decision. The prescribing physician also must inform the patient of alternatives to suicide, including hospice care and pain control, and give the patient the opportunity to change his or her mind after the 15 day waiting period.

The strict DWDA requirements have not silenced its critics. Opponents in the medical community, including Physicians for Compassionate Care, believe that physician-assisted suicide is contrary to the profession's purpose—to promote health. Religious opponents, including the Roman Catholic Church, Mormons, and Christian fundamentalists, feel that suicide of any kind devalues life. Not Dead Yet, an organization of disabled persons, believes that states should instead enact legislation to improve access to health and hospice care, and the over-all quality of life, for terminally ill patients. Many opponents are concerned that poor or uneducated patients will be pressured by family members or the healthcare insurance industry to chose death over life with its medically expensive consequences.

To the supporters of physician-assisted suicide, the issue is a matter of personal autonomy and control. The Hemlock Society, an organization that supports physician-assisted suicide, claims that terminally ill patients must be allowed to end their lives voluntarily rather than suffer through the painful and disabling effects of a terminal illness.

cross-references

Death and Dying; Euthanasia; Patients' Rights; Physicians and Surgeons.

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suicide

suicide Current attitudes toward suicide derive from the debates of centuries long past. Aristotle condemned suicide on political grounds, arguing that the allegiance individuals owe to the state precludes them from taking their lives. Plato had likened the state to a parent in the Crito, a position which might seem to support a similar restriction of the individual's right to commit suicide. But Plato actually objected to self- destruction on religious grounds, claiming that human beings are the gods' possessions and risk punishment for daring to decide when to die. Nevertheless, a precedent for the right-to-die position may be found in the Phaedo, where Socrates argues against prolonging life at any cost.

The death of Socrates seemed to embody both reason and self control, qualities prized by the early Stoics, and euthanasia was practised among elderly members of the school. In theory, suicide was an option available to the Stoic at any time. In practice, however, only the first century statesman and philosopher Seneca glorified death to the point of advocating self-destruction as an end in itself. His own death at the command of the emperor Nero was entirely consistent with the principles he espoused. Witnesses described how he managed to stretch the event over the course of a full day, drinking wine and conversing with his friends while periodically opening his veins until he eventually bled to death. Seneca's willingness to end his career in cold blood earned the admiration of his contemporaries — and his was but one of the many heroic suicides that have come down to us from Roman antiquity. The legends of Lucretia, Cato, Brutus, Portia, Antony, and Cleopatra became models for the suicide of honour. To die for some higher ideal, for the sake of virtue, patriotism, or faith, as would become the case with the early Christians, was to make death a cause for celebration.

The Christian case against suicide was formally stated by St Augustine, who prohibited the act as a violation of the sixth commandment, ‘Thou shalt not kill’. But Augustine was actually ambivalent on the question of suicide, permitting it in instances where individuals behaved with divine sanction in ending their lives. This exception was necessary to allow for the voluntary sacrifice of Jesus, who freely chose to die on the cross for humanity's sins. In subsequent centuries the escape clause was widened to admit the martyrs of the early Church, whose sacrifices were essential to the mythology of medieval Christianity.

The Church policy regarding suicide that emerged during the Middle Ages was loosely based on Roman law. Picking up on ancient Greek traditions, the Romans had punished self- destruction, but only under certain conditions: when an individual killed himself to escape legal prosecution or in the case of a soldier or a slave. The act of suicide was not itself considered blameworthy. Rather, the suicide's civil status, combined with his presumed motivations — the cowardliness of the accused man who sought to pre-empt the law, the disobedience of the soldier or the audacity of the slave who disposed of a life that was not truly his — determined whether the act should be punished. (The legal status of Roman women was akin to that of the slave. An unmarried female was treated as her father's dependent; the pater familias held absolute power over his daughter's life. With marriage, this power was transferred to her husband.)

The Christian position was different. What made suicide a sin was its voluntary nature. Self- destruction was prohibited because it represented an individual's choice to do wrong, a deliberate challenge to divine authority. Following the publication of the Summa Theologiae of Thomas Aquinas, suicide came to be seen as a crime against society as well. Aquinas revived Aristotle's view of suicide as an act of political insubordination and also condemned self-destruction on the grounds that it went against the natural instinct for self-preservation. To the traditional religious objection, which served to deny the sinner a Christian burial, Aquinas thus added a provision which could be used to support the implementation of civil penalties against people who killed themselves. During the high Middle Ages, civil legislation against self-murder was enacted in the majority of Western European states. Under no circumstances were men or women permitted to sacrifice themselves without divine sanction or to place their needs above the needs of the community to which they belonged.

The Enlightenment brought into question the moral implications of self-destruction. For the eighteenth-century philosophes, the issue proved to be an effective weapon in their crusade against absolutism and the Christian religion. Voltaire and others revitalized the classical tradition in the name of rationalism and freedom, portraying Lucretius, Cicero, and Seneca — all advocates of the right to die — as early upholders of the secular cause. The Romantics turned self-destruction into a literary convention, further weakening the stigma attached to the act. Driven to despair by the death of their beloved or, worse still, loving and being loved by someone who belonged to another, countless characters in nineteenth-century fiction actively courted the solace which death alone could provide.

Suicide was decriminalized during the French Revolution, and neither Napoleon nor his monarchist successors reinstated the laws against it. And with the emergence of the psychiatric profession in the nineteenth century, the tendency to interpret the act as the inadvertent consequence of psychological problems, which could be diagnosed, treated, and cured, displaced the religious impulse to judge it in moral terms. Thus, while the Catholic Church continues to regard suicide as a sin, the modern inclination to attribute it to depression makes the deprivation of a religious funeral rare.

The greatest controversy today is over the question of assisted suicide. It is a felony to help someone commit suicide in Great Britain and in twenty-eight American states, but in neither country is it illegal to kill oneself. In effect, this means that only healthy people are allowed by the law to take their lives, since people who are seriously ill are often unable to kill themselves without assistance. Supporters of euthanasia aim to do nothing more than to decriminalize assisted suicide for the terminally ill, as has been done in the Netherlands. Opponents of the right to die range from Christian activists who invoke religious arguments against the taking of human life to physicians who think the need for assisted suicide would vanish with more effective strategies for pain management in the last months of life. On a policy level, some argue in favour of allocating limited health care resources toward people whose lives can be saved instead of prolonging the existence of someone already near death, particularly when that person no longer wishes to live. This line of argument has been criticized by those who envision the day when sick people will be hurried to their deaths for reasons of economic expediency.

Current thinking on suicide also owes much to the development of the social sciences, and to the work of Durkheim in particular. What distinguishes the sociological approach from the psychological is that it diminishes the importance of individual intentions in assessing the causes of suicide. Even the most private of human activities, the decision to end one's own life, turns out to be socially determined. Like other forms of collective behaviour, its incidence is governed by regular laws. To isolate the social factors conducive to high rates of self-destruction is the object of suicide prevention programmes today.

Lisa Lieberman

Bibliography

Kushner, H. I. (1989) Self-destruction in the Promised Land. Rutgers University Press, New Brunswick and London.
Lieberman, L. (2003) Leaving You: the cultural meaning of suicide. Ivan R. Dee, Chicago.


See also euthanasia.

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Suicide

SUICIDE

Suicide exists in all countries of the world and there are records of suicides dating back to the earliest historical records of humankind. In 2000 the World Health Organization estimated that approximately 1 million people commit suicide annually. Suicide is among the top ten causes of death and one of the three leading causes in the fifteen-to-thirty-five-years age group worldwide. In the United States, where suicide is the ninth leading cause of death (and where the number of victims is 50% higher than the number of homicides), the Surgeon General in 1999 issued a Call to Action to Prevent Suicide, labeling suicide "a significant public health problem."

Suicide is a tragic phenomenon that has preoccupied professionals from a variety of disciplines. Deaths by suicide have broad psychological and social impacts on families and societies throughout the world. On average, each suicide intimately affects at least six other people, and if the suicide occurs in the school or workplace it can significantly impact hundreds. Suicide's toll on the living has been estimated by the World Health Organization in terms of disability-adjusted life years, which indicates the number of healthy years of life lost to an illness or event. According to their calculations, the burden of suicide is equal to the burden of all wars and homicides throughout the world. Despite progress in controlling many other causes of death, suicide has been on the rise becoming one of the leading causes of death.

The taking of one's own life is the result of a complex interaction of psychological, sociological, environmental, genetic, and biological risk factors. Suicide is neither a disease nor the result of a disease or illness, but rather a desperate act by people who feel that ending their life is the only way to stop their interminable and intolerable suffering.

Despite the magnitude of social damage caused by suicide, it is a fairly rare event. Suicide rates of between 15 to 25 deaths per 100,000 population each year may be considered high. Most people who are seriously suicidal, even those who attempt suicide, rarely have a fatal outcome (although, in the United States, 500,000 people annually require emergency room treatment because of their attempts). For each completed suicide (a suicide that results in death) there are at least six or seven suicide attempts that result in hospitalizations and, according to community surveys, for each completed suicide at least 100 people report that they attempted suicide without being hospitalized as a suicide attempter. Furthermore, if one asks in a community survey if people seriously considered suicide, about one person in twenty-five says that they have done so.

Research shows that the vast majority, at least 80 percent, of persons who died by suicide had been or could be diagnosed as suffering from a mental disorder, usually mood disorders and depression. People who suffer from the mental disorders of depression and manic depression, alcoholism, or schizophrenia have between a 4 percent and 15 percent lifetime risk of suicide. These mental disorders do not "cause" suicide, but people with mental disorders are at much greater risk of committing suicide. For this reason, the diagnosis and treatment of mood disorders, alcoholism, and schizophrenia may prevent suicides.

Besides mental disorders, there are numerous other risk factors that help identify who is at greater risk of suicide. The most important risk factor is gender, with men in Europe and the Americas committing suicide about five times more than women even though women are more likely to attempt suicide. People with some physical illnesses have greater suicide risks. In most countries, men over the age of seventy-five have the greatest risk of suicide of all age groups. Those who live alone or are separated are more vulnerable to suicide, including divorced, widowed, and single people. Also at higher risk are individuals who have lost a job.

Various situational factors also increase the risk of suicide. Individuals who are exposed to suicide in real life or through the media have a higher like-lihood of suicidal behavior. Research on firearms and the availability of other means of suicide has shown that if a method is readily available a death by suicide is more likely to occur. For this reason control of firearms and reducing access to other preferred means of suicide, such as putting up barriers on bridges and getting rid of medications in the home of a suicidal adolescent, may help prevent suicides.

The crisis situation in which a person attempts or commits suicide is often precipitated by a stressful life event. Suicides are more likely to occur after an argument with family members or lovers following rejection or separation, financial loss and bereavement, job loss, retirement, or failure at school. Usually these events are "the last straw" for a suicidal person. They are generally not what caused the suicide but what resulted in an increased likelihood that the suicide would occur then.

People who consider suicide generally feel ambivalent about ending their own life. It is this ambivalence that leads desperately suicidal people to talk about their plans as they "cry for help." Telephone help lines, therapists, and friends strengthen the will to live of ambivalent people by helping them explore other options for changing their situation.

The psychoanalyst Edwin Shneidman described the mental state of suicidal individuals experiencing unendurable psychological pain and feelings of frustration. According to Shneidman, suicide is seen as the only solution to their problems, one that results in stopping intolerable feelings. Besides feeling ambivalent, suicide-prone individuals tend to have what he calls "constriction"rigid and persistent preoccupations with suicide as the solution to their problems. These individuals believe that the drastic option of ending their own life by suicide is the only way out unless others help break this pattern of constricted thought.

Many countries, including the United States, have created national suicide prevention programs that utilize a variety of strategies. These programs involve a variety of actions. Some prevention methods begin very early, teaching young children ages five to seven how to better cope with everyday problems. Other programs focus on teaching high school students how to better recognize signs of suicide in friends and how to obtain help. Actions also focus upon educating "gatekeepers," such as physicians, counselors, and teachers, who may come into contact with suicidal persons. The World Health Organization publishes resources on preventing suicide in its web site (www.who.org), and Befrienders International has extensive information on suicide and its prevention available in several languages at www.befrienders.org.

See also: Suicide Basics; Suicide Influences and Factors; Suicide over the Life Span; Suicide Types

Bibliography

Hawton, Keith, and Kees van Heeringen, eds. The International Handbook of Suicide and Attempted Suicide. New York: John Wiley and Sons, 2000.

Phillips, David P. "The Werther Effect: Suicide and Other Forms of Violence are Contagious." Sciences 25 (1985):3239.

Shneidman, Edwin. Suicide As Psychache: A Clinical Approach to Self-Destructive Behavior. Northvale, NJ: Jason Aronson, 1993.

World Health Organization. World Health Statistics Annual, 1995. Geneva: Author, 1996.

BRIAN L. MISHARA

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Suicide

SUICIDE

Suicide is a symptomatic act connected most frequently to the framework of depression and melancholy. Its etiology is varied and complex, since it is characterized by the collapse of the ego, along with self-reproach and a diminution or a loss of self-esteemand, at the same time, by a magic omnipotence which allows the annihilation of internal persecutors, as well as a manic feeling based on the denial of death itself. While suicide may appear to be a response to persecutory guilt, it is also a projection of this guilt onto objects as well as a liberation from their control through the death the subject has chosen for himself.

Suicide was discussed in the psychoanalytic literature as early as 1907, as recorded in the Minutes of the Vienna Psychoanalytic Society (Nunberg, Hermann, and Federn, Ernst, 1962-75), but it was a rather superficial discussion, centered on the fact that the differing choice of means by men and women reveals a primal sexual symbolism. From this came the formula that "suicide is the climax of negative autoeroticism" (Minutes, Vol. 1, February 13, 1907, p. 114). This should be understood in the context of the opposition between the ego instincts and sexual instincts in Freud's earliest theorization: "In suicide the life instinct is overwhelmed by the libido" (Vol. 2, April 20, 1910, p. 494).

In this approach, suicide, interpreted as a substitute for psychosis, seems linked both to an inability to tolerate reality and to autoerotic regression: "Suicide is an act of defense of the normal ego against psychosis" (June 6, 1907). Drive regression is equally central to Freud's ideas on the subject of the suicide of high school students; at school "Teachers. . . .must exercise a life-maintaining influence. [The function of] school is to give the child, in this stage of his detachment from his parents, a new footing within a larger relationship" (Vol. 2, April 20, 1910, p. 495). This should extend as far as not to "deny them the right to linger even in those phases of their development that seem vexing." There might well have been some evolution in Freud's thought here, especially if it is considered that, at the very beginning he insisted on the connection between neurasthenia, masturbation, and the risk of suicide. However, Freud also stressed that "in many cases it is the fear of incest itself that drives [children] to suicide" (p. 494), because of the enormous augmentation of their need for love at puberty; Freud went so far as to suggest, this being the case, that homosexuals make the best teachers, the worst being those whom the repression of their homosexuality has turned into sadists, pushing their students to suicide.

Later psychoanalytic thought on suicide followed the main ideas of Freud on the subject. First of all, in the depressive context, suicide was considered self-punishment for the desire to kill, primally directed toward another, as Freud himself stated in Totem and Taboo : "The law of talion, which is so deeply rooted in human feelings, lays it down that a murder can only be expiated by the sacrifice of another life: self-sacrifice points back to blood-guilt" (1912-13a, p. 154). Since then, the risk of self-mutilation or suicide with infantile or borderline personalities has been much emphasized (Kernberg, Otto, 1984); this risk is especially a factor during fits of rage following disappointments which are blamed on others; or else there is a risk of suicide because of failure to achieve success (guilt), or, even the failure of the cure (negative therapeutic reaction).

In fact, the idea that suicide is self-punishment for the desire to kill someone else cannot be understood completely apart from the process of melancholia, whereby the loved/hated object has been introjected within the ego and has become the target of the attack. More even than "self-punishment," suicide would be murder of the other within oneself. "Probably no one finds the mental energy required to kill himself unless, in the first place, in doing so he is at the same time killing an object with whom he has identified himself, and, in the second place, is turning against himself a death-wish which had been directed against someone else" (1920a, p. 162). Freud explained that "the ego is destroyed by the object."

The enigma constituted by suicide in relation to the self-preservative or ego instincts has also been approached in another way, through considering that it is accompanied paradoxically by a tentative intent to reappropriate vital energy, or, indeed, is even prompted by the fantasy of beginning a new life (Grinberg, León, 1983). Accordingly, suicide would result from a state of crisis dominated by the feeling that something must change. The person committing suicide "convokes death imaginally to assure himself paradoxically that life exists" (Triandafillidis, Alexandra, 1991). Ideal images of oneself and others can then survive, at the price of the death of the bad objects cluttering the ego.

The vital stakes involved in this symptomatic conduct have inclined authors not only to attempt to understand the suicidal mechanism, but also to describe its advance symptoms, evaluating the risk of suicide in order to decide on a therapeutic approach, especially in a care-giving institutional setting. León Grinberg (1983) emphasized suicidal premeditation and the fact that a suicidal plan follows the idea of suicide, which was at first only a way of dealing with anxiety. Continuing to the act of suicide depends on an "encounter," which might favor tipping the fantasy into reality. This author also examined factors of present or past vulnerability (feeling of culpability, narcissistic wound, loss of loved object, and so forth). Otto Kernberg (1984) emphasized the need for the therapist not to be fooled by an accentuation of the manic element; he stressed the seriousness of cases where "aggressiveness has infiltrated the grandiose Self," joined to an inability to enter into interpersonal relations and feel emotions. These considerations, however, concern psychotherapeutic strategies rather than the etiology of suicide.

Sophie de Mijolla-Mellor

See also: Bettelheim, Bruno: Bjerre, Poul; Great Britain; Morgenstern-Kabatschnik, Sophie: Rosenthal, Tatiana; Secret; Silberer, Herbert; Sokolnicka-Kutner, Eugénie; Stekel, Wilhelm; Tausk, Victor.

Bibliography

Freud, Sigmund. (1912-13a). Totem and taboo. SE, 13: 1-161.

Grinberg, León. (1983). Culpabilité et dépression. Paris: Les Belles Lettres.

Kernberg, Otto. (1984). Les trouble graves de la personnalité. Paris: Presses Universitaires de France.

Nuberg, Hermann, and Federn, Ernst. (1962-1975). Minutes of the Vienna Psychoanalytic Society. New York: International Universities Press.

Triandafillidis, Alexandra. (1991). La dépression et son inquiétante familiarité. Paris:Éditions Universitaires.

Further Reading

Laufer, M. (Ed.). (1995). The suicidal adolescent. Madison, CT: International Universities Press.

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Suicide

619. Suicide (See also Remorse, Self-Sacrifice.)

  1. Achitophel hanged himself when his advice went unheeded. [O. T.: II Samuel 17:23]
  2. Aegeus throws himself into the sea believing that his son, Theseus, has come to harm. [Gk. Myth.: Brewer Dictionary, 12]
  3. Ajax (the Greater) kills himself in rage over loss of Achilles armor. [Rom. Lit.: Aeneid ]
  4. Antigone imprisoned, kills herself in despair. [Gk. Lit.: Antigone ]
  5. Antony, Mark thinking Cleopatra is dead, he falls upon his sword. [Br. Lit.: Shakespeare Antony and Cleopatra ]
  6. Bart, Lily social climber takes poison when all her scheming comes to naught. [Am. Lit.: The House of Mirth in Hart, 385]
  7. Brand, Ethan acknowledging the unpardonable sin, throws himself into a lime kiln. [Am. Lit.: Hawthorne Ethan Brand in Hart, 261]
  8. Butterfly, Madama (Cio-cio-san) stabs herself when her American lover returns with his lawful wife. [Ital. Opera: Madama Butterfly in Osborne Opera, 192]
  9. Calista stabs herself on disclosure of adultery. [Br. Lit.: The Fair Penitent ]
  10. Cassandra commits suicide to escape the Athenians. [Fr. Opera: Berlioz, The Trojans, Westerman, 174]
  11. Charmian kills herself after mistress Cleopatras death. [Br. Lit.: Antony and Cleopatra ]
  12. Chuzzlewit, Jonas wicked murderer, found out, takes poison. [Br. Lit.: Dickens Martin Chuzzlewit ]
  13. Cleopatra kills herself rather than being led through Rome in defeat. [Br. Lit.: Shakespeare Antony and Cleopatra ]
  14. Compson, Quentin unable to prevent the marriage of his sister, he drowns himself on her wedding day. [Am. Lit.: Faulkner The Sound and the Fury in Magill I, 917]
  15. Deianira accidentally kills husband, Hercules; kills herself out of guilt. [Gk. Myth.: Kravitz, 76]
  16. Dido kills herself when Aeneas abandons her. [Rom. Myth.: Avery, 392393; Rom. Lit.: Aeneid ]
  17. Dobson, Zuleika Oxford undergraduates commit suicide when she spurns them. [Br. Lit.: Magill II, 1169]
  18. Eden, Martin disgusted by society snobbery, he drowns him-self. [Am. Lit: Martin Eden ]
  19. Ekdal, Hedvig heartbroken by her fathers rejection, puts a bullet through her breast. [Nor. Drama: Ibsen The Wild Duck in Magill I, 1113]
  20. Enobarbus kills himself for deserting Antony. [Br. Lit.: Antony and Cleopatra ]
  21. Erigone hangs himself in grief over fathers murder. [Gk. Myth.: Kravitz, 91]
  22. Evadne immolates herself on husbands funeral pyre. [Gk. Myth.: Kravitz, 100]
  23. Gabler, Hedda shoots herself upon realizing that she is in the power of a man aware that she drove another man to suicide. [Swed. Drama: Ibsen Hedda Gabler ]
  24. Goneril stabs herself when her murder plot is discovered. [Br. Drama: Shakespeare King Lear ]
  25. Hero grief-stricken when her beloved Leander drowns while swimming the Hellespont, she drowns herself. [Gk. Myth.: Brewer Dictionary, 450]
  26. Iseult (Yseult, Isolde) of Ireland arriving too late to save Tristram (Tristan) from death, she kills herself. [Medieval Legend: Brewer Dictionary, 913]
  27. Javert French inspector drowns himself to escape self-perpetuating torment. [Fr. Lit.: Les Misérables ]
  28. Jonestown in Guyana; scene of mass-murder and suicides. [Am. Hist.: Facts (1978), 889892]
  29. Julie, Miss compromised by a clandestine affair and thwarted in her plans to run away, she decides to kill herself. [Swed. Drama: Strindberg Miss Julie in Magill II, 675]
  30. Juliet stabs herself on seeing Romeo dead. [Br. Lit.: Shakespeare Romeo and Juliet ]
  31. Kamikaze WWII Japanese pilot corps plunge own planes into enemy ships in banzai attacks. [Jap. Hist.: Fuller, III, 618619]
  32. Karenina, Anna throws herself in front of approaching train. [Russ. Lit.: Anna Karenina ]
  33. Little Father Time solemn child hangs his foster-brothers and himself because of the familys misfortunes. [Br. Lit.: Hardy Jude the Obscure ]
  34. Loman, Willy crashes his car to bring insurance money to his family. [Am. Drama: Arthur Miller Death of a Salesman ]
  35. Mannon, Christine when her lover is killed she shoots herself. [Am. Drama: Eugene ONeill Mourning Becomes Electra ]
  36. Nickleby, Ralph learning that poor Smike is his own son, hangs himself. [Br. Lit.: Dickens Nicholas Nickleby ]
  37. Ophelia driven insane by Hamlets actions, she drowns herself. [Br. Drama: Shakespeare Hamlet ]
  38. Panthea kills herself upon death of lover, Abradates. [Gk. Lit.: Walsh Classical, 3]
  39. Paul deluded youth kills himself when his grandiose yearnings come to nothing. [Am. Lit.: Willa Lather Pauls Case]
  40. Phaedra Athenian queen drinks poison after confessing guilt. [Fr. Lit.: Phaedra, M agill I, 741742]
  41. Romeo thinking that Juliets sleep is death, he drinks poison. [Br. Lit.: Shakespeare Romeo and Juliet ]
  42. Rudolf, Archduke crown prince of Austria (18581889) died in suicide pact with his mistress at Mayerling. [Aust. Hist.: Colliers, XVI: 606]
  43. Saul falls on sword to avoid humiliation of capture. [O.T.: I Samuel 31:46]
  44. Sophonisba Carthaginian who took poison to avoid falling into Roman hands. [Rom. Hist.: Benét, 947]
  45. Suicide Club members wishing to die are chosen by lot, as are those who are to effect their deaths. [Br. Lit.: Stevenson The Suicide Club]
  46. Vane, Sibyl young actress kills herself after Dorians betrayal. [Irish Lit.: The Picture of Dorian Gray, Magill I, 746748]

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Suicidal Behavior

SUICIDAL BEHAVIOR

The term suicidal behavior is understood to mean both suicidal equivalents not recognized as such (accidents, repeated risk-taking) and repeated suicide attempts whose chronic and unsuccessful nature certainly constitutes a real risk, but which are also acts of essentially relational significance.

The idea that accidents can be interpreted as unconscious suicide attempts appeared in Sigmund Freud's The Psychopathology of Everyday Life (1901b): "[I]n addition to consciously intentional suicide there is such a thing as a half-intention self-destruction [sic] (self-destruction with an unconscious intention), capable of making skillful use of a threat to life and of disguising it as a chance mishap. There is no need to think such self-destruction rare. For the trend to self-destruction is present to a certain degree in very many more human beings than those in whom it is carried out" (pp. 180-181). This essentially involves the person waiting for the occasion that will divert the forces of personal preservation, and there is thus a "meeting" between the event and the unconscious intention. Involuntary mutilations, which constitute a compromise between the self-destructive tendency and self-preservation, are also included within the framework of accidental suicidal behaviors.

Similarly, with regard to accidents that happen to babies, Melanie Klein spoke of suicide attempts with inadequate means, as if the infant did not yet have the ability to fantasize and premeditate its own death, and that it could only realize by unconsciously putting itself in danger.

In a letter to Freud dated 1 June 1911, Ernest Jones proposed a comparison between accidental suicide and "with the way in which the unconscious seizes on unassociated indifferent material in dream making" (1993 [1908-39], p. 105).

Systematic risk-taking requires a different psychic disposition. The idea of the possibility of death is present and even hypercathected, but at the same time denied in a megalomaniacal narcissistic affirmation. Death is thus "provoked" in the sense of a challenge that is also a relational challenge to those whose fantasized omnipotence cannot effectively protect the subject, the idealized parents. These situations are very common, especially during adolescence, and can involve the risk of accidents, but also toxic risks or even anorexia. Such risk-taking has a function similar to that of the ordalia, or trial by ordeal, in the sense that the subject expects to get from it an affirmation, if not of their own innocence, at least of their invulnerability. In the face of this excessiveness, the accident imposes a limit and brings the person into contact with reality, including that of the body's fragility.

Authors such as Philippe Jeammet and Elisabeth Birot who have studied suicide attempts in adolescents have emphasized the fact that the idea of death has an organizing function during adolescence. It can be noted that the idea of death is unavoidable at this age in conjunction with the obligation to renounce childhood, to which there is no possible return. The idea of death is linked to a sense of the ephemeralhence the ease during this period of identifying with romantic heroes (as seen in Freud's Manuscript N., 31 May 1897, regarding Goethe's hero Werther).

Beyond gambling with the idea of death, a suicide attempt can represent a way of trying to restore a lost identity (the prepubescent body of the anorexic) or a delusional identity. Similarly, the integration of the drives during adolescence, notably with respect to homosexuality, is a factor that can be conducive to suicidal behavior. Such behavior then appears in its relational significance, whether in the form of a threat, or even blackmail against those close to the subject, or a call for help when communication has broken down. Chronic suicidal behavior can have various etiologies; it remains the case that it cannot be dissociated from suicide proper, the potential for which is inherent in it.

Sophie de Mijolla-Mellor

See also: Suicide.

Bibliography

Freud, Sigmund. (1901b). The psychopathology of everyday life. SE,6.

Freud, Sigmund, and Jones, Ernest. (1993 [1908-1939]). The complete correspondence of Sigmund Freud and Ernest Jones, 1908-1939 (R.A. Paskauskas Ed.). London: The Belknap Press of Harvard University Press.

Garfinkel, Barry D.; Froese, A.; and Hood, J. (1982). Suicide attempts in children and adolescents. American Journal of Psychiatry, 139, 10, 1257-1261.

Jeammet, Philippe, and Birot, Elisabeth (Eds.). (1994)Étude psychopathologique des tentatives de suicide chez l 'adolescent et le jeune adulte. Paris: Presses Universitaires de France.

Further Reading

Hartmann, H. P., and Milch, W. (2000). Efficacy treatment of suicidal patients: Transference and countertransference. Progress in Self Psychology, 16, 87-102.

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suicide

suicide Commonly defined as the intentional killing of oneself. Émile Durkheim, in his classic study Suicide (1897), defined it as ‘every case of death which results directly or indirectly from a positive or negative act, accomplished by the victim himself which he knows must produce this result’. Controversially he did not require that the death must be intentional, arguing that intentions are hard to identify. Consequently he extended the definition, including for example heroic military deaths, where there is no chance of survival but no specific intention to kill oneself.

Durkheim chose to study suicide because it seemed to illustrate perfectly the necessity for and value of sociological explanation: a patently private, individual act, which was, none the less, subject to social forces and required a distinctively sociological explanation. He maintained that the tendency to suicide depended not on individual psychology or features of the physical environment, but on the nature of the individual's relation to society. Suicide as an individual action represented the failure of social solidarity and was indicative of the ineffectiveness of social bonds. He distinguished three main types of suicide according to causation. Altruistic and egoistic suicide depend on the individual's relations to social ideals and purposes. In altruistic suicide the individual is too strongly integrated into society—a society which encourages or even requires the individual to sacrifice his or her own life (as when a wife is expected to commit suicide on her husband's death). Conversely, in egoistic suicide the individual is insufficiently integrated into society, and so is not subject to the collective forces that prevent suicide—and, indeed, experiences an isolation and detachment conducive to it. Finally, anomic suicide depends on the social regulation of the individual's desires and ambitions. Where anomie—normlessness—is heightened in society, the individual's passions, ambitions, and appetites are increased to a level where they cannot find satisfaction.

Durkheim's analysis has been criticized on numerous grounds: for his definition of suicide and the mismatch between this definition and that embodied in the suicide statistics he employs to substantiate his argument; for his classification of types of suicide in terms of cause (so-called aetiological classification) which incorporates into the classification the very causal links he is seeking to establish; for his extreme polarization of social and psychological explanations (where complementarity should be assumed); and for using aggregate data to make inferences about individuals (the so-called ecological fallacy).

A major strand of subsequent sociological discussions concerns the limitations of official statistics of suicide. Jack D. Douglas, influenced by the work of interactionists and ethnomethodologists, argued in Social Meanings of Suicide (1967) that what was defined or treated as suicide differed from culture to culture, thereby calling into question cross-cultural and historical comparisons of suicide rates, or even data on suicide generated by different coroners. However, it does not follow that suicide statistics have no value in analysing the social causes of suicide; rather, that they need to be treated with exceptional care. One must assess the impact of social and cultural factors on the construction of suicide statistics as well as the tendency to commit suicide. Significantly, the tradition developed by Durkheim has continued, and a range of studies have provided some empirical support for his ideas and evidence of the impact of social factors (such as unemployment) on levels of suicide.

One important development has been the attention to attempted or parasuicide, frequently claimed to be a very different phenomenon from successful suicide, and representing a cry for help. However, some authors argue that the distinction between attempted and successful suicide is a matter of contingency, and it is wrong to exclude unsuccessful cases from the analysis.

The theoretical basis and empirical adequacy of Durkheim's explanation is most fully explored in Whitney Pope's Durkheim's Suicide (1976).

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suicide

suicide [Lat.,=self-killing], the deliberate taking of one's own life. Suicide may be compulsory, prescribed by custom or enjoined by the authorities, usually as an alternative to death at the hands of others, or it may be committed for personal motives. Depending on the time and place, it may be regarded as a heroic deed or condemned by religious and civil authorities.

Compulsory suicide may be performed out of loyalty to a dead master or spouse. Examples of this are suttee in India and the similar behavior expected of the dead emperor's favorite courtiers in ancient China. Such practices, now largely extinct, undoubtedly derived from the ancient and widespread custom of immolating servants and wives on the grave of a chief or noble (see funeral customs). Self-murder may also be enjoined for the welfare of the group; among pre-industrial peoples, the elderly who could no longer contribute to their own subsistence are an example. Finally, suicide may be offered to a favored few as an alternative to execution, as among the feudal Japanese gentry (see hara-kiri), the Greeks (see Socrates), the Roman nobility, and high-ranking military officers, such as Erwin Rommel, accused of treason. In traditional Japanese society, in certain situations suicide was seen as the appropriate moral course of action for a man who otherwise faced the loss of his honor. Self-killing may be practiced by peoples lacking a codified law of punishment; the Trobriand Islanders hurled themselves ceremonially from the tops of palm trees after a serious public loss of face. In these situations, the line between social pressure and personal motivation begins to blur.

In less traditional societies the causes of suicide are more difficult to establish. The problem has been approached from two different angles: the sociological, which stresses social pressures and the importance of social integration, and the psychoanalytic, which centers on the driving force of guilt and anxiety and the inverting of aggressive impulses. Recent studies have done much to dispel some of the myths surrounding suicide, such as the beliefs that suicidal tendencies are inherited, that suicidal tendencies cannot be reversed, and that persons who announce their intention to commit suicide will not carry out the threat.

Self-killing is expressly condemned by Judaism, Christianity, and Islam, and attempts are punishable by law in certain countries. Suicide was a felony in 11th-century England because the self-murderer was considered to have broken the bond of fealty, and the suicide's property was forfeited to the king. Suicides were interred on public highways with a stake driven through the heart; this practice was observed as late as 1823. In 1961, Great Britain abolished criminal penalties for attempting to commit suicide. Very few U.S. states still list suicide as a crime, but most states have laws against helping someone to commit suicide. A right-to-die movement has supported the principle of doctor-assisted suicide in certain cases (see euthanasia).

In the United States, suicide is the ninth leading cause of death. About twice as many women attempt suicide as men, but out of roughly 31,000 successful suicides in 1996, about four fifths were by men. A striking characteristic, which has concerned and baffled public health workers, has been the increase in suicides in the age group 10 to 14 years. In the period from 1980 to 1995, suicides in this age group rose from 139 to 330 per 100,000 individuals. Worldwide, suicide rates have been notably high in Russia, Hungary, and Finland.

Bibliography

See E. Durkheim, Suicide (1897, tr. 1951); R. Cavan, Suicide (1928, repr. 1965); E. Stengel, Suicide and Attempted Suicide (1965); J. Douglas, The Social Meanings of Suicide (1967); E. Shneidman, ed., Essays in Self-Destruction (1967); M. L. Farber, The Theory of Suicide (1968); E. A. Grollman, Suicide (1970); A. Alvarez, The Savage God (1972); J. Choron, Suicide (1972); D. Lester, Why People Kill Themselves (1972); G. Colt, The Enigma of Suicide (1991); P. Singer, Rethinking Life and Death (1994); H. Hendin, Suicide in America (new and enl. ed. 1995); K. R. Jamison, Night Falls Fast (1999).

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Suicide

Suicide. The deliberate taking of one's own life is condemned in all religions, although exceptions on the margins (death accepted or embraced for religious reasons) are usually made. In Judaism, there is no explicit condemnation in the Bible, but it came to be prohibited, partly on the basis of the sixth commandment (‘Thou shalt not kill’). However, suicide to avoid even greater offence (e.g. to avoid murder or idolatry) was regarded as praiseworthy: the reported suicides at Masada, to avoid falling into the hands of the Romans at the end of the Jewish revolt, 66–70, remained a model of martyrdom—see kiddush ha-Shem. Among Christians, martyrdom is commended in the pattern of Christ who laid down his life for others, but the deliberate taking of one's own life is condemned on much the same grounds as those of the Jews, but with an added sense of the wrong done to family and society at large. Suicides could not, until recently, receive Christian burial. The sense of compassion and support needed for those tempted to commit suicide led to the founding of the Samaritans by Chad Varah in 1953. Islam shares the same kind of attitude: martyrs (shahīd) are highly commended, but suicide (although barely mentioned in the Qurʾān: see 4. 29) is strongly condemned in ḥadīth.

In Eastern religions, the ambiguous border is not so much between martyrdom and suicide as between suicide and sacrifice. Among Jains, the religious relinquishing of the body is taken to a marked extreme in sallekhanā. In Buddhism, the propriety of suicide to benefit another is recognized. But the consideration of ahiṃsā (of doing no harm to a sentient being) makes suicide generally forbidden. Japanese hara-kiri (seppuku) was originally a social rather than specifically religious act, but its endorsement by Zen Buddhism gave it a religious support.

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suicide

suicide. Whereas in ancient Greece and Rome (for example, Socrates and Seneca) and in Japan (seppuku or hara-kiri) suicide was sometimes considered honourable, the Judaeo-Christian tradition and Islam have rejected the taking of one's own life as self-murder. God alone gives life and takes it away. But martyrdom, dying for a religious cause, blurs the distinction. Early Christian martyrs were almost theatrically suicidal as they went to death; mass suicide of Jews at Masada (ad 74) and at York (1190) and of cultic followers in Guyana (1978) also makes distinction difficult. Augustine (428), later church councils, and Aquinas condemned suicide as sinful and secular powers made it a crime. The custom of burying suicides in unconsecrated ground at crossroads, with stakes driven through their hearts to prevent their ghosts causing harm, ended in 1823 and property ceased to be confiscated (1870). Though no longer criminal in Britain (1961), suicide is still widely regarded as sinful. The issue is now ethically complicated by the advance of medical science, whereby the life of the elderly or terminally ill can be greatly extended to the detriment of themselves, relatives, and society. Meanwhile ‘living wills’ to prevent unnatural lengthening of life become more commonplace.

Revd Dr William M. Marshall

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suicide

su·i·cide / ˈsoōiˌsīd/ • n. the action of killing oneself intentionally: he committed suicide at the age of forty | gun control laws may reduce suicides. ∎  a person who does this. ∎  a course of action that is disastrously damaging to oneself or one's own interests: it would be political suicide to restrict criteria for unemployment benefits. ∎  [as adj.] relating to or denoting a violent act or attack carried out by a person who does not expect to survive it: a suicide bombing. • v. [intr.] intentionally kill oneself: she suicided in a very ugly manner.

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suicide

suicide the action of killing oneself intentionally; a person who does this. The term is recorded from the mid 17th century, and comes ultimately from Latin sui ‘of oneself’ and caedere ‘kill’.

In Christian theology, suicide is regarded as a sin; it was also formerly a criminal act in the UK (see felo de se). A person who had killed themselves was regarded as someone whose ghost might walk; there was a traditional belief that this could be averted by a stake through the heart, or by the body's being buried at a crossroads. Suicides were also buried at the north side of a churchyard.

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Suicide

Suicide

Who Commits Suicide?

What Factors Make People More Likely to Commit Suicide?

What Are the Signs That a Person Is Thinking of Committing Suicide?

Why Do People Commit Suicide?

If You Suspect Someone Is Suicidal

Resources

Suicide is the intentional taking of a persons own life.

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Depression

As shocking as it may seem, in the United States every year there are more suicides than murders and twice as many suicides as deaths from acquired immunodeficiency syndrome (AIDS). Yet suicide gets far less press than murder or AIDS. Why? It may be because talking about suicide makes people very uncomfortable, because there are religious prohibitions against suicide, because suicide is thought of as a shameful act, or because many people simply cannot believe that someone they know and love could intentionally take his or her own life.

Who Commits Suicide?

Suicide is a complex act that results from many factors, not all of which are understood. It is not clear or predictable why the setbacks, losses, or difficulties that would lead one person to feel very unhappy may lead another person to be suicidal.

It is estimated that about 30,000 Americans die as the result of suicide each year, while about 20,000 people are murdered. Some experts, however, believe that the number of suicides is even higher. Many accidents, such as self-inflicted gunshot wounds or single-car crashes, actually may be unrecognized or unreported suicides. Although no official record is kept of suicide attempts, it is estimated that there are between 8 and 25 attempts for each completed suicide. Overall, suicide is the eighth leading cause of death in the United States.

Suicides are not spread equally throughout the population. Although more women than men attempt suicide, about four times more men die, because they use more lethal means. Men of European ancestry committed 72 percent of all suicides in 1997, while women of European ancestry accounted for about 18 percent of these deaths. The rate of suicide among people of Native American ancestry, especially young men ages 15 to 24, is particularly high. The suicide rate among men of African ancestry ages 15 to 19 doubled between 1980 and 1996. Age is another factor in suicide. After age 65, the rate of suicide among men of European heritage increases steadily as they get older. Men of European heritage who are older than 85 have a suicide rate that is six times the national average. The reasons for the different rates of suicide among people of different ethnic backgrounds, gender, and ages vary. Some factors include increased rates of alcoholism, poverty, loneliness, and violence for particular groups at a particular time of life.

Young people also have higher than average rates of suicide. Suicide is the third leading cause of death among people 15 to 24 years old. A 1997 survey found that 1 in 13 high school students said that they had attempted suicide. Meanwhile, the number of children ages 10 to 14 committing suicide has increased sharply during the past decade. The most common methods of committing suicide are by intentionally taking a drug overdose (prescription or over-the-counter medicines), inhaling carbon monoxide from car exhausts, or using guns.

What Factors Make People More Likely to Commit Suicide?

About 90 percent of people who commit suicide have a diagnosed psychiatric disorder. Depression and substance abuse (either alone or in combination) are the two most common disorders that play a part in suicide. This does not mean that everyone who has depression or an alcohol or drug problem will commit suicide. The majority of people with these problems are not suicidal.

People who are more likely to kill themselves also may:

  • have previously attempted suicide
  • live alone and have no social support network
  • have chronic (long-lasting or recurring) physical pain or a terminal (life-ending) illness
  • have a family history of suicide
  • be unemployed
  • be impulsive
  • keep a gun in the home
  • have spent time in jail
  • have experienced family violence, child abuse, or sexual abuse.

What Are the Signs That a Person Is Thinking of Committing Suicide?

It is a myth that people who talk about killing themselves do not do it. Four of five people who attempt suicide have given clues about their intentions before they acted on them. It is important to take seriously any talk about suicide or any indication that suicide is a possibility.

Some common warning signs that a person is thinking about suicide include:

  • talking about death or making suicide threats
  • making such statements asYou would be better off without meorIm no good to anybody(even if these are said jokingly)
  • having any of the symptoms or signs of depression
  • exhibiting major personality changes or unexplainable odd behavior
  • making a will or giving away cherished possessions
  • seeking isolation and becoming uncommunicative
  • being fascinated with death
  • taking a sudden interest in religion if previously not religious, or rejecting religion if previously devout.

Trained adults staff a suicide hotline. These crisis lines are entirely confidential, and can be called 24 hours a day, 7 days a week. Stock Boston

Why Do People Commit Suicide?

No one can explain why some people commit suicide and others do not. One theory is that suicide is an act of rage or anger. Another theory is that people may commit suicide because they feel they have no other choice. Hopelessness and distorted thinking may prevent a person from seeing solutions to their problems.

For a mentally healthy person, the idea that a person would have no choice except to seek death sounds absurd. But depression, substance abuse, and other mental illnesses, such as schizophrenia, alter the healthy mind. People with these problems may feel that they are in a deep, dark hole from which there is no escape and that life is so painful that there are no alternatives except death.

Researchers are finding that there may be inherited tendencies for depression, schizophrenia, alcoholism, substance abuse, and certain personality disorders. All of these problems can increase a persons vulnerability to suicidal thoughts when things go wrong. Some studies suggest that the brain chemistry of people who commit suicide is abnormal. Research is under way to examine the effects of certain medications that alter brain chemistry in a way that could decrease suicidal behavior.

If You Suspect Someone Is Suicidal

People who are thinking about committing suicide need professional help. They have usually sunk so deeply into their mental and emotional black holes that they may be unable to recognize that they are in trouble or to seek help on their own. It is important to pay attention when people talk about wanting to die and to take their words seriously. Having another person approach the subject directly is often a relief to them. It is sometimes thought that speaking to people about their possible wish to commit suicide willput thoughts in their heads.But people who talk about suicide often are already thinking about suicide.

Professional help is available through suicide prevention and crisis intervention centers, mental health clinics, hospitals and emergency rooms, family doctors, health maintenance organizations, mental health practitioners, and members of the clergy. When a person is possibly suicidal, it is a good idea to talk to another mature, responsible person and ask that person to join in helping to deal with the crisis. Many telephone books have community service sections that list suicide and mental health crisis hotlines. Immediate help can be obtained by calling emergency services (911 in most communities).

Other ways of possibly minimizing the risk of suicide include:

  • removing guns and ammunition from the house
  • locking up medications and alcohol
  • staying with the person, since suicide is an act most often performed alone
  • talking calmly, without lecturing, being judgmental, or pointing out all the reasons a person has to continue living.

Suicide places a heavy emotional burden on the survivors. People who have been close to someone who has attempted or completed suicide might consider mental health counseling to help them deal with their own emotions.

See also

Bipolar Disorder

Brain Chemistry (Neurochemistry)

Death and Dying

Depression

Substance Abuse

Therapy

Resources

Books

Cobain, Bev. When Nothing Matters Anymore: A Survival Guide for Depressed Teens. Minneapolis: Free Spirit Publishing, 1998. A guide to depression treatment and prevention. For ages 13 and up.

Crutcher, Chris. Chinese Handcuffs. New York: Bantam Doubleday Dell Publishing Group, 1991. A fictional account of teens dealing with suicide.

Hahn, Mary Downing. The Wind Blows Backward. New York: William Morrow and Co., 1994. A fictional account of teens dealing with suicide.

Organizations

American Psychiatric Association, 1400 K Street NW, Washington, DC, 20005. This professional organization provides online information on suicide (especially teen suicide) and depression at its website. Telephone 888-357-7924 http://www.psych.org

National Center for Injury Prevention and Control, Mailstop K65, 4770 Buford Highway NE, Atlanta, GA 30341-3724. The website of this organization provides up-to-date statistics and research findings about suicide. Telephone 770-488-1506 http://www.cdc.gov/ncipc

U.S. National Institute of Mental Health (NIMH), 6001 Executive Boulevard, Room 8148, MSC 9663, Bethesda, MD 20892-9663. This government agency conducts research on suicide and depression and provides information to the public through pamphlets and a website. Telephone 301-443-4513 http://www.nimh.nih.gov

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suicidal

su·i·cid·al / ˌsoōiˈsīdl/ • adj. deeply unhappy or depressed and likely to commit suicide: far from being suicidal, he was clearly enjoying life. ∎  relating to or likely to lead to suicide: I began to take her suicidal tendencies seriously. ∎  likely to have a disastrously damaging effect on oneself or one's interests: a suicidal career move. DERIVATIVES: su·i·cid·al·ly adv.

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suicide

suicide (soo-i-syd) n. self-destruction as a deliberate act. assisted s. the act of helping a person to commit suicide by giving them the means (e.g. drugs) to do so, which is a criminal offence in England and Wales. attempted s. an attempt at self-destruction in which death is averted although the person concerned intended to kill himself (or herself). Compare deliberate self-harm.

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suicide

suicide1 one who takes his own life. XVIII. — modL. suīcīda, f. L. suī of oneself; see -CIDE1.
So suicide2 taking one's own life XVII; see -CIDE2. Hence suicidal (-AL1) XVIII.

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suicide

suicide Deliberate act of terminating one's own life.

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suicidal

suicidaladdle, paddle, saddle, skedaddle, staddle, straddle •candle, Coromandel, dandle, Handel, handle, mishandle, Randall, sandal, scandal, vandal •manhandle, panhandle •packsaddle • side-saddle •backpedal, heddle, medal, meddle, pedal, peddle, treadle •Grendel, Kendall, Lendl, Mendel, Rendell, sendal, Wendell •cradle, ladle •beadle, bipedal, credal, needle, wheedle •diddle, fiddle, griddle, kiddle, Liddell, middle, piddle, riddle, twiddle •brindle, dwindle, kindle, spindle, swindle, Tyndale •paradiddle, taradiddle •pyramidal • apsidal •bridal, bridle, fratricidal, genocidal, germicidal, homicidal, idle, idol, infanticidal, insecticidal, intertidal, matricidal, parricidal, patricidal, pesticidal, regicidal, sidle, suicidal, tidal, tyrannicidal, uxoricidal •coddle, doddle, model, noddle, swaddle, toddle, twaddle, waddle •fondle, rondel •mollycoddle •caudal, chordal, dawdle •poundal, roundel •Gödel, modal, yodel •crinoidal •boodle, caboodle, canoodle, doodle, feudal, noodle, poodle, strudel, udal •befuddle, cuddle, fuddle, huddle, muddle, puddle, ruddle •bundle, trundle •prebendal • synodal •antipodal, tripodal •citadel •curdle, engirdle, girdle, hurdle •dirndl

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suicide

suicidebackside, trackside •bedside • airside •Tayside, wayside •lakeside • stateside • graveside •quayside, seaside, Teesside •beachside • hillside • ringside •suicide • herbicide • regicide •fungicide • filicide • Barmecide •homicide •germicide, spermicide •tyrannicide • parricide •fratricide, matricide, patricide •uxoricide • countryside • infanticide •insecticide • pesticide • parasiticide •mountainside • Merseyside •Tyneside •dioxide, dockside, hydroxide, monoxide, oxide, peroxide •alongside •diopside, topside •broadside • downside • roadside •poolside • upside • nearside •fireside • Humberside • underside •genocide • waterside • riverside •silverside • overside •kerbside (US curbside) • Burnside

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Suicide

SUICIDE

What role may a person play in the end of his or her own life? Is suicide wrong, always wrong, profoundly morally wrong? Or is it almost always wrong, but excusable in a few cases? Or is it sometimes morally permissible? Is it not intrinsically wrong at all though perhaps often imprudent? Is it sick? Is it a matter of mental illness? Is it a private or a social act? Is it something the family, community, or society could ever expect of a person? Or is it solely a personal matter, perhaps a matter of right, based in individual liberties, or even a fundamental human right?

What role a person may play in the end of his or her own life is the central ethical issue in suicide around which a set of related issues also form: What should the role of other persons be towards those intending suicide? What should the role of medical and psychiatric clinicians be toward a patient who intends suicide since it is they who are said to be charged with protecting human life? What intervention may the state make to interfere with a person's intention to end his or her own life? What responsibility do othersboth immediate others such as family and friends or more distant or generalized others such as employers or institutions or society as a wholebear when a person commits suicide?

This spectrum of views about the ethics of suicidefrom the view that suicide is profoundly morally wrong to the view that it is a matter of basic human right, and from the view that it is primarily a private matter to the view that it is largely a social onelies at the root of contemporary practical controversies over suicide. These practical controversies include at least three specific matters of high contemporary saliency:

  • Physician-assisted suicide in terminal illness, the focus of intense debate in parts of the world with people who have long life expectancies and with high-tech medical systems, particularly the Netherlands, the United States, the United Kingdom, Canada, Switzerland, Belgium, Germany, and Australia;
  • Hunger strikes and suicides of social protest, as in Turkey, Northern Ireland, and wartime Vietnam;
  • Suicide bombings and related forms of self-destruction employed as military, guerilla, or terrorist tactics in ongoing political friction, including kamikaze attacks by wartime Japan; suicide missions by groups from Tamil separatists to al-Qaeda, and suicide bombings in the conflicts in Israel, Palestine, Iraq, and elsewhere.

Ethical issues have occupied the center of attention in the philosophical discussion of suicide, but conceptual and epistemological ones also play a role, as do a broad range of further issues raised within world historical, religious, and cultural traditions.

Conceptual and Linguistic Issues

The term suicide carries extremely negative connotations. However, there is little agreement on a formal definition. Some authors count all cases of voluntary, intentional self-killing as suicide; others include only cases in which the individual's primary intention is to end his or her life. Still others recognize that much of what is usually termed suicide neither is wholly voluntary nor involves a genuine intention to die, such as suicides associated with depression or other mental illness. Many writers exclude cases of self-inflicted death that, while voluntary and intentional, appear aimed to benefit others or to serve some purpose or principlefor instance, Socrates drinking the hemlock, Captain Lawrence Oates's (18901912) walking out into the Antarctic blizzard to allow his fellow explorers to continue without him, or the self-immolation of war protesters. These cases are usually not called suicide but self-sacrifice or martyrdom, terms with strongly positive connotations.

Attempts to differentiate these positive cases from negative ones often seem to reflect moral judgments, not genuine conceptual differences, and the linguistic framing of a practice plays a substantial role in social policies about suicide. For example, supporters of physician-assisted suicide often use the term aid-in-dying as well as earlier euphemisms such as self-deliverance to avoid the negative connotations of suicide while opponents insist on the more negative term suicide. Islamic militants attacking civilians are called martyrs by their supporters and those who recruit them but suicide bombers by their targets and by the Western press.

Differences among languages also play a role in the conceptualization of suicide. While for example English, French, Spanish, and many other languages have just a single, primary word for suicide, German has four: Selbstmord (self-murder), Selbsttötung (self-killing), Suizid (the Latinate term), and Freitod (free death). This latter German term has comparatively positive, even somewhat heroic, connotations, making it possible for German-speakers to think about the deliberate termination of their lives in a linguistic way not easily available to speakers of English or other languages that rely on a single, principal term with strongly negative connotations.

Linguistic issues also arise in attempts to refer to the performance of the act of suicide. The expression to "commit" suicide has been common, echoing the phrase to commit a crime ; contemporary suicidologists typically use a variety of less-stigmatizing alternatives, including suicided, completed suicide, and died by suicide.

Some authors claim that it is not possible to reach a rigorous formal definition of suicide and prefer a criterial or operational approach to characterizing the term, noting its varied, shifting, and often inconsistent range of uses. Translation from one language to another may also prove difficult since there is sometimes little way to preserve comparatively positive connotations of some terms. Cases of death from self-caused accident, self-neglect, chronic self-destructive behavior, victim-precipitated homicide, high-risk adventure, refusal of life-saving medical treatment, and self-administered euthanasiaall of which share many features with suicide but are not usually termed suchcause still further conceptual difficulty.

Nevertheless, conceptual and linguistic issues concerning suicide are of considerable practical importance in policy formation, affecting, for instance, coroners' practices in identifying causes of death, insurance disclaimers, psychiatric protocols, religious prohibitions, codes of medical ethics, laws prohibiting or permitting assistance in suicide, social stigma and respect, and public response to international and political issues such as suicide bombing and protest suicide.

Epistemological Issues

Closely tied to conceptual issues, the central epistemological issues raised by suicide involve the kinds of knowledge available to those who contemplate killing themselves. The issue of what, if anything, can be known to occur after death has generally been regarded as a religious issue answerable only as a matter of faith; few philosophical writers have discussed it directly, despite its clear relation to theory of mind. Some writers have argued that since we cannot have antecedent knowledge of what death involves, we cannot knowingly and voluntarily choose our own deaths; suicide is therefore always irrational. Others, rejecting this argument, instead attempt to establish conditions for the rationality of suicide. Others consider whether death is always an evil for the person involved and whether death is appropriately conceptualized as the cessation of life. Still other writers examine psychological and situational constraints on decision making concerning suicide. For instance, the depressed, suicidal individual is described as seeing only a narrowed range of possible future outcomes in the current dilemma, the victim of a kind of tunnel vision constricted by depression. The possibility of preemptive suicide in the face of deteriorative mental conditions such as Alzheimer disease is characterized as a problem of having to use that very mind which may already be deteriorating to decide whether to bear deterioration or die to avoid it. Still others suggest that suicide would be the most straightforward expression of normative skepticism, expressing the view that life has no meaning and nothing is of value.

Suicide in World Historical Traditions: The West

Much of the extremely diverse discussion of suicide in the history of Western thought has been directed to ethical issues. Plato acknowledges Athenian burial restrictionsthe suicide was to be buried apart from other citizens with the hand severed and buried separatelyand in the Phaedo, he also reports the Pythagorean view that suicide is categorically wrong. But Plato also accepts suicide under various conditions, including shame, extreme distress, poverty, unavoidable misfortune, and external compulsions of the sort imposed on Socrates by the Athenian court: Socrates was condemned to drink the hemlock. In the Republic and the Laws, respectively, Plato obliquely insists that the person suffering from chronic, incapacitating illness or uncontrollable criminal impulses ought to allow his life to end or cause it to do so. Aristotle held more generally that suicide is wrong, claiming in the Nichomachean Ethics that it is cowardly and treats the state unjustly. The Greek and Roman Stoics, in contrast, recommended suicide as the responsible, appropriate act of the wise man, not to be undertaken in emotional distress but as an expression of principle, duty, or responsible control of the end of one's own life, as exemplified by Marcus Porcius Cato Uticencis (Cato the Younger) (95 BCE46 BCE), Lucretia (sixth century BCE), and Lucius Annaeus Seneca.

Although Old Testament texts describe individual cases of suicide (Abimilech, Samson, Saul and his armor-bearer, Ahithophel, and Zimri), nowhere do they express general disapproval of suicide. However, the Greek-influenced Jewish soldier and historian Flavius Josephus (37 CE100 CE) rejects it as an option for his defeated army, and clear prohibitions of suicide appear in Judaism by the time of the Talmud during the first several centuries CE, often appealing to the Biblical text Genesis 9:5: "For your lifeblood I will demand satisfaction." New Testament does not specifically condemn suicide, and mentions only one case: the self-hanging of Judas Iscariot after the betrayal of Jesus. There is evident disagreement among the early Church Fathers about the permissibility of suicide, especially in one specific circumstance: among others, Eusebius Pamphilus (c. 264340), Ambrose (c. 340397), and Jerome (c. 342420) all considered whether a virgin may kill herself in order to avoid violation.

While Christian values clearly include patience, endurance, hope, and submission to the sovereignty of God, values that militate against suicide, they also stress willingness to sacrifice one's life, especially in martyrdom, and absence of the fear of death. Some early Christians (e.g., the Circumcellions, a subsect of the rigorist Donatists) apparently practiced suicide as an act of religious zeal. Suicide committed immediately after confession and absolution, they believed, permitted earlier entrance to heaven. Rejecting such reasoning, St. Augustine asserted that suicide violates the commandment Thou shalt not kill and is a greater sin than any that could be avoided by suicide. Whether he was simply clarifying earlier elements of Christian faith or articulating a new position remains a matter of contemporary dispute. In any case, it is clear that with this assertion, the Christian opposition to suicide became unanimous and absolute.

This view of suicide as morally and religiously wrong intensified during the Christian Middle Ages. St. Thomas Aquinas argued that suicide is contrary to the natural law of self-preservation, injures the community, and usurps God's judgment "over the passage from this life to a more blessed one" (Summa theologiae 2a 2ae q64 a5). By the High Middle Ages the suicide of Judas, often viewed earlier as appropriate atonement for the betrayal of Jesus, was seen as a sin worse than the betrayal itself. Enlightenment writers began to question these views. Thomas More incorporated euthanatic suicide in his Utopia. In Biathanatos, John Donne (c. 15721631) treated suicide as morally praiseworthy when done for the glory of Godas, he claimed, was the case for Christ; David Hume mocked the medieval arguments, justifying suicide on autonomist, consequentialist, and beneficent grounds.

Later thinkers such as Mme. de Staël (Anne Louise Germaine, née Necker, the baroness Staël-Holstein)although she subsequently reversed her positionand Arthur Schopenhauer construed suicide as a matter of human right. Throughout this period, other thinkers insisted that suicide was morally, legally, and religiously wrong: among them, John Wesley (17031791) said that suicide attempters should be hanged, and Sir William Blackstone (17231780) described suicide as an offense against both God and the king. Immanuel Kant used the wrongness of suicide as a specimen of the moral conclusions the categorical imperative could demonstrate. In contrast, the Romantics tended to glorify suicide, and Friedrich Nietzsche insisted that "suicide is man's right and privilege."

Although religious moralists have continued to assert that divine commandment categorically prohibits suicide, that suicide repudiates God's gift of life, that suicide ruptures covenantal relationships with other persons, and that suicide defeats the believer's obligation to endure suffering in the image of Christ, the volatile discussion of the moral issues in suicide among more secular thinkers ended fairly abruptly at the close of the nineteenth century. This was due in part to Émile Durkheim's insistence that suicide is a function of social organization, and also to the views of psychological and psychiatric theorists, developing from Jean Esquirol (17721840) to Sigmund Freud, that suicide is a product of mental illness. These new scientific views reinterpreted suicide as the product of involuntary conditions for which the individual could not be held morally responsible. The ethical issues, which presuppose choice, reemerged only in the later part of the twentieth century, stimulated primarily by discussions in bioethics of terminal illness and other dilemmas at the end of life.

Suicide and Martyrdom in Monotheist Religious Traditions

The major monotheisms, Judaism, Christianity, and Islam, all repudiate suicide though in each, martyrdom is recognized and venerated. Judaism rejects suicide but venerates the suicides at Masada and accepts Kiddush Hashem, self-destruction to avoid spiritual defilement. At least since the time of Augustine, Christianity has clearly rejected suicide but accepts and venerates martyrdom to avoid apostasy and to testify to one's faith. Islam also categorically prohibits suicide but at the same time defends and expects martyrdom to defend the faith. Yet whether the distinction between suicide and martyrdom falls in the same place for Judaism, Christianity, and Islam is not clear. Judaism appears to accept self-killing to avoid defilement or apostasy; Christianity teaches submission to death where the faith is threatened but also celebrates the voluntary embrace of death in such circumstances; some Islamic fundamentalists support the political use of suicide bombing, viewing it as consistent with Islam and its teachings of jihad, or holy war to defend the faith, though others view this as a corruption of Islamic doctrine.

Thus, while all three traditions revere those who die for the faith as martyrs and all three traditions formally repudiate suicide, at least by that name, the practices they accept may be quite different: Christians would not accept the mass suicide at Masada; Jews do not use the suicide-bombing techniques of their Islamic neighbors in Palestine; and Muslims do not extol the passive submission to death of the Christian martyrs, appealing on Quranic grounds to a more active self-sacrificial defense of the faith.

Other Religious and Cultural Views of Suicide

Many other world religions hold the view that suicide is prima facie wrong but that there are certain exceptions. Still others encourage or require suicide in specific circumstances. Known as institutionalized suicide, such practices in the past have included the sati of a Hindu widow who was expected to immolate herself on her husband's funeral pyre; the seppuku or hara-kiri of traditional Japanese nobility out of loyalty to a leader or because of infractions of honor; and, in traditional cultures from South America to Africa to China, the apparently voluntary submission to sacrifice by a king's retainers at the time of his funeral in order to accompany him into the next world. Inuit, Native American, and some traditional Japanese cultures have practiced voluntary abandonment of the elderly, a practice closely related to suicide, in which the elderly are left to die, with their consent, on ice floes, on mountaintops, or beside trails.

In addition, some religious cultures have held comparatively positive views of suicide, at least in certain circumstances. The Vikings recognized violent death, including suicide, as guaranteeing entrance to Valhalla. Some Pacific Island cultures regarded suicide as favorably as death in battle and preferable to death by other means. The Jains, and perhaps other groups within traditional Hinduism, honored deliberate self-starvation as the ultimate asceticism and also recognized religiously motivated suicide by throwing oneself off a cliff. On Mangareva, members of a traditional Pacific Islands culture also practiced suicide by throwing themselves from a cliff, but in this culture not only was the practice largely restricted to women, but a special location on the cliff was reserved for noble women and a different location assigned to commoners. The Maya held that a special place in heaven was reserved for those who killed themselves by hanging (though other methods of suicide were considered disgraceful), and, though the claim is disputed, may have recognized a goddess of suicide, Ixtab. Many other pre-Columbian peoples in the Western hemisphere engaged in apparently voluntary or semi-voluntary ritual self-sacrifice, notably the Aztec practice of heart sacrifice, which was generally characterized at least at some historical periods by enhanced status and social approval. The view that suicide is intrinsically and without exception wrong is associated most strongly with post-Augustinian Christianity of the medieval period, surviving into the present; this absolutist view is not by and large characteristic of other cultures.

Ethical Issues in Contemporary Application: Physician-Assisted Suicide

The right to die movement emerging in the 1970s, 1980s, and 1990s, counting among its achievements the passage of natural death, living will, and durable power of attorney statues that gave patients greater control in decision making about their end-of-life medical care, also raised the question of what role the dying person might play in shaping his or her own death and what role the physician might play in directly assisting the patient's dying. These notions have often appealed to the concept of death with dignity, though the coherence of that notion is sometimes challenged. Public rhetoric quickly labeled the practice at issue physician-assisted suicide although less negatively freighted labels such as physician-aid-in-dying or physician-negotiated death have also been advanced as more appropriate.

Proponents of legalizing the practice have argued in its favor on two principal grounds: (1) autonomy, the right of a dying person to make his or her own choices about matters of deepest personal importance, including how to face dying, and (2) the right of a person to avoid pain and suffering that cannot be adequately controlled. Opponents offer two principal competing claims: (1) that fundamental moral principle prohibits killing, including self-killing, and (2) that allowing even sympathetic cases of physician assistance in suicide would lead down the slippery slope, as overworked doctors, burdened or resentful family members, and callous institutions eager to save money would manipulate or force vulnerable patients into choices of suicide that were not really their own. Pressures would be particularly severe for patients with disabilities, even those who were not terminally ill, and the result would be widespread abuse.

Compromise efforts, launched by bioethicists, physicians, legal theorists, and others on both sides, have focused primarily on the mercy argument from avoiding pain: It is claimed that improving pain control in terminal illness, including accelerated research, broader education of physicians, rejection of outdated concerns about addiction associated with opioid drugs, and recourse to terminal sedation or induced permanent unconsciousness if all else fails will serve to decrease requests for physician assistance in suicide. These compromise views also hold that assistance in suicide should remain, if available at all, a last resort in only the most recalcitrant cases.

However, although proponents of physician-assisted suicide welcome advances in pain control, many reject this sort of compromise arguing that it restricts the freedom of a person who is dying to face death in the way he or she wants. They point out that other apparent compromises, such as the use of terminal sedation, are both repugnant and can be abused, since full, informed consent may not actually be sought. Proponents also object on grounds of equity: It is deeply unfair, they insist, that patients dependent on life-support technology such as dialysis or a respirator can achieve a comparatively easy death at a time of their own choosing by having these supports discontinuedan action fully legalbut patients not dependent on life supports cannot die as they wish but must wait until the inevitable end when the disease finally kills them.

Many opponents of physician-assisted suicide reject attempts at compromise as well, sometimes arguing on religious grounds that suffering is an aspect of dying that ought to be accepted, sometimes holding that patients' wishes for self-determination ought not override the scruples of the medical profession, and sometimes objecting to any resort at all to assisted dying, even in very rare, difficult cases. And some who accept the claim that death is sometimes a benefit to which a person can be morally entitled still object that placing this choice in the hands of patient would make him or her worse off by obliging him or her to choose at all, even if the choice is against. There is little resolution, however, of the competing claims of autonomist and mercy claims on the one hand and wrongness-of-killing and social-consequences views on the other. Like the social arguments over abortion, disagreement continues both at the level of public ferment and at the deeper level of philosophical principle although the raising of the issue itself has meant far greater attention to issues about death and dying.

Ethical Issues in Contemporary Application: Suicide in Old Age

While comparatively rarely discussed in contemporary moral theory, the more difficult applied question concerns suicide in old age for reasons of old age alone though this is said to be an issue that will increasingly confront an aging society. In both historical argumentation and the very small amount of contemporary theorizing, the fundamental issues of suicide in old age concern two distinct sets of reasons for suicide, in practice often intertwined: (1) Reasons of self-interest : suicide in order to avoid the sufferings, physical limitations, loss of social roles, and stigma of old age; (2) Other-regarding reasons : suicide in order to avoid becoming a burden to others, including family members, caretakers, immediate social networks, or society as a whole.

Contemporary reflection, at least explicitly, countenances neither of these as adequate reasons for suicide in old age. With regard to self-interested reasons, modern gerontology maintains a resolutely upbeat and optimistic view of old age, insisting that it is possible to ameliorate many of the traditional burdens of old agechronic illness, isolation, poverty, depression, and chronic painby providing better medical care, better family and caregiver education, and more comprehensive social programs. With respect to other-regarding reasons, including altruistic reasons, contemporary views consider it unconscionableespecially in the wealthy societies of the developed worldto regard elderly persons as burdens to families or to social units or to the society; nor is it thought ethically permissible to allow or encourage elderly persons to see themselves this way. While the notion that the elderly are to be venerated is associated primarily with the traditional cultures of the Asia, especially China, Western societies also insist, though sometimes ineffectually in a youth-oriented culture, on respect for the aged and on enhancing long lives. Simply put, the prevalent assumption in the Western cultures in the twenty-first century is that there can be no good reasons for suicide in old age even though suicide is frequent, especially in men in old age. Daniel Callahan (1930), although opposing suicide in old age, points to contemporary medicine's relentless drive for indefinite extension of life, arguing that the elderly should forgo heroic life-prolonging care and refocus their attention instead on turning matters over to the next generation. Carlos Prado (1937), exploring issues of declining competence, raises the issue of preemptive suicide in advanced age. Colorado Governor Richard Lamm's widely (mis)quoted remark that the elderly have a "duty to die," unleashed a small storm of academic and public discussion concerning suicide in terminal illness and in old age (Hardwig 1997).

Hints of real social friction can be seen over both self-interested and other-regarding and altruistic reasons for suicide in old age. Having fully legalized physician-assisted suicide and voluntary active euthanasia, the Netherlands is now considering whether to honor advance directives such as living wills in which a now-competent person requests physician-aided death after the onset of Alzheimer disease, a condition particularly frequent among the elderly. Double-exit suicides, often of married partners in advanced age even though only one is ill, startle public awareness. Disputes over generational equity in the face of rising health care costs question whether life prolongation means merely the extension of morbidity and whether health care ought to be preferentially allocated to the young rather than the old. The issue of whether a person may ethically and reasonably refuse medical treatment in order to spare health care costs to preserve an inheritance for his or her family is already beginning to be discussed; the same issue also raises the question of suicide. And issues about suicide in old age are posed by far-reaching changes in population structure, the graying of societies in Europe and the developed world: As birthrates fall and the proportion of retirees threatens to overwhelm the number of still-working younger people, could there be any obligation, as Euripides (c. 480406 BCE) put it in The Suppliants nearly 2,500 years ago, go "hence, and die, and make way for the young"?

No party now encourages suicide for the elderly, and, indeed, no party even raises the issue; but the issue of suicide as a response to self-interested avoidance of the conditions of old age and to other-interested questions about social burdens of old age cannot be very far away. Drawing as they might on both Stoic and Christian roots in the West and on non-Western practices now coming to light, the ethical disputes over suicide in old age, independent of illness, are likely to intensify the currently vigorous debate over suicide in terminal illness: Can suicide in old age represent, as one author puts it, the last rational act of autonomous elders, or does it represent the final defeated event in a series of little tragedies of all kinds?

See also Aristotle; Augustine, St.; Consequentialism; Durkheim, Émile; Epistemology; Freud, Sigmund; Hume, David; Kant, Immanuel; More, Thomas; Nietzsche, Friedrich; Plato; Pythagoras and Pythagoreanism; Romanticism; Schopenhauer, Arthur; Staël-Holstein, Anne Louise Germanie Necker, Baronne de; Socrates; Stoicism; Thomas Aquinas, St.

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Margaret Pabst Battin (2005)

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Suicide

SUICIDE

SUICIDE . The topic of religiously motivated suicide is a complex one. Several of the major religious traditions reject suicide as a religiously justifiable act but commend martyrdom; among them are Judaism, Christianity, and Islam. These religions distinguish between actively willing to end one's life in suicide and passively accepting one's death as the divine will by means of martyrdom at the hands of another. Nonetheless, the actions of some of the early Christian martyrs and the deaths of the Jews at Masada in 74 ce blur this distinction.

In contrast to religiously motivated suicide one may speak of heroic and altruistic suicide, the act of a person who decides that he or she has an ethical responsibility to die for the sake of community or honor. One must also differentiate between religiously motivated suicide and suicide that may be virtually forced upon an individual by the norms of society and may constitute either a duty or a punishment. One thinks of satī, widow burning in India, and of seppuku, self-disembowelment, when it occurred as a punishment in Japan. In these cases too, however, no simple distinction holds true. Satī became an accepted practice within medieval Hinduism, upheld by the brahmans, and accounts indicate that even into modern times it was often a voluntary practice. By her self-sacrifice the widow both achieved an honored status for herself and atoned for the sins and misdeeds of herself and her husband. Seppuku was often the voluntary last act of a defeated warrior who chose to demonstrate both his fealty to his lord and his mastery over himself.

Like the major Western traditions, both Buddhism and Confucianism condemn suicide, but there are examples of self-immolation by Buddhist monks and of the seeking of honorable death by Confucian gentlemen. In contrast to these traditions, Jainism regards favorably the practice of sallekhana, by which a Jain monk or layperson at the end of his lifetime or at the onset of serious illness attains death by gradual starvation.

These few examples demonstrate the complexity of the topic of religiously motivated suicide and the difficulty in distinguishing it from martyrdom or sacrifice, on the one hand, and from heroic or altruistic suicide, on the other. In addition, the occurrence in 1978 of the mass suicides at Jonestown, Guyana, raises the question of the relation between religious motivations for suicide and general fear of persecution, combined with mass paranoia. This question applies equally well to the mass suicide of Jews faced with persecution in York, England, in 1190 and to the mass suicides of Old Believers in Russia in the late seventeenth century.

On the whole, what may be termed religiously motivated suicides constitute but a small proportion of the total number of suicides. In his classic work Le suicide, Émile Durkheim discussed the social causes for egoistic, altruistic, and anomic suicides. His work and that of many other scholars demonstrate that suicide has most often occurred for reasons other than religious ones. These include the desire to avoid shame, to effect revenge, to demonstrate one's disappointment in love, and to escape senility and the infirmities of old age. Suicide as a means of avoiding shame and upholding one's honor was considered a creditable act in societies as different as those on the Melanesian island of Tikopia, among the Plains and Kwakiutl Indians of North America, and in ancient Rome.

Scholars have argued that the incidence of and attitude toward suicide are largely dependent on the individual's and society's view of the afterlife. Where death is perceived as a happy existence, scholars such as Jacques Choron believe, there is an inducement to suicide. In the first known document that apparently reflects on suicide, the Egyptian text entitled The Dialogue of a Misanthrope with His Own Soul, death is seen as attractive because it will lead to another and better existence. The tendency toward suicide is strengthened when suicide is regarded either as a neutral act or as one worthy of reward. Suicide rates also increase when this life is regarded as no longer acceptable or worthwhile. For example, Jim Jones, the founder of the Peoples' Temple, urged his followers in Guyana to commit suicide in order to enter directly into a new and better world, where they would be free of persecution and would enjoy the rewards of the elect. In the Jonestown community, suicide on a mass scale was appreciated as a religiously justifiable act that would be rewarded in the afterlife.

Ancient Greek and Roman Civilization

While the ancient Greek writers and philosophers did not consider suicide an action that would lead to a better existence, they did see it as an appropriate response to certain circumstances. The fact that Jocasta, the mother of Oedipus, chose to commit suicide upon learning of her incestuous relationship with her son was understood and appreciated by the ancients as an appropriate response to a disastrous situation. Heroic suicide in the face of a superior enemy and the choice of death to avoid dishonor or the agony of a lengthy terminal illness were accepted as justifiable actions. Through the voice of Socrates, Plato in his Phaedo did much to form the classical attitude toward suicide. Socrates himself chose to drink the hemlock, but he also affirmed the Orphic notions that humans are placed in a prison from which they may not release themselves and that they are a possession of the gods. The decision to commit suicide is thus an act against the gods, depriving them of their prerogative to end or to sustain human life. The key word for both Plato and Socrates is necessity. A person may appropriately end his life only when the gods send the necessity to do so upon him, as in fact they did to Socrates. Plato's disciple, Aristotle, argued even more strongly against suicide. He regarded it as an offense against the state, since by such an act a person fails to perform his obligations as a citizen. Thus it became a social outragea view that has continued to dominate thought in the West until the most recent times.

Whereas the Pythagoreans and Epicureans opposed suicide, the Stoics regarded it favorably under certain circumstances. The Stoic was obliged to make a decision that properly addressed the demands of the situation; at times the decision might be to commit suicide. Both Zeno and his successor, Cleanthes, are reported to have done so.

Heroic suicide and suicide to avoid dishonor or suffering became frequent within the society of the Roman empire. Seneca, in particular, moved beyond the insistence on a divine call or necessity for suicide to the assertion that suicide at the appropriate time is a basic individual right. For Seneca, the central issue was freedom, and he affirmed that the divine had offered humankind a number of exits from life; he himself chose to exercise the right to suicide. His successor, Epictetus, placed more limits on suicide, stressing again the belief that one must wait for the divine command before acting: The suffering that is a normal part of daily life for much of humanity does not of itself constitute a sufficient reason for suicidealthough exceptional pain and suffering offer justifiable cause. For Epictetus, Socrates was the best model and guide in deciding when one might legitimately choose to end one's life.

Judaism

Whereas suicide was at the very least tolerated, and often applauded, among the ancient Greeks and Romans, the Hebrew people disapproved of it. Judaism draws a clear distinction between suicide, which it defines as self-murder, and martyrdom, which it defines as death on behalf of one's faith and religious convictions. Nonetheless, the Hebrew scriptures, which contain few references to dying by one's own hand, do describe several instances of heroic suicide. The king Abimelech, gravely wounded by a woman, called upon his armor-bearer to kill him (Jgs. 9:5254). Although he did not literally kill himself, his command to his aide may be regarded as effecting what he could not perform himself, so that he might not die in dishonor. The death of Samson (Jgs. 16:2831) may certainly be judged a heroic suicide, since by his act he brought about the demise of a large number of the enemy Philistines. The gravely injured Saul fell upon his own sword in order to avoid a disgraceful death at the hands of his enemies (1 Sm. 31:4), and his armor-bearer, who had failed his master's request to kill him, then fell upon his own sword. The death of Ahithophel, the counselor to David and then to David's son Absalom, would appear to be a suicide motivated by disgrace. When Absalom refused to follow the advice Ahithophel gave him regarding his battle with David, Ahithophel returned home, set his affairs in order, and hanged himself (2 Sm. 17:23). The last suicide recorded in the Hebrew scriptures, the death of the king Zimri, occurred because of the loss of a decisive battle (1 Kgs. 16:18).

Although Hebrew scriptures do not explicitly forbid suicide, the Judaic tradition came to prohibit it, partly in the belief that God alone gives life and takes it away, and partly on the basis of the sixth commandment, which forbids unjustified homicide. However, rabbinic law regards persons committing suicide as most frequently being of unsound mind and thus not responsible for their actions. Under these circumstances, they may still receive normal Jewish burial rites. Furthermore, suicides committed under duress, as for example to avoid murder, idolatry, or adultery, were considered blameless and indeed even praiseworthy. The mass suicide at Masada in 74 ce and other mass suicides in Europe during the Middle Ages were considered in this light.

Concerning Masada, the historian Josephus Flavius recounts, on the basis of the report of a few survivors, that on the eve of the Roman assault on that hill the leader of the vastly outnumbered Jewish resistance, Elʿazar ben Yaʾir, called the community together and reminded them of their vow not to become the slaves of the Romans. That night many of the soldiers killed their families and committed suicide. Others drew lots to decide who would kill his fellows and then die by his own hand. It is impossible to say how many of the more than nine hundred defenders allowed themselves to be killed and how many ended their lives by suicide. In spite of the Jewish prohibition against suicide, Masada came to be regarded as a heroic sacrifice, and it remains a living symbol of a people's response to oppression.

Although accounts of individual suicide within Judaism are rare, there are examples of mass suicides during times of persecution. During the First Crusade, in 1096, Jews who had obtained sanctuary in the bishop's castle at Worms chose mass suicide over baptism; similar instances of suicide to avoid baptism occurred in various Rhineland towns, such as Mayence, and in York, England, where in 1190 some 150 Jews set fire to the building in which they had sought safety and then consigned themselves to the flames. Yet other instances of mass suicide occurred during the Black Death, when popular superstition blamed the outbreak of the plague on the Jews. Although abuse and persecution were certainly major motivating factors during the periods of the Crusades and the Black Death, these mass or multiple suicides appear to have arisen from a deep religious desire to remain true to the faith. They point again to the difficulty in distinguishing between, on the one hand, suicides motivated by fear of persecution and, on the other, suicides motivated by religious convictions and ideals, deaths that in the latter case the tradition judges to be acts of martyrdom. Certainly the deaths at Masada must be regarded as both faithful obedience to religious affiliation and identity and the culmination of a desire to give the Jews' enemies a hollow victory.

Christianity

Christianity repudiates suicide on much the same biblical grounds as does Judaism. The only suicide recorded in the New Testament is that of Jesus' betrayer, Judas Iscariot; it is described in such a way as to indicate that it was a sign of repentance for his deed (Mt. 27:35). The church father Tertullian referred even to Jesus' death as voluntarya description approximating that of suicide, since clearly a divine being controls his own life. In his book Conversion (1962), Arthur Darby Nock points to the "theatricality" present in some of the actions of the early martyrs, as in "the frequent tendency of Christians in times of persecution to force themselves on the notice of the magistrates by tearing down images or by other demonstrations" (p. 197). Bishop Ignatius of Antioch, writing to his fellow Christians in Rome, pleaded that they do nothing to hinder his martyrdom but allow him to be consumed entirely by the beasts. But whereas Tertullian asserted that only martyrs would reach paradise before the Parousia, Clement of Alexandria sought to stem the tide of those rushing to martyrdom by differentiating between self-motivated suicide and genuine martyrdom for the faith.

In his City of God, which appeared in 428 ce, the church father Augustine wrote against suicide in a way that became determinative for the tradition. He discussed various situations in which a Christian might find himself or herself, and concluded that suicide is not a legitimate act even in such desperate circumstances as those of a virgin seeking to protect her virtue. Augustine argued that suicide is a form of homicide, and thus prohibited by the sixth commandment; that a suicide committed in order to avoid sin is in reality the commission of a greater sin to avoid a lesser; and that one who commits suicide forfeits the possibility of repentance. Subsequent church councils, as well as such eminent theologians as Thomas Aquinas in the thirteenth century, sided with Augustine. Suicide, in contrast to martyrdom, came to be regarded as both a sin and a crime. Dante placed suicides in the seventh circle of the inferno in his Divine Comedy, and popular opinion throughout Christian Europe regarded suicides in the same light as witches and warlocks. Indeed, their corpses were treated in a similar manner: Suicides were frequently buried at crossroads with stakes driven through their hearts to prevent their ghosts from causing harm. The last recorded instance of such a burial in England occurred in 1823, and the law mandating confiscation of the property of a convicted suicide remained on the books until 1870.

In spite of ecclesiastical censure, religious impulse did lead to suicides, sometimes on a mass scale. Some thirteenth-century Cathari or Albigensians may have chosen suicide by starvation. Even more dramatic are the accounts of the Old Believers (raskolʾniki) in late-seventeenth-century Russia who chose death by fire over obedience to liturgical changes introduced by the archbishop Nikon, with the subsequent backing of the tsars. According to tradition, on several occasions one to two thousand people who had been besieged by government troops, as at Paleostrovskii monastery in 1688, locked themselves within chapels or monasteries and burned them to the ground, consigning their own bodies to the flames.

Although martyrdom as a testimony to one's faith continues to be honored within Christianity, suicide as an individual act undertaken for nonreligious motives is regarded as a sin, and until recently it was regarded as a crime unless done in ignorance of its implications or in a state of lunacy. Few Christian theologians and philosophers challenged this view. John Donne, who served as dean of Saint Paul's in London, was a notable exception. In his book Biathanatos, written in 1608 but not published until 1644, Donne challenged the Augustinian belief that suicides cannot repent; he argued that a totally negative attitude toward suicide places limitations on the mercy and charity of God. New attitudes toward suicide were subsequently expounded by a variety of philosophers such as David Hume, who argued that suicide is not a crime. However, although the Christian attitude toward suicide may now be characterized as more compassionate than during earlier periods, the act of suicide, in contrast to martyrdom, continues to be regarded as a serious sin.

Islam

Islam joined Judaism and Christianity in prohibiting suicide (intiār ) while glorifying those who die the death of a martyr (shahīd) or witness to the faith. While scholars debate whether or not the Qurʾān itself specifically forbids suicide, they agree that the adīth, the traditions that preserve the words of the Prophet on a wide variety of issues, prohibit suicide. According to these sources, Muammad proclaimed that a person who commits suicide will be denied Paradise and will spend his time in Hell repeating the deed by which he had ended his life. By the tradition's own standards, religiously motivated suicide is an impossibility, since the taking of one's own life is both a sin and a crime. Nonetheless, as with Judaism and Christianity, the line between suicide and martyrdom is not clear. Since it is believed that the Muslim martyr who dies in defense of the faith is rewarded with immediate entrance into Paradise, where he or she will enjoy great pleasures and rewards, it would not be surprising if some Muslims readily participated in battles even when badly outnumbered, in the hope that they might die while fighting.

Within Islam the Shīʿī sect emphasizes the self-sacrifice and suffering of its imams, the successors to Muammad. The death of usayn, the grandson of the Prophet, and the third imam, was regarded by his followers as an act of voluntary self-sacrifice that could be termed a religiously motivated death. Although he died on the battlefield, his death was subsequently interpreted as a goal he both desired and actively sought; the passion play enacted as the climax of ʿshūrāʾ (tenth of Muarram) depicts his death as actively willed. In a translation of this play (Muhammedan Festivals, edited by G. E. von Grunebaum, New York, 1951) Husayn says: "Dear Grandfather [Muammad], I abhor life; I would rather go visit my dear ones in the next world" (p. 92). Within Shiism, and the Ismāʿīlī sect, asan-i Sabbā in the twelfth century formed the order of the Assassins, which was devoted to establishing its own religious and governmental autonomy, in part by killing both Crusaders and Sunnī Muslims. The death of a member of this order was regarded not as a suicide, even when his mission had been one almost certain to result in his death, but rather as a glorious martyrdom that would earn him both the veneration of society and the delights of Paradise. The tradition cites many accounts of a mother who rejoiced on hearing of the death of her son, only to put on mourning clothes when she learned subsequently that he had not died and thus had not attained the glorious state of martyrdom.

Hinduism and Jainism

In discussing Judaism, Christianity, and Islam, this article has pointed to the close relationship between suicide and martyrdom and the difficulty frequently encountered in distinguishing between them. Regarding the religions of the East, the difficult issue is the relation between suicide and sacrifice. In Hinduism, the Brāhmaas laid the foundation for religiously motivated suicide by declaring that the fullest and most genuine sacrifice is that of the individual's self. The Śatapatha Brāhmaa outlines the procedure by which one renounces the world, forsaking one's belongings and departing into the forest. Certainly Hinduism affirms that suicide must be a thoughtful decisionas in the resolve of a person to end the sufferings of old ageor that it must be a religiously motivated act. One Upaniad condemns those who attempt suicide without having attained the necessary degree of enlightenment. The Dharmasūtras firmly prohibit any suicide other than one religiously motivated. In ancient and medieval Hinduism a number of methods of committing suicide were regarded favorably, such as drowning oneself in the Ganges, jumping from a cliff, burning oneself, burying oneself in snow, or starving oneself to death. Various places of pilgrimage, such as Prayāga (present-day Allahabad) or Banaras, were seen as particularly auspicious places for ending one's life.

Two types of suicide in Hinduism, very different in form and intention, are worthy of special examination. The first is the death by suicide of the enlightened person, the world renouncer. Such a person, in his or her quest for release from sasāra, has been devoted to increasingly difficult acts of penance and to a thorough study of the Upaniads. Once this person has attained the goal of freedom from all desires, he or she may begin the great journey in the direction of the northeast, consuming nothing other than air and water. According to the lawgiver Manu, a brahman might also follow this procedure when beginning to be overcome by a serious illness.

The second form of suicide in Hinduism that deserves special attention is satī, widow burning. It appears to have been a form of suicide motivated by both social and religious considerations. Although the custom is not unique to India, it nonetheless was practiced there most frequently and over the longest period of time. The practice may go back as far as the fourth century bce, but it began to grow in popularity only after about 400 ce. According to Upendra Thakur in his study The History of Suicide in India, "satī in its latest forms was a mediaeval growth though it had its germs in ancient customs and rituals" (1963, p. 141). The practice of satī might take one of two forms. In one, sahamaraa, the woman ascended the funeral pyre and was burned alongside the corpse of her husband. In the second, anumaraa, when the wife learned that her husband had died and his body had already been cremated, she would ascend the pyre and die alongside his ashes, or with some belonging of his. Certainly, at least in some cases, satī was motivated by genuine feelings of grief and affection on the part of the widow. Although the practice remained voluntary, in some areas social pressure may have made satī more the rule than the exception. No doubt the practice also gained popularity because the life of a widow was both lonely and degrading. On the other hand, the blessing or curse of a woman on her way to perform satī was believed to be very powerful, and her act of sacrifice was believed to purify both herself and her husband. Thus, although the act of satī may not always have been religiously motivated, it did have its religious reward. The British, during their rule of India, made a determined effort to abolish the practice, finally outlawing it as homicide in 1829.

Perhaps the tradition that most explicitly condones religiously motivated suicide is Jainism. Following the teaching of their saint Mahavira, who lived in the sixth century bce, the Jain monk and the Jain layperson lead, in differing degrees, a rigorously ascetic life in order to attain liberation and to free the soul from karma. Members of the laity as well as monks are encouraged to practice sallekhanā (austere penance), in order to attain a holy death through meditation. Jains believe it is their duty to prevent disease or the infirmities of old age from undermining the spiritual progress they have attained through asceticism and meditation. Jainism prescribes strict rules for when sallekhanā is appropriate. As Padmanabh S. Jaini indicated in his book The Jaina Path of Purification, Jainism distinguishes between impure suicide, by which the passions are increased, and pure suicide, the holy death attained with "inner peace or dispassionate mindfulness" (Jaini, 1979, p. 229). Sallekhanā involves gradual fasting, often under the supervision of a monastic teacher, until the stage is reached whereat the individual no longer consumes any food or drink and thus gradually attains death by starvation. Jains perceive sallekhanā to be the climax of a lifetime of spiritual struggle, ascetic practice, and meditation. It allows the individual to control his own destiny so that he will attain full liberation or at the very least reduce the number of future reincarnations that he will undergo.

Buddhism and Confucianism

Turning to Buddhism and Confucianism, one finds that suicide is legislated against in both traditions, but that there are notable exceptions involving religiously motivated suicide. Gautama Buddha, in his personal search for salvation, deliberately chose against the practice of fasting unto death. Nonetheless, under certain extraordinary circumstances, Buddhists see religiously motivated suicide as an act of sacrifice and worship. Indications of this positive attitude toward suicide, or self-sacrifice, are found in some of the accounts of the Buddha's previous lives contained in the Jatakas (Birth Tales). The stories of the Buddha's previous lives as a hare (Śaśa Jātaka) and as a monkey (Mahākapi Jātaka) both describe suicide as an act of self-sacrifice to benefit another, and only in the story of the monkey does this act lead to death. Another famous account is that from the Suvaraprabhāsa, a Mahāyāna sūtra, which describes the suicide or sacrifice of the Buddha, during his life as the prince Mahāsattva, in order to feed a hungry tigress unable to care for herself. Following this model, Buddhism in its various forms affirms that, while suicide as self-sacrifice may be appropriate for the person who is an arhat, one who has attained enlightenment, it is still very much the exception to the rule.

Confucianism based its attitude toward suicide on another consideration, that of filial piety and obligation. The person who commits suicide robs his ancestors of the veneration and service due them and demonstrates his ingratitude to his parents for the gift of life. The duty of a gentleman is to guide his life according to li, the code or rules of propriety. In rare cases, suicide was required of the gentleman who failed to uphold these rules. In some instances a gentleman might commit suicide to protest improper government, since above all a gentleman was obliged to uphold the virtue of humaneness. Thus, in these unusual instances suicide was the correct way to demonstrate adherence to the precepts of Confucianism.

Although the Japanese tradition of seppuku, or harakiri, should be regarded in its voluntary form as heroic rather than as religiously motivated suicide, it nonetheless does contain certain religious elements. The standard by which all acts of seppuku (disembowelment) were judged was set by the heroic Minamoto Yorimasa during a desperate battle in 1180. While suicide was usually performed as an individual act by a noble warrior or samurai, there are examples in Japanese history of mass suicides, such as that of the forty-seven ronin who accepted the penalty of seppuku in order to avenge the death of their lord in 1703.

While Christian missionaries in Japan, from the time of the arrival of the first Jesuits, sought to prevent seppuku, the Zen Buddhist tradition continued to regard it as a form of honorable death. The selection of the hara, or belly, as the point at which the sword was plunged into the body reflected the belief that the abdomen is the place where one exercises control over one's breathing and is, indeed, the central point of self-discipline. More generally, as Ivan I. Morris states in his book The Nobility of Failure, the abdomen was considered in the Japanese tradition as "the locus of man's inner being, the place where his will, spirit, generosity, indignation, courage, and other cardinal qualities were concentrated" (Morris, 1975, p. 367). Thus, by committing oneself to the performance of seppuku, which became a clearly defined ritual, one demonstrated in this final act the greatest degree of self-control, discipline, and courage.

Conclusion

This article has focused directly on religiously motivated suicide. It has omitted references to suicide among elderly Inuit (Eskimo) and among young Tikopia islanders, to cite only two examples from a vast number of possibilities. In these cases, as in many others, although the suicides may be heroic or altruistic, they do not demonstrate a clear religious motivation. Suicides by reason of financial failure, or loss of honor or of a loved one, occur among the Kwakiutl and Iroquois Indians, as well as among Bantu-speaking peoples of Africa. Occurrences of suicide are not limited by geography or time, but of the many suicides that have taken place throughout the ages, only a small proportion can be judged to be religiously motivated.

The examples of religiously motivated suicide discussed here demonstrate the wide variety of forms and purposes that the act may take. Many of the examples, from both East and West, illustrate the difficulty in distinguishing between suicide that is religiously motivated and suicide that is motivated by heroism, altruism, or fear of persecution and suffering. The deaths at Jonestown in 1978 raise anew the problem of how to differentiate between religiously motivated suicide and suicide induced by paranoia and terror. There is no simple distinction between suicide and martyrdom, on the one hand, or between suicide and sacrifice, on the other. In formulating these distinctions and in evaluating the morality and religious value of certain acts that result in death, each person brings to bear his or her own religious and ethical values and tradition. Such personal judgment must, however, be conjoined with the awareness that what may be perceived by one observer as needless self-sacrifice or even self-murder may be judged by another as the noblest example of religiously motivated suicide in behalf of beliefs, values, or tradition.

See Also

Martyrdom.

Bibliography

There is a vast literature on suicide, but relatively little of it focuses on the act as religiously motivated. Any student of the topic must begin with Émile Durkheim's Le suicide, translated by John A. Spaulding and George Simpson as Suicide: A Study in Sociology (New York, 1951). It is the classic work on the varieties of suicide analyzed from a sociological viewpoint. Jacques Choron's chapters on "Suicide in Retrospect" and "Philosophers on Suicide" in his volume Suicide (New York, 1972) are quite helpful in understanding the place of suicide in the West at different times. A volume edited by Frederick H. Holck, Death and Eastern Thought: Understanding Death in Eastern Religions and Philosophies (Nashville, 1974), contains several chapters that refer to suicide. Alfred Alvarez also discusses the themes of religious motivation for suicide and religious prohibition of the act in his book The Savage God: A Study of Suicide (London, 1971). He includes personal reflections on his own suicide attempt, and describes his friendship with the poet Sylvia Plath, who committed suicide in 1963.

Among the older studies of the topic, still useful are Suicide: A Social and Historical Study by Henry Romilly Fedden (London, 1938) and To Be or Not to Be: A Study of Suicide by Louis I. Dublin and Bessie Bunzel (New York, 1933).

There are relatively few sources that consider religiously motivated suicide in specific traditions. For the Western religious traditions, the reader should refer to the bibliography of the article Martyrdom as well as to the various primary sources mentioned throughout this article. In addition, for Judaism, the reader will find useful Yigael Yadin's Masada: Herod's Fortress and the Zealots' Last Stand (New York, 1966) and Cecil Roth's A History of the Jews in England (Oxford, 1941), which discusses the events at York. On Christianity, particularly informative is Samuel E. Sprott's The English Debate on Suicide from Donne to Hume (La Salle, Ill., 1961). William A. Clebsch has prepared a new edition of John Donne's work, translated as Suicide (Chico, Calif., 1983), with a very helpful introduction. Robert O. Crummey presents a fascinating account of suicides among the Raskolʾniki in his book The Old Believers and the World of Antichrist: The Vyg Community and the Russian State, 16941855 (Madison, Wis., 1970). See especially his chapter entitled "Death by Fire." On Islam, the most useful secondary source remains Franz Rosenthal's "On Suicide in Islam," Journal of the American Oriental Society 66 (1946): 239259. For the Assassins, one should consult the comprehensive historical account by Marshall G. S. Hodgson in The Order of Assassins: The Struggle of the Early Nizârï Ismâʿïlïs against the Islamic World (1955; New York, 1980).

For the Eastern traditions, in addition to the volume edited by Holck and the primary texts mentioned in the article, the following books are useful sources for individual traditions. For Hinduism, see both the older account by Edward Thompson, Suttee: A Historical and Philosophical Enquiry into the Hindu Rite of Widow-Burning (London, 1928), and the more comprehensive study by Upendra Thakur, The History of Suicide in India: An Introduction (Delhi, 1963). For Jainism, Padmanabh S. Jaini offers a detailed account of sallekhanā in his book The Jaina Path of Purification (Berkeley, 1979). The Buddhist account entitled "The Bodhisattva and the Hungry Tigress" may be found in the volume edited by Edward Conze, Buddhist Scriptures (Harmondsworth, 1959). For the Japanese attitude toward suicide and death, see the fascinating work by Ivan I. Morris, The Nobility of Failure: Tragic Heroes in the History of Japan (New York, 1975), and for the study of seppuku among the warrior class, see The Samurai: A Military History by S. R. Turnbull (New York, 1977).

New Sources

Buddhism

Jan, Yün-Hua. "Buddhist Self-Immolation in Medieval China." History of Religions 4 (1965): 243268. A survey of Chinese Buddhist texts providing justifications of religious suicide.

Lamotte, Etienne. "Le suicide religieux dans le bouddhisme." Bulletin de la Classe des Lettres et des Sciences de l'Académie royale de Belgique 51 (1965). 156168. A monographic study by the foremost scholar of classic Buddhism.

McCutcheon, Russell. Manufacturing Religion. Oxford, 1997. See the pp. 167177 for the self-immolations of the Vietnamese Buddhist monks, providing a non-historical political explanation which is unreliable from the religious-historical point of view.

Hinduism

Bosch, Lourens P. van den. "A Burning Question: Sati and Sati Temples as the Focus of Political Interest." Numen 37 (1990): 174194. The issue is situated in the context of religion's definition.

Weinberger-Thomas, Catherine. Ashes of Immortality: Widow-Burning in India. Chicago, 1999. A radically new interpretation of satī based on fieldwork in northern India as well as extensive textual analysis.

New Cults

Introvigne, Massimo. "The Magic of Death: The Suicides of the Solar Temple." In Millennialism, Persecution, and Violence. Historical Cases edited by Catherine Wessinger. Syracuse, N.Y., 2000, pp. 287321.

Kabazzi-Kisiniria, S. Deusdedit, R. K. Nkurunziza, and Gerald Banura. The Kanungu Cult-Saga. Suicide, Murder or Salvation? Kampala, Uganda, 2000.

Mayer, Jean-François. Il Tempio Solare. Turin, Italy, 1997.

Nesci, Domenico Arturo. The Lessons of Jonestown. An Ethnopsychoanalytic Study of Suicidal Communities. Rome, 1999. The author is a professional psychoanalyst and psychiatrist but writes as a humanist

Wessinger, Catherine. How the Millenium Comes Violently. From Jonestown to Heaven's Gate. New York and London, 2000.

Islam

Cook, David. "Suicide Attacks or 'Martyrdom Operations' in Contemporary Jihad Literature" Nova Religio: The Journal of Alternative and Emergent Religions. 6, no. 1 (2002): 744.

Marilyn J. Harran (1987)

Revised Bibliography

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Suicide

SUICIDE

A term derived from the Latin suicidium, meaning the taking of one's own life. In the broadest sense it is applied to any voluntary act by which one causes his own death. In the strictest moral sense it means an unlawful moral act, positive or negative, by which one directly causes his own death.

One can cause his own death voluntarily either by a positive act of self-destruction or by refusing or neglecting to do something known to be necessary for the preservation of one's life. The difference between a positive act and an omission is notable from a physical point of view, but it is of little moral consequence. To fail to do something physically and morally necessary to the preservation of life is the moral equivalent of a positive act of self-destruction. A man who bleeds to death because he will not close an open artery is no less a suicide than one who opens an artery with the intent of taking his own life.

Morality. Catholic moralists are generally agreed that direct suicide is intrinsically evil, and they hold therefore that no circumstances can ever justify it. Examples of suicide in cases in which its malice is less apparent have been the subject of much discussion. Samson's deed as recorded in Jgs 16.2930 and that of Eleazar as recorded in 1 Mc 6.46 would seem to be examples of indirect rather than direct suicide, although the distinction between the two was not clearly drawn by older authors who found difficulty in explaining the incidents. The deaths of Saul and Ahithophel (1 Sm 31.26 and 2 Sm 17.23) are recorded in the Scriptures without comment, and there is no need to justify them. The same is true of the suicide of Razis (2 Mc 14.4146); although the incident is narrated sympathetically, it is possible to regard suicide as an objectively wicked thing, but committed in inculpable ignorance of its malice.

If suicide is intrinsically evil, God could not command it, and it is not true, as some have alleged, that direct suicide is permissible if it is committed in response to a special inspiration of God, the Lord of life and of death. This is a solution proposed by some to explain the suicides of certain holy virgins, venerated as saints and martyrs, who killed themselves in defense of their virtue. However, virtue can be adequately defended by other means than suicide, and a person who is forcibly violated does not, on that account, lose her or his virtue. Surrendering One's Life. It is important to distinguish between the willing surrender of one's life and the deliberate taking of it. It has been common for some writers to refer to the former as indirect suicide and to apply the principle of double effect to justify it as in cases when a person knowingly gives up his life in the pursuit of some good end or to prevent some grave wrong. Examples are the soldier who throws himself on a hand grenade to protect those around him, the truck driver who chooses to steer his vehicle over a precipice to avoid a collision with a school bus, the action of St. Maximillian kolbe who volunteered to take the place of a fellow prisoner who was sentenced to be executed, or an individual who dies on a hunger strike as part of a non-violent response to social injustice. More and more, writers avoid speaking of indirect suicide because such actions reflect neither the true nature of suicide as a choice to end one's life, nor an appropriate application of the principle of double effect. Rather, these examples embody the supreme charity of willingly sacrificing one's life for others in imitation of him who taught that there is no greater love than to lay down one's life for one's friends (Jn 15, 13).

Pastoral Considerations. Although the 1917 Code of Canon Law denied ecclesiastic burial to individuals who committed suicide (c. 1240), the Church's pastoral attitude grew more lenient over time. While recognizing suicide is objectively ("materially") sinful, the culpability of the act depends on the state of mind of the individual. Illness or depression, for example, may diminish the person's freedom in acting. Great discretion is allowed the pastor in determining culpability, and in allowing the full rites of Christian burial.

Another question, both practical and urgent, that is difficult to resolve apart from knowing the particular requires concerns individuals engaged in guerilla activities, espionage, or other operations employed in modern warfare. If captured by the enemy, they may face the probability or even the certainty of interrogation under torture so artfully contrived that no one could be reasonably expected to endure it without breaking. People likely to be put in such a situation are not uncommonly given a capsule of poison to be used in case of capture. Can it be argued that a person, when captured under such circumstances, is on the point of becoming, in a material sense at least, an unjust aggressor against those whose secrets he possesses, and as such, may he be slain if there is no other way to control his aggression? Again, if an individual sees himself faced with the immediate prospect of becoming an aggressor in this way, can he legitimately take his own life? These and related questions require deep reflection and great sensitivity on the part of pastoral ministers.

See Also: euthanasia; health, care of.

Bibliography: thomas aquinas, Summa Theologiae 2a2ae, 64.5. m. p. battin, Ethical Issues in Suicide (Englewood Cliffs, N.J. 1982). a. salvatore, "Professional Ethics and Suicide: Toward an Ethical Typology," Ethics, Law, and Aging Review 6 (2000): 257-69.

[t. c. kane/

j. f. tuohey]

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Suicide

SUICIDE

The duty of preserving life, including one's own, is one of the paramount injunctions of Judaism (see *pikku'aḥ nefesh). The prohibition of suicide is a natural corollary to this, and yet it is nowhere explicitly forbidden in the Talmud. However, post-talmudic authorities considered suicide a most heinous sin, even worse than murder. It was thought to be a denial of the doctrines of reward and punishment, the world to come, and the sovereignty of God, and the opinion was expressed that the suicide forfeits his portion in the world to come. Suicide is sharply to be differentiated from martyrdom, which, under certain circumstances, is the greatest mitzvah of Judaism; a difference must also be made between letting oneself be killed and active suicide (see *Kiddush ha-Shem and Ḥillul ha-Shem).

Four definite suicides are recorded in the Bible. Samson (Judg. 16:30), Saul and his armor-bearer (i Sam. 31:4–5), and Ahithophel (ii Sam. 17:23). The first three are regarded as "suicide under mitigating circumstances," so to speak. The Midrash, which regards suicide as rare (Gen. R. 82:8), includes the prohibition of suicide ("self-strangulation") in the injunction "and surely your blood of your lives will I require" (Gen. 9:5), but specifically excludes Saul as well as *Hananiah, Mishael, and Azariah (Gen. R. 34:13). The Shulḥan Arukh (yd 345:3) takes Saul as an example of permitted suicide "because he knew that the Philistines would do with him as they wished, and put him to death" (Siftei Kohen, ad loc.). Samson's suicide, which brought in its train the death of the Philistines, is extolled as kiddush ha-Shem. The most famous act of suicide in Jewish history is the mass self-immolation of the garrison of *Masada in 73 c.e. as reported by Josephus (Wars, 7:320ff.). It has been suggested that they acted in accordance with their interpretation of the halakhah which included slavery and subjection to a foreign power as one of those principles concerning which one was enjoined "to be killed rather than transgress" (Rabinowitz, see bibl.). Other cases of suicide – such as the mass suicide in York in 1190 – which were motivated by either a desire to avoid forced conversion or fear, are considered to be acts of martyrdom.

It was only in the late post-talmudic tractate Semaḥot (Evel Rabbati 2:1–5) that the laws regarding suicide are formulated. It is laid down that no rites are to be performed in honor of the dead (e.g., *keri'ah and *hesped), but everything which appertains to respect for the mourners is permitted (yd 345:1; Maim. Yad, Evel 1:11). Solomon b. Abraham *Adret states that the "nothing to be done" does not include burial and shrouds (Rashba, Resp., vol. 2, no. 763). R. Ishmael states that an announcement was made concerning the suicide, "Woe, he has taken his life," but R. Akiva disagreed, saying to him, "Leave him in silence. Neither honor him nor curse him." Two cases are mentioned in the context of children (not necessarily minors) who committed suicide out of fear of punishment. The suicides were granted the full respects due to the dead. The moral which the rabbis derived from it was that it is better to punish than threaten punishment (Sem. 2:4–5).

A distinction is made between suicide while of sound mind (la-da'at) – to which alone these restrictions apply and suicide while of unsound mind (she-lo la-da'at), to which they did not apply; thus the suicide of a minor is not regarded as culpable. Only when there is the clearest evidence of felo-dese, deliberate intent, is a suicide to be considered as being of sound mind. "Who is a suicide of sound mind? It is not so regarded if a man climbed a tree or a roof and fell to his death, but only where he states, 'I am climbing the roof or the tree and I am going to throw myself to my death,' and one sees him acting accordingly… a man found strangled or hanging from a tree or cast upon a sword is regarded as a suicide while of unsound mind" (Sem. 2:2–3). It was, and in some places still is, the custom to bury suicides in a special section of the cemetery, but in recent years the tendency has grown to remove this stigma from the suicide, since the verdict is usually suicide while of unsound mind. The slightest indication is enough to establish a state of "unsound mind" (J.M. Tukacinsky, Gesher ha-Ḥayyim, 1 (19602), ch. 25, which also contains a full list of the laws regarding a suicide).

Apart from exceptional circumstances, such as during the Nazi persecutions, the incidence of suicides among Jews has been small. The mass suicides which took place during the Middle Ages to avoid forcible baptism, which are generally regarded as belonging to the category of kiddush ha-Shem, were not without their critics (see the incident recounted in Da'at Zekenim, to Gen. 9:5). The self-immolation of Meir Feinstein and Moshe Barazani who blew themselves to death in prison in Jerusalem in 1947 on the eve of their execution in order to cheat the hangman, was justified on the analogy of Saul. Their original intention, to commit the act on the way to the scaffold, causing the simultaneous death of their potential executioners, was based on the example of Samson. Rabbi S. *Goren (see bibl.), the chief rabbi of the Israel Defense Army, expressed the view that a soldier taken prisoner was entitled, and even obliged, to commit suicide if he feared that he might not be able to withstand torture, or that under it he might reveal military secrets. He was, however, subjected to considerable criticism for this view. However, with the growth of acculturation in the Western world, there is evidence that the rate among Jews is rising and approximating to that of the general population. See *Mental Illness.

[Louis Isaac Rabinowitz]

In Jewish Law

"But for your own life-blood I will require a reckoning" (Gen. 9:5) – these are the suicides whose blood is claimed by God (Gen. R. 34:13; Yad, Roẓe'aḥ 2:3). The "reckoning" is, of course, God's only, but on earth the suicide is denied certain honors due to the dead, provided the surviving mourners are not aggrieved by such denials (Sem. 2:1; yd 345:1). The suggestion that words of scorn be exclaimed at this grave was met by R. Akiva with the rejoinder, "do not abase him and do not praise him" (Sem. 2:1). In order to be reprehensible, the suicide must be voluntary and premeditated (me'abbed aẓmo la-da'at, that is, he must knowingly destroy himself). A person destroying himself is presumed to do so without the necessary premeditation (she-lo la-da'at) – whether from pathological depression and not being in possession of his mental faculties (cf. Yad, Sanhedrin 18:6), or from "duress" (see *Penal Law). Duress includes not only compulsion, such as the necessity to kill oneself rather than surrender to the enemy or violate God's laws (see below), but also the (subjectively) reasonable despair of life or the identification with a person who just died. Most of the suicides reported in Bible, Talmud, and Midrash fall into either of these categories, which may explain the fact that they are not adversely or deprecatingly commented upon. (For those in the Bible, to which the (possible) suicide of Zimri (i Kings 6:18) may be added, see above.) Examples in the Talmud are that of the servant of Judah ha-Nasi who killed himself when learning of his master's death (Ket. 103b), and of the pagan executioner who joined Hananiah (Ḥanina) b. Teradyon in the flames (Av. Zar. 18a).

Duress is also present where the suicide amounts to self-inflicted punishment for real or imagined sinfulness: the apostate Yakum of Ẓerorot is said to have entered paradise after having taken his own life in a manner devised to combine all four modes of judicial execution (Mid. Ps. to 11:7); and Ḥiyya b. Ashi is said to have caused his own death in despair over an offense he intended to commit and thought he had committed, though in fact he had not committed it at all (Kid. 81b). Where a man chooses to die rather than surrender to the heathen, no question of duress arises, because his conduct is highly praiseworthy (Git. 57b); the most notable instances are those related in the Books of the Maccabees (e.g., ii Macc. 14:37–46) and the reported mass suicide at Masada (which has recently given rise to some halakhic discussion). As for the violation of Divine law, while every man has to decide for himself whether he will kill himself rather than commit any such violation (Git. 57b), the law was settled to the effect that where he is required to commit idolatry, adultery (gillui arayot), or murder, he must kill himself or let himself be killed rather than commit any of those crimes (Sanh. 74a; Sh. Ar., yd 157).

The scope of duress being as wide as it is, the law will presume that a man found dead from his own hand took his life involuntarily and without premeditation (Sem. 2:3), until the contrary is proved from what the man himself had been heard to say before his death (Sem. 2:2). As far as minors are concerned, the presumption of duress appears to be irrebuttable (Sem: 2:4–5; yd 345:3). So long as the presumption is not rebutted, a suicide may not in any way be discriminated against (Yad, Evel 1:11). The law, however, has to take cognizance of attempted suicide: a person who does any act by which he endangers his own life is liable to disciplinary *flogging (makkat mardut; Yad, Roẓeʾaḥ 11:5). Opinions are divided whether a man may inflict nonfatal wounds on himself (bk 91b); and the law is that while he is not allowed to do so, he is not punishable if he does so (bk 8:6; Ḥm 420:31); yet not only might he be punished at the hands of heaven (Tosef., bk 9:31), but the disciplinary flogging may always be imposed in lieu of punishment (Yad, Roẓe'aḥ 11:5; Ḥm 427:10). If suicide attempts are epidemic or otherwise constitute a threat to national security, the court may exercise its emergency powers and impose not only floggings but also *imprisonment (cf. Yad, Roze'ah 2:4–5).

[Haim Hermann Cohn]

Suicide to Avoid Severe Torture

Throughout the generations halakhic authorities have confronted questions concerning the permissibility of suicide in situations other than when it becomes necessary to avoid committing one of the three cardinal prohibitions previously discussed. These questions arose during periods of anti-Jewish violence and pogroms and attempts to coerce Jews into to apostasy.

Rabbenu Tam (Tos. Avodah Zarah, 18a) ruled that it is a mitzvah to commit suicide in order to escape extreme pain and torture, especially when used against a person to coerce apostasy. According to other halakhic authorities, suicide under such circumstances, is not required but permitted (Maim., Torat ha-Adam), while according to other authorities, such suicide is prohibited (Maharshal, Yam shel Shelomo, bk 8:59).

During the *Holocaust, this question again arose in a practical context. In Resp. Mi-Ma'amakim (1.6), Rabbi Ephaim Oshry relates to a question submitted by a Jew from the Kovno ghetto who asked whether he was allowed to commit suicide to avoid a horrible death accompanied by severe suffering as well as to avoid witnessing the deaths of his family.

The responsum discusses the opinions of earlier authorities, and cites the incident of the suicide of King Saul (i Samuel 31:4), The answer given was that, under the circumstances, suicide was permitted, but the author requested that the responsum not be publicized to prevent it from providing assistance to Nazi murderers by sowing despair among the Jews.

The responsum concludes with the following comment: "Nonetheless we may take pride in the fact that there were no suicides in the Kovno ghetto with the exception of three people whose morale was completely shattered. The remaining Ghetto residents continued to believe and were fully confident that God would not abandon His people and would halt the murderers."

[Menachem Elon (2nd ed.)]

bibliography:

S. Goren, in: Maḥanayim, 87 (1964), 7–12; L.I. Rabinowitz, in: Sinai, 55 (1964), 329–32; Ch. W. Reines, in: Juda, 10 (1961), 160–70. in jewish law: A. Roth, Eine Studie ueber den Selbstmord, vom juedischen Standpunkte (1878); J. Ginzburg, Mishpatim le-Yisra'el (1956), 247–57, 307f.; J. Nedava, in: Mishpat ve-Kalkalah, 3 (1956/57), 87–99; Z. Rabinowicz, in: Harofe Haivri, 34 (1961), 153–6; et, 12 (1967), 681f. add. bibliography: M. Elon, Ha-Mishpat ha-Ivri (1988), 2:1156; idem, Jewish Law (1994), 3:1389; A. Ben Zimra, "Kedushat ha-Ḥayyim u-Messirut Nefesh bi-Ymei ha-Shoah al-pi ha-Halakhah," in: Sinai, 80 (1977), 151–85; J.D. Bleich, Judaism and Healing (1981), 158–61; S. Goldstein, Suicide in Rabbinic Literature (1989); S. Goren, "She'elah u-Teshuvah be-Niddon Gibborei Meẓadah," in: Or ha-Mizraḥ, 7:3 (1960), 22–27; M.Z. Neriah, "Hitabdut le-Da'at – Giborei Meẓada le-Or ha-Halakhah," in: Or ha-Mizraḥ, 8 (1961) 8–12; A. Steinberg, Enẓiklopedyah Hilkhatit Refu'it, 1: 7–17; idem, "Hitabdut le-Or ha-Halakhah," in: Halakhah ve-Refu'ah (1988) 281–95.

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Suicide

Suicide

Definition

Demographics of suicide

Causes

Treatment of attempted suicide

Related issues

Prevention

Resources

Definition

Suicide is defined as the intentional taking of one’s own life. In some European languages, the word for suicide translates into English as “self-murder.” Until the end of the twentieth century, approximately, suicide was considered a criminal act; legal terminology used the Latin phrase felo-de-se, which means “a crime against the self.” Much of the social stigma that is still associated with suicide derives from its former connection with legal judgment, as well as with religious condemnation.

In the social climate of 2007, suicidal behavior is most commonly regarded—and responded to—as a psychiatric emergency.

Demographics of suicide

There are almost 11 suicide deaths each year for every 100,000 people living the United States, and for every suicide, there were between eight and 20 attempts. There are over 30,000 suicides each year in the United States, or about 82 each day; each day about 1,500 people attempt suicide. The demographics of suicide vary considerably from state to state, with rates higher than the national average in the West and lower in the Midwest and Northeast. Some states, like Alaska, have suicide rates that are almost twice the national average; others, such as Massachusetts, have notably lower rates.

These variations from state to state result in part from differences in age and ethnic distributions and gender ratios among the states. In 2004, suicide was the eleventh leading cause of death in the United States, according to the National Institute of Mental Health, and it was the eighth leading cause of death among males and sixteenth leading cause of death among females. Males are four times more likely

than females to succeed in their suicide attempts, but females report attempting suicide sometime in their lives three times as often as men. Among ethnic groups, suicide rates are highest among white males, followed closely by American Indian and Native Alaskan males. In terms of age, most suicides are committed by people under age 40, but suicide rates (percentages in a given group) increase with age. People over age 65 have high suicide rates, with men outnumbering women who commit suicide nearly four to one. Among people over age 65, suicide rates are high compared to the national average, with slightly more than 14 deaths for every 100,000 people in this age group, and among Hispanic men in this age group, rates are even higher at almost 18 deaths per 100,000 men.

The overall rate of suicide among young people has declined slowly since 1992, but it still remains the third leading cause of death in age groups spanning children 10 years old to young adults up to age 24. Suicides among young people ages 15 to 24 show an extreme male bias: Four times as many males as females ages 15 to 19 and six times as many males age 20 to 24 committed suicide in 2004. Over half of suicides in this group were firearm related, and males in general are far more likely to use firearms.

High-risk factors

Research indicates that the following factors increase a person’s risk of suicide:

  • Male sex.
  • Age over 75.
  • A family history of suicide.
  • A history of suicide attempts.
  • A history of abuse in childhood.
  • Traumatic experiences after childhood
  • Recent stressful events, such as separation or divorce, job loss, or death of spouse.
  • Chronic medical illness. Patients with AIDS have a rate of suicide 20 times that of the general population.
  • Access to a firearm. Death by firearms now accounts for the majority of suicides.
  • Alcohol or substance abuse. While mood-altering substances do not cause a person to kill himself or herself, they weaken impulse control.
  • High blood cholesterol levels.
  • Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a mental illness. Major depression accounts for 60% of suicides, followed by schizophrenia, alcoholism, substance abuse, borderline personality disorder, Huntington’s disease, and epilepsy. The lifetime mortality due to suicide in psychiatric patients is 15% for major depression; 20% for bipolar disorder; 18% for alcoholism; 10% for schizophrenia; and 5-10% for borderline and certain other personality disorders.

Low-risk factors

Factors that lower a person’s risk of suicide include:

  • A significant friendship network outside the workplace.
  • Religious faith and practice, especially those that discourage suicide and encourage self preservation.
  • A stable marriage.
  • A close-knit extended family.
  • A strong interest in or commitment to a project or cause that brings people together: community service, environmental concerns, neighborhood associations, animal rescue groups, etc.

Suicide in other countries

Suicide has become a major social and medical problem around the world. The World Health Organization (WHO) reported that one million people worldwide died from suicide in the year 2000. That is a global mortality rate of 16:100,000—or one death by suicide every 40 seconds. Since the mid-1950s, suicide rates around the world have risen by 60%. Rates among young people have risen even faster, to the point where they are now the age group at highest risk in 35% of the world’s countries.

The specific demographics, however, vary from country to country. China’s pattern, for example, is very different from that of most other countries. China has a suicide mortality rate of 23:100,000, with a total of 287,000 deaths by suicide each year. The rate for women is 25% higher than that for men, and rates in rural areas are three times higher than in cities. The means also vary; in China, Sri Lanka, and Turkey the primary means of suicide is ingestion of pesticides, rather than using firearms.

Causes

Suicide is an act that represents the end result of a combination of factors in any individual. One model that has been used by clinicians to explain why people suffering under the same life stresses respond differently is known as the stress/diathesis model. Diathesis is a medical term for a predisposition that makes some people more vulnerable to thoughts of suicide. In addition to factors at the individual level, factors in the wider society have been identified as contributing to the rising rate of suicide in the United States:

  • Stresses on the nuclear family, including divorce and economic hardship.
  • The loss of a set of moral values held in common by the entire society.
  • The weakening of churches, synagogues, and other mid-range social groups outside the family. In the past, these institutions often provided a sense of belonging for people from troubled or emotionally distant families.
  • Frequent geographical moves, which makes it hard for people to make and keep long-term friendships outside their immediate family.
  • Sensationalized treatment of suicide in the mass media. A number of research studies have shown that there is a definite risk of “contagion” suicides from irresponsible reporting, particularly among impressionable adolescents.
  • The development over the past century of medications that allow relatively painless suicide. For most of human history, the available means of suicide were uncertain, painful, or both.
  • The easy availability of firearms in the United States.

Treatment of attempted suicide

Researchers estimate that 8-25 people attempt suicide for every person who completes the act. Suicide attempts can be broadly categorized along a continuum that ranges from seriously planned attempts involving a highly lethal method that fail by chance to impulsive or poorly planned attempts using a less lethal method. Suicide attempts at the lower end of the spectrum are sometimes referred to as suicide gestures or pseudocide.

A suicide attempt of any kind, however, is treated as a psychiatric emergency by rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation, a mental status examination, and a detailed assessment of the circumstances surrounding the attempt. The physician will interview relatives or anyone else who accompanied the patient in order to obtain as much information as possible. As a rule, suicide attempts requiring advance planning, including precautions taken against discovery, and the use of violent or highly lethal methods are regarded as the most serious. The patient will be kept under observation while decisions are made about the need for hospitalization.

A person who has attempted suicide and who is considered a serious danger to him- or herself or to others can be hospitalized against their will. The doctor will base the decision on the severity of the patient’s depression or agitation; availability of friends, relatives, or other social support; and the presence of other suicide risk factors, including a history of previous suicide attempts, substance abuse, recent stressful events, and symptoms of psychosis. If the attempt is judged to be a nonlethal suicide gesture, the patient may be released after the psychiatric assessment is completed.

Related issues

Survivors of suicide

One group of people that is often overlooked in discussions of suicide is the friends and family of the victim. It is estimated that each person who kills himself or herself leaves six survivors to deal with the aftermath. Based on this figure, there are some 4.5 million survivors of suicide in the United States. In addition to the grief that ordinarily accompanies death, survivors of suicide often struggle with feelings of guilt and shame as well. In spite of a general liberalization of social attitudes since World War II, suicide is still stigmatized in many parts of Europe and the United States. Survivors often benefit from group or individual psychotherapy in order to work through such issues as wondering whether they could have prevented the suicide or whether they are likely to commit suicide themselves. Increasing numbers of clergy as well as mental health professionals are taking advanced training in counseling survivors of suicide.

Assisted suicide

One question that has been raised in developed countries as the average life expectancy increases is the legalization of assisted suicide a person suffering from a painful terminal illness. Physician-assisted suicide and euthanasia have become topics of concern since legalization of one or both by recent legislation in the Netherlands (in April 2001), Belgium (in 2002), and in the state of Oregon (passed in 1994; upheld by the U.S. Supreme Court in 2005). It is important to distinguish between physician-assisted suicide and euthanasia, or “mercy killing.” Assisted suicide, which is often called “self-deliverance” in Britain, refers to a person’s bringing about his or her own death with the help of another person. Because the other person is often a doctor, the act is often called “physician-assisted suicide.” Strictly speaking, euthanasia means that the physician or other person is the one who performs the last act that causes death. For example, if a physician injects a patient with a lethal overdose of a medication, he or she is performing euthanasia. If the physician leaves the patient with a loaded syringe and the patient injects himself or herself with it, the act is an assisted suicide. As of 2007, assisted suicide is illegal everywhere in the

KEY TERMS

Assisted suicide —A form of self-inflicted death in which a person voluntarily brings about his or her own death with the help of another, usually a physician, relative, or friend.

Cortisol —A steroid hormone released by the cortex (outer portion) of the adrenal gland when a person is under stress. Cortisol levels are now considered a biological marker of suicide risk.

Dexamethasone test —Serves as a marker of suicide risk by reflecting signaling activity between the brain and the adrenal gland.

Diathesis —The medical term for predisposition. The stress/diathesis model is a diagram that is used to explain why some people are at greater risk of suicidal behavior than others.

Euthanasia —The act of putting a person or animal to death painlessly or allowing them to die by withholding medical services, usually because of a painful and incurable disease. Mercy killing is another term for euthanasia.

Frontal cortex —The part of the human brain associated with aggressiveness and impulse control. Abnormalities in the frontal cortex are associated with an increased risk of suicide.

Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle, and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.

Slow suicide —A term used to refer to lifestyle behaviors known to shorten life expectancy, such as smoking, drinking heavily, having unsafe sex, etc.

Suicide gesture —Attempted suicide characterized by a low-lethality method, low level of intent or planning, and little physical damage. Pseudocide is another term for a suicide gesture.

United States except for Oregon, and euthanasia is illegal in all fifty states.

Media treatment of suicide

In 1989, the Centers for Disease Control (CDC) sponsored a national workshop to address the issue of the connection between sensationalized media treatments of suicide and the rising rate of suicide among American youth. The CDC and the American Association of Suicidology subsequently adopted a set of guidelines for media coverage of suicide intended to reduce the risk of suicide by contagion.

The CDC guidelines point out that the following types of reporting may increase the risk of “copycat” suicides:

  • Presenting oversimplified explanations of suicide, when in fact many factors usually contribute to it. One example concerns the suicide of the widow of a man who was killed in the collapse of the World Trade Center on September 11, 2001. Most newspapers that covered the story described her death as due solely to the act of terrorism, even though she had a history of depressive illness.
  • Excessive, ongoing, or repetitive coverage of the suicide.
  • Sensationalizing the suicide by inclusion of morbid details or dramatic photographs. Some news accounts of the suicide of an Enron executive in January 2002 are examples of this problem.
  • Giving “how-to” descriptions of the method of suicide.
  • Referring to suicide as an effective coping strategy or as a way to achieve certain goals.
  • Glorifying the act of suicide or the person who commits suicide.
  • Focusing on the person’s positive traits without mentioning his or her problems.

Prevention

Research on brain physiology has become an important aspect of suicide prevention. Because major depression is the single most common diagnosis in suicidal people, earlier and more effective recognition of depression is a necessary preventive measure. Known biological markers for an increased risk of suicide can now be correlated with personality profiles linked to suicidal behavior under stress to help identify individuals at risk. One new clinical parameter that may be considered with personality profiles is the dexamethasone suppression test, which serves as an indicator of hyperactivity of a neuroendocrine hormonal pathway between the brain and the adrenal gland. Another clinical parameter that may be combined with psychological assessment is an assessment of

serotonin function based on cholesterol levels, with high levels indicating a risk. In addition, brain imaging studies using positron emission tomography (PET) are being used to detect abnormal patterns of serotonin uptake in specific regions of the brain. Genetic studies are also yielding new information about inherited predispositions to suicide.

A second major preventive measure is education of clinicians, media people, and the general public. Public health studies carried out in Sweden have shown that seminars for primary care physicians in the recognition and treatment of depression resulted in a rise in the number of prescriptions for antidepressants and a drop in suicide rates. Education of the general public includes a growing number of CDC, NIMH, and other web sites posting information about suicide, tips for identifying symptoms of depressed and suicidal thinking, and advice about helping friends or loved ones who may be at risk. Many of these web sites have direct connections to suicide hotlines.

An additional preventive strategy is restricting access to firearms in the developed countries and to pesticides and other poisons in countries where these are the preferred method of suicide.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington D.C.: American Psychiatric Association, 2000.

Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. “Psychiatric Disorders.” Current Medical Diagnosis & Treatment 2001. Ed. L. M. Tierney Jr., MD, and others. 40th ed. New York: Lange Medical Books/McGraw-Hill, 2001.

“Psychiatric Emergencies.” Section 15, Chapter 194. The Merck Manual of Diagnosis and Therapy. Ed. Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

“Suicidal Behavior.” Section 15, Chapter 190. The Merck Manual of Diagnosis and Therapy. Ed. Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

“Suicide in Children and Adolescents.” Section 19, Chapter 264. The Merck Manual of Diagnosis and Therapy. Ed. Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

PERIODICALS

Coryell, William H., MD. “Clinical assessment of suicide risk in depressive disorder.” CNS Spectrums 11(2006): 255–461.

Fu, Q., A. C. Heath, K. K. Bucholz, and others. “A Twin Study of Genetic and Environmental Influences on Suicidality in Men.” Psychology in Medicine 32 (January 2002): 11–24.

Gibb, Brandon E., Lauren B. Alloy, Lyn Y. Abramson, and others. “Childhood Maltreatment and College Students’ Current Suicidal Ideation: A Test of the Hopelessness Theory.” Suicide and Life-Threatening Behavior 31 (2001): 405–15.

Mancinelli, Iginia, MD, and others. “Mass Suicide: Historical and Psychodynamic Considerations.” Suicide and Life-Threatening Behavior 32 (2002): 91–100.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. www.aacap.org

American Association of Suicidology. Suite 310, 4201 Connecticut Avenue, NW, Washington, DC 20008. (202) 237-2280. Fax: (202) 237-2282. www.suicidology.org

National Institutes of Mental Health (NIMH). NIMH Public Inquiries: (800) 421-4211. www.nimh.nih.gov

WEB SITES

World Health Organization. “Suicide: Fact Sheet” http://www.cdc.gov/ncipc/factsheets/suifacts.htm and http://www.cdc.gov/nchs/fastats/suicide.htm

National Institute of Mental Health. NIH publication 03-4594 (2006) “Suicide in the U.S.: statistics and prevention.” http://www.nimh.nih.gov/publicat/harmaway.cfm

Suicide Prevention Resource Center. State-by-state information. http://www.sprc.org/stateinformation and http://www.sprc.org/stateinformation/datasheets.asp

National Library of Medicine. “Suicide” http://www.nlm.nih.gov/medlineplus/suicide.html

World Health Organization. “Suicide prevention” http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

OTHER

Befrienders International. www.befrienders.org

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Programs for the Prevention of Suicide Among Adolescents and Young Adults; and Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop. MMWR 1994; 43 (No. RR-6). www.cdc.gov/ncipc

Mann, J. John, MD. “The Neurobiology of Suicide.” Mental Health Clinical Research Center for the Study of Suicidal Behavior, Columbia-Presbyterian Medical Center, New York. www.afsp.org

National Suicide Hotline: (800) SUICIDE (800-784-2433).

Rebecca Frey, Ph.D.
Emily Jane Willingham, Ph.D.

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Suicide

Suicide

Definition

Suicide is defined as the intentional taking of one's own life. In some European languages, the word for suicide translates into English as “self-murder.” Until fairly recently, suicide was considered a criminal act; legal terminology used the Latin phrase felo de se, which means “a crime against the self.” Much of the social stigma that is still attached to suicide derives from its former association with legal as well as religious condemnation.

As of the early 2000s, however, suicidal behavior is most commonly regarded as and treated as a psychiatric emergency. Law enforcement personnel may be involved in preventing an attempted suicide or taking suicidal individuals to a hospital emergency department but not in arresting these persons for breaking the law.

Description

Researchers estimate that 8 to 25 people in the general population attempt suicide for every person who completes the act; however, seniors have a lower

U.S. suicide deaths, 2005
Age group Number of deaths
source: National Center for Injury Prevention and Control,
Centers for Disease Control and Prevention, U.S. Department of
Health and Human Services
(Illustration by GGS Information Services. Cengage Learning, Gale)
50–543,227
55–592,477
60–641,733
65–691,198
70–741,146
75–791,143
80–841,057
85+860
Total 12,841

rate of suicide attempts than younger Americans. The ratio of attempted suicides to completed suicides among people over 65 is thought to be as low as 4:1. By contrast, according to the National Strategy for Suicide Prevention (NSSP), seniors are more likely than younger persons to use highly lethal means of suicide. According to a Canadian study published in 2008, seniors are most likely to use firearms to commit suicide, followed by hanging, self-poisoning, and leaping from heights.

Demographics

The incidence of suicide and attempted suicide among seniors is widely perceived as a growing public health problem in the United States; as of 2008, older adults represent about 13 percent of the U.S. population but account for 20 percent of suicides. According to the National Institute of Mental Health (NIMH), the highest suicide rate in the nation is for Caucasian men ages 85 and older: 65.3 deaths per 100,000 persons, about six times the national U.S. rate of 10.8 per 100,000.

In the United States, the rate of suicide has continued to rise since the 1950s. More people in the general population die from suicide than homicide in North America. Suicide is the eighth leading cause of death in North America; there are over 30,000 suicides per year in the United States, or about one every 17 minutes; and each day about 1,500 people attempt suicide.

Risk factors in seniors

Research conducted by the NIMH indicates that the following factors increase a senior's risk of suicide:

  • Male sex; three-fourths of suicides among seniors involve males.
  • Age over 65.
  • White race. Asian men, Hispanic men, and African American men are less likely to attempt or commit suicide than Caucasians.
  • A family history of suicide.
  • A history of previous suicide attempts.
  • A history of abuse in childhood.
  • Recent stressful events: separation or divorce; job loss or financial difficulty; death of spouse, partner, friend, or pet.
  • Medical illness. Many elderly people commit suicide when they are diagnosed with a terminal illness.
  • Chronic, severe, or intractable pain.
  • Loss of mobility or independence.
  • Alcohol or substance abuse. Mood-altering substances do not inevitably drive individuals to kill themselves; however, these substances weaken impulse control.
  • Presence of a psychiatric illness. Over 90 percent of Americans, including seniors, who commit suicide had a significant mental illness. Major depression accounts for 60 percent of all suicides. Other mental disorders accounting for suicide among seniors include schizophrenia, alcoholism, substance abuse, borderline personality disorder, Huntington's disease, and epilepsy.

Protective factors

Factors that lower seniors' risk of suicide include:

  • A significant friendship network.
  • Religious faith and practice. Older African American women have a particularly low rate of suicide and a high rate of church membership.
  • A stable marriage or close-knit extended family.
  • A strong interest in or commitment to a project or cause that brings people together, for example, community service, neighborhood associations, book clubs, and hobby groups.

Treatment of attempted suicide

Suicide attempts can be broadly categorized along a continuum that ranges from planned attempts, involving highly lethal methods that fail by good fortune, to impulsive or poorly planned attempts, using less lethal methods. Suicide attempts that are unlikely to succeed are sometimes referred to as suicide gestures or pseudocide.

A suicide attempt of any kind, however, is treated as a psychiatric emergency by police or other rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation, a mental status examination, and a detailed assessment of the circumstances surrounding the attempt. The physician will interview the senior's relatives or anyone else who accompanied the patient in order to obtain as much information as possible. As a rule, suicide attempts requiring advance planning and the use of violent or highly lethal methods are regarded as the most serious. The patient will be kept under observation while decisions are made about the need for hospitalization.

Seniors who have attempted suicide and who are considered a serious danger to themselves or to others can be legally hospitalized against their will. The doctor bases the decision on the severity of the patient's depression or agitation; the presence of other suicide risk factors, including a history of previous suicide attempts, substance abuse, recent stressful events, and symptoms of psychosis; and the availability of friends, relatives, or other social support. If the attempt is judged to be a nonlethal suicide gesture, and the patient has adequate support outside the hospital, then the patient may be released after the psychiatric assessment is completed.

Viewpoints

Social changes and suicide among seniors Some observers have identified several changes in the United States since the 1950s that are thought to contribute to the rising rate of suicide among the elderly:

  • The loss of a set of moral values held in common by the entire society.
  • The lessened effect of religious and other social groups outside the family. In the past, these institutions often provided fellowship and a sense of belonging for the elderly and others living alone.
  • Media images that glamorize youth and present negative stereotypes of seniors.
  • Frequent geographical moves, which make it hard for seniors to keep in touch or visit members of their extended family.
  • Sensationalized treatment of suicide in the mass media. Some research studies have shown a definite risk of so-called contagion suicides from irresponsible reporting.
  • The development over the past century of medications that allow relatively painless suicide. For most of human history, the available means of suicide were uncertain, painful, or both.
  • The easy availability of lethal methods of suicide, most notably firearms, and so-called suicide magnets such as bridges or tall buildings that do not have suicide barriers and are easy even for seniors who do not drive to reach. The Golden Gate Bridge in San Francisco is the most notorious suicide magnet in the United States; others include the Aurora Bridge in Seattle, the Sunshine Skyway Bridge in Florida, and the Duke Ellington Bridge in Washington, D.C.

A right to suicide?

The idea that suicide is a right among the elderly surfaced with the 1991 publication of Derek Humphry's Final Exit, a controversial book described by its author as a how-to manual for suicide and assisted suicide. Humphry is the founder of the Euthanasia Research and Guidance Organization (ERGO), known until 2003 as the Hemlock Society. Humphry maintains that people have a right to choose the time, place, and method of their death and that rational suicide is a legitimate and even reasonable choice.

People often overlooked in discussions of the right to commit suicide are the relatives and friends who are bereaved by the suicide. It is estimated that each person who commits suicide leaves six survivors to deal with the aftermath. On the basis of this figure, there are at least 4.5 million survivors of suicide in the United States. In addition to the grief that ordinarily accompanies death, survivors of suicide often struggle with feelings of guilt and shame as well. Some people blamed Humphry and his book for their loved one's decision to commit suicide.

Assisted suicide

Questions pertaining to the legalization of assisted suicide for persons suffering from a terminal illness are connected in part to increases in the average lifespan.

Physician-assisted suicide (also known as physician-assisted death or PAD) was legalized in the Netherlands in April 2001 and in the state of Oregon. As of 2008 it was also legal in Belgium and is practiced openly in Switzerland. It is important to distinguish between physician-assisted suicide and euthanasia, or mercy killing. Assisted suicide, which is called “self-deliverance” in Britain, refers to individuals bringing about their own death with the help of another person. Because the other person is often a physician, the act is often called doctor-assisted suicide.

Euthanasia strictly speaking means that the physician or other person is the one who performs the last act that causes death. For example, if a physician injects a patient with a lethal dose of a pain-killing medication, the physician is performing euthanasia. If the physician leaves the patient with a loaded syringe and the patient injects himself or herself with it, the act is an assisted suicide. As of 2008, assisted suicide is illegal everywhere in the United States except Oregon, and euthanasia is illegal in all fifty states. The Merck Manual of Geriatrics states: “Physicians can provide treatment intended to minimize [a patient's] physical and emotional suffering, even if a secondary result is the shortening of life, but they cannot specifically intend to hasten death.”

Suicide prevention

In the late 2000s research was ongoing to discover better methods of treating depression and other disorders that may influence a senior's decision to commit suicide. In addition, primary care physicians were continually learning how to better identify and intervene when treating suicidal seniors. Too often, physicians and relatives may think that signs of depression and hints that the senior is contemplating suicide are normal signs of aging. An estimated 80 percent of the elderly who committed suicide saw their doctors within a month prior to their deaths. Thus primary care physicians are in a good position to evaluate a senior for signs of depression. The good news is that depression in the elderly is highly treatable, particularly when antidepressant medications are combined with psychotherapy.

Warning signs of suicidal thinking have been identified:

  • Reading a lot of books or articles on death and suicide
  • Talking a lot about death or suicide or expressing feelings of hopeless
  • Stockpiling medications
  • Refusing to take care of oneself
  • Sudden interest in guns
  • Giving away cherished possessions, writing long letters, or making other elaborate farewells
  • Disrupted sleep patterns
  • Hurriedly revising a will
  • Increased intake of alcohol or prescription drugs

People who are concerned about a senior at risk of self-harm should take the following steps:

  • Become educated about warning signs and risk factors
  • Identify physicians and other healthcare professionals who know the senior and can provide help and keep their telephone numbers readily available
  • Talk openly with the senior about the senior's feelings. Although many people are afraid to ask whether the senior is thinking about suicide for fear of angering the person or giving the person an idea, in many cases honest concern is welcomed by the senior.
  • Call the local hospital emergency department if the senior seems to be at immediate risk of suicide.

KEY TERMS

Assisted suicide —A form of self-inflicted death in which individuals voluntarily bring about their own death with the help of another, usually a physician, relative, or friend. Assisted suicide is sometimes called physician-assisted death (PAD).

Euthanasia —The act of putting individuals or animals to death painlessly or allowing them to die by withholding medical services, usually because of an incurable disease; also called mercy killing.

Self-deliverance —Another term for assisted suicide, more commonly used in Great Britain than in the United States.

Suicide gesture —Attempted suicide characterized by a low-lethality method, low level of intent or planning, and little physical damage; sometimes called pseudocide.

Suicide magnet —A bridge or tall building that acquires a reputation for attracting people who want to commit suicide and attempt it.

Resources

BOOKS

Beers, Mark H., and Robert Berkow, eds. Merck Manual of Geriatrics, 3rd ed. Whitehouse Station, NJ: Merck, 2005.

PERIODICALS

American Academy of Hospice and Palliative Medicine. “Position Statement on Physician-Assisted Death.” Journal of Pain and Palliative Care Pharmacotherapy 21 (April 2007): 55–57.

Beyer, J. L. “Managing Depression in Geriatric Populations.” Annals of Clinical Psychiatry 19 (October/December 2007): 221–238.

Centers for Disease Control and Prevention (CDC). “Increases in Age-Group-Specific Injury Mortality—United States, 1999–2004.” Morbidity and Mortality Weekly Report 56 (December 14, 2007): 1281–1284.

Elison, N. W. “Senior Suicide.” New Jersey Nurse 37 (September/October 2007): 5–9.

Hamlin, Jesse. “Family Grief: A Suicide Leaves a Legacy of Anguish.” San Francisco Chronicle, October 31, 2005 [cited April 1, 2008]. Part 2 of a seven-part series on the Golden Gate Bridge as a suicide magnet. http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2005/10/31/MNG2NFG1L61.DTL.

Mann, J. J., et al. “Suicide Prevention Strategies.” Journal of the American Medical Association 294 (October 26, 2005): 2064–2074.

Voaklander, D. C., B. H. Rowe, D. M. Dryden, et al. “Medical Illness, Medication Use, and Suicide in Seniors: A Population-Based Case Control Study.” Journal of Epidemiology and Community Health 62 (February 2008): 138–146.

OTHER

“At a Glance: Suicide among the Elderly.” National Strategy for Suicide Prevention (NSSP) Fact Sheet. [cited April 1, 2008]. http://mentalhealth.samhsa.gov/suicide-prevention/elderly.asp.

Evans, Garret D., and Heidi L. Radunovich. “Suicide and the Elderly: Warning Signs and How to Help.” Gainesville: University of Florida, Family, Youth, and Community Sciences Department, February 28, 2006 [cited April 1, 2008]. http://edis.ifas.ufl.edu/FY101.

“Older Adults: Depression and Suicide Facts.” NIH Publication No. 4593. National Institute of Mental Health (NIMH). April 2007 [cited February 6, 2008]. http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts.shtml.

Soreff, Stephen. “Suicide.” eMedicine. September 28, 2006 [cited February 6, 2008]. http://www.emedicine.com/med/topic3004.htm.

ORGANIZATIONS

American Association of Suicidology (AAS), 5221 Wisconsin Ave. NW, Washington, DC, 20015, (202) 237 2280, (202) 237-2282, [email protected], http://www.suicidology.org/index.cfm.

American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, Arlington, VA, 22209, (703) 907-7300, [email protected], http://www.psych.org/.

Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Suicide Prevention, 4770 Buford Hwy NE, MS K-65, Atlanta, GA, 30341, (800) CDC-INFO, (770) 488-4760, [email protected], http://www.cdc.gov/ncipc/dvp/Suicide/default.htm.

National Institute of Mental Health (NIMH), 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD, 20892, (301) 443-4513, (866) 615-6464, (301) 443-4279, [email protected], http://www.nimh.nih.gov/index.shtml.

National Suicide Prevention Hotline, (800) 273-8255.

Rebecca J. Frey Ph.D.

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Suicide

SUICIDE

Suicide is defined as the deliberate killing of oneself. Tragically, suicide is a problem that affects people of all ages, but most dramatically, adolescents and young adults. In fact, suicide is the most rapidly growing cause of death among youth between the ages of fifteen and twenty-four. In the mid-1990s, the National Center for Health Statistics ranked suicide as the third-leading cause of adolescent death, as it claimed the lives of approximately 5,000 American teenagers and young adults. In addition, the number of recorded deaths by suicide is apparently an underestimate of reality since a large number of completed suicides go unreported or are labeled as accidents.

Suicide attempts are defined as intentional, self-inflicted, and life-threatening acts that do not result in death. During adolescence, the documented prevalence rates of suicide attempts are higher than at any other time in the human lifespan. According to the Centers for Disease Control and Prevention (CDC), about one-half million adolescents and young adults attempt suicide each year with as many as 6 percent of high school males and 11 percent of high school females reporting at least one suicide attempt.

Suicidal ideation is broadly defined as a range of thoughts an individual may have related to the act of committing suicide. Suicidal ideation can range from thoughts that others might be better off if the person were dead to very specific, detailed planning for completing suicide. Signs of suicidal ideation may be expressed behaviorally, in written form, or through speech. Several surveys conducted in the mid-1990s suggest that 10 percent to 15 percent of adolescents have meaningful suicidal thoughts within a one-week or one-month time span. The CDC reported that in 1991 about 27 percent of high school students reported having thought seriously about attempting suicide and 16 percent reported having made a detailed suicide plan.

These facts and statistics become more meaningful when one considers what these findings suggest for a typical high school with an enrollment of 2,000 students. It is quite likely that in such a setting, approximately 500 students will have thoughts of suicide during the school year, 50 students will actually make a suicide attempt during the year, and 1 student will complete suicide once every four years.

Adolescent suicide is a reality that, although difficult and frightening for most of society to think about and discuss, can often be prevented. The key is for people to be informed about the potential reasons individuals might engage in suicidal behavior, the types of individuals who are at risk of engaging in suicidal behavior, the common myths about suicide, the warning signs of suicide, and the actions to take if one suspects a suicide might be attempted. An introductory examination of this vital information follows.

Reasons for Suicidal Behavior

Why do people kill themselves? This is an extremely difficult question to answer. Although there are many ideas or theories about why people commit suicide, there is no single comprehensive theory that describes and explains all life-threatening behaviors. The major theories of suicide can be categorized into sociological theories, psychological theories, and biological theories. In general, sociological theories are based on the idea that suicide results from the level and amount of control society has over an individual and the effects of social conditions and social changes on the person. Psychological theories of suicide typically focus on conflicts within the individual; the role of one's thought processes, emotions, and personality characteristics; the person's developmental stage; and the ways in which the person's family functions. Finally, biological theories are based on the examination of biological aspects of suicide such as the influence of genetics, hormone levels, and neuro-transmitter levels in the brain.

Suicidal acts take on very different meanings based upon the lenses one uses to examine each individual case of suicide. It is tempting to make sense of suicidal behavior by applying one of the many theories that have been developed by researchers to explain suicidal behavior. It appears, however, that the most complete understanding requires one to look beyond theories and ideas to the concrete evidence. Rather than asking why someone would commit suicide, the question can be rephrased as follows: What problem or problems was the person trying to solve?

Based upon the ways in which adolescents attempt to kill themselves, those who work with suicidal teens have found that most do not really want to die. When adolescents attempt suicide, most do it in their own homes, which is the place they are most likely to be found, and between the hours of 4 P.M. and midnight, which is the time of the day when someone in the family is most likely to be around. Thus, the chance of rescue is high, and those who hope for rescue do not really want to die. It appears then, that suicidal teens are simply attempting to solve one or more problems occurring in their life, but they, unfortunately, choose a permanent solution to their temporary problems. These teens are looking for a way to escape the emotional and physical pain that results from the problems they perceive or experience in their lives, and suicide appears to be a sure way to make the pain stop.

Those Who Are at Risk

People at risk of suicide come from a wide variety of backgrounds. There is not a special set of characteristics or personality traits that are common to all suicides. Unfortunately, suicide knows no boundaries. This is obvious since all kinds of youth end their own lives regardless of age, gender, ethnicity, economic background, and mental or physical state. Nevertheless, there are some general risk factors that apply to a large number of suicidal teens that may make suicide more likely for a given individual.

In general, adolescents are at higher risk for engaging in suicidal behaviors following a significant loss such as the death of a friend or family member, parental divorce or separation, or a breakup with a boyfriend or girlfriend. Teens who are depressed, involved with alcohol or other drugs, or are victims of physical, emotional, or sexual abuse have a higher potential for suicide. There is also heightened risk for those who have attempted suicide in the past or who come from a home where someone has committed suicide.

Research shows that adolescent females attempt suicide more often than adolescent males, but that males complete suicide at a higher rate. The most likely reason for this is that males tend to choose methods that are more lethal (e.g., gunshot, hanging, automobile crash), whereas females often use methods that are considered less lethal (e.g., drug overdose, slashing of wrists, carbon monoxide poisoning).

The rates of attempted suicide among gay and lesbian populations are two to six times greater than suicide rates for the general population. These statistics suggest that gay youth are at a greater risk for suicide than their straight counterparts. Finally, suicide risk is higher for teens who are gifted, have learning disabilities, or are pregnant or responsible for a pregnancy.

Warning Signs of Suicide

Most people who are suicidal put out warning signs to the public as a cry for help. They either directly or indirectly tell or show others about their suicide plan. Direct verbal threats such as "I am going to kill myself," "I am going to swallow a bottle of aspirin," or "By the weekend I will be dead" leave nothing to the imagination. These statements should be taken seriously, no matter how overdramatic they may sound, because very few people make such serious statements for the sake of just being funny. Indirect verbal threats are much more subtle and, therefore, more difficult to pick up on. Indirect threats tend to slide right into regular conversations and may easily be overlooked if one is not aware of these subtle cues. Statements such as "I hate my life," "Sometimes I wish I were dead," or "I just can't go on any longer" are all potential clues that someone may be thinking about suicide and that should lead anyone hearing the statement to act to prevent it.

In addition to direct and indirect verbal threats, suicidal people often exhibit a number of behaviors that serve as warning signs. Such signs include sudden changes in behavior related to eating and sleeping patterns, performance at school, physical appearance and hygiene, participation in activities and hobbies, and interactions with friends and family. When people suddenly stop acting like themselves for days or weeks, it is usually a signal that something has gone wrong in their lives and that this behavior should be examined further.

Teens who are making plans to die often try to tie up loose ends before they attempt to take their own life. They do this in a number of ways, including giving away the things that matter most to them, getting their rooms organized and their lockers or work spaces cleaned out, returning borrowed materials, and paying loans. These behaviors are not suspicious in and of themselves, but in combination with other suicide warning signs, these acts may serve as signals that the adolescent does not plan to be alive much longer.

Finally, teens who suddenly become aggressive, rebellious, or disobedient or who engage in risky or self-destructive behavior are also exhibiting signs that could be related to suicidal intent. These behaviors should not be ignored.

Actions to Take to Prevent Suicide

Adolescents who are suicidal need someone who will talk with them openly and honestly, who will listen attentively, and who will find them the help that they need. In order to help prevent a suicide from occurring, one must be informed of the questions to ask when suicide is suspected, the dos and don'ts of interacting with a person contemplating suicide, and who to contact for further assistance.

When signs of suicide have been observed, it is important to reach out to the person to find out what is going on. A good way to do this is by asking questions and listening attentively without making judgments. The goal is to get the person who may be considering suicide to talk about his or her problems out in the open. Specifically, there are four important questions that need to be asked directly: (1) Are you thinking about killing yourself? (2) How do you plan to do it? (3) When do you plan to do it? and (4) Where do you plan to do it? Contrary to popular belief, such candor will not give a person dangerous ideas or encourage a suicidal act. In fact, these questions not only allow the helper to assess the danger so she knows who to contact for further assistance, but also give the helpee permission to talk about suicide and the thoughts and problems that may be occurring. Such action can be a relief to individuals who are suicidal because it shows that someone is taking them seriously.

Some important information to remember when helping a person through a suicidal crisis is to remain calm even if what is said is shocking, to remain positive and never give up hope, and to know one's own limits and when it is time to seek outside help. One should never make promises to keep a person's suicide plans a secret. Instead, the helper should suggest that the suicidal person turn to help from trusted adults (e.g., parents, teachers, coaches), crisis hotlines, or trained professionals (e.g., counselors, therapists, doctors). Most importantly, one should never leave an individual in crisis alone, and one must act quickly if the person appears to be in danger.

See also:MENTAL DISORDERS; PERSONALITY DEVELOPMENT

Bibliography

Berman, Alan, and David Jobes. Adolescent Suicide: Assessment and Intervention. Washington, DC: American Psychological Association, 1991.

Kirk, William. Adolescent Suicide. Champaign, IL: Research Press, 1993.

Maris, Ronald, Morton Silverman, and Silvia Canetto. Review of Suicidology, 1997. New York: Guilford Press, 1997.

Nelson, Richard, and Judith Galas. The Power to Prevent Suicide. Minneapolis: Free Spirit Publishing, 1994.

Page, Randy. "Youth Suicidal Behavior: Completions, Attempts, and Ideations." High School Journal 80, no. 1 (1996):60-65.

Popenhagen, Mark, and Roxanne Qualley. "Adolescent Suicide:Detection, Intervention, and Prevention." Professional School Counseling 1, no. 4 (1998):30-36.

Robbins, Paul R. Adolescent Suicide. Jefferson, NC: McFarland, 1998.

Jeana L.Magyar-Moe

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Suicide

SUICIDE

•••

Philosophical issues concerning suicide arise in a wide range of contemporary end-of-life dilemmas: the withdrawal or withholding of medical treatment; involuntary treatment; high-risk, experimental, and unconventional treatment; euthanasia, assistance, and physician assistance in suicide; requests for maximal treatment; and many others. Although suicide is often popularly understood in a narrower sense of active, pathological self-killing, traditionally abhorred, the underlying issue most broadly conceived concerns the role that individuals may play in bringing about their own deaths.

Two focal issues concerning suicide are evident in these broader dilemmas. First, should suicide be recognized as a right, and if so, under what conditions? On this first question rest the foundations for various applications of the "right to die," as well as a variety of other issues in high-risk and self-sacrificial behavior.

Second, what should the role of other persons be toward those intending suicide? On this second question rest practical, legal, and public-policy issues in suicide prevention and suicide assistance. Both focal issues concerning suicide raise larger questions about the nature of choices to die and the relevance of mental illness, about the role of the state, about conceptual issues in determining what actions are to be counted as suicide, about the role of religious belief concerning suicide, about the possibility of an autonomous choice of suicide, and about the moral status of suicide.

The Incidence of Suicide

The United States exhibits a rate of reported suicide—10.7 per 100,000 year (year 2000 figures)—that falls approximately midway between societies in which reported suicide rates are extremely low, such as the Islamic countries, and those in which reported rates are extremely high, for example, Hungary. In the United States, there are almost 30,000 reported suicides per year and twenty-five times that many reported attempts; it is the eleventh highest cause of death for the U.S. population as a whole, ahead of homicide, the fourteenth highest. This means that, as John L. McIntosh points out, more Americans kill themselves than are killed by others.

Suicide rates are approximately equivalent across socioeconomic groups. Suicide rates are four times higher for males than females, but attempted suicide rates are four times higher for females than males. Attempt rates for whites and blacks are equivalent; rates of death by suicide are twice as high for whites. Suicide is the third leading cause of death for fifteen-to twenty-four-year-olds. For white males, suicide rates increase with age, rising to a peak of 61.7 per 100,000 in the age range eighty-four to eighty-nine; for women, suicide rates peak in midlife and decline thereafter; and elderly black women have the lowest rate of all adult groups, with those eighty-five and above showing the lowest risk (0.04 per 100,000, a rate based on such a low number of deaths that it is considered unreliable). In the United States, suicide rates declined throughout the 1990s and early 2000s—possibly due, among other factors, to the increased availability of antidepressant medications. Nevertheless, the number of deaths remains high. On average, one person commits suicide in the United States every eighteen minutes.

There are no reliable estimates of the number of unreported suicides, particularly those in medical situations involving terminal illness, the very cases that raise the most pressing current ethical issues. Suicide statistics, including those just cited, primarily reflect suicide in the narrower sense of active, pathological self-killing, whereas deaths brought about by refusal of treatment, by self-sacrifice or voluntary martyrdom, by high-risk behavior, or by self-deliverance in terminal illness are rarely described or reported as suicides. Rates of physician-assisted suicide where legal are quite low: In the Netherlands, where both voluntary active euthanasia and physician-assisted suicide are legal, the former comprises approximately 2.4 percent of the total annual mortality and the latter approximately 0.2 percent, figures fairly constant over the sixteen-year period, 1985 to 2001, for which reliable data is available. In Oregon, where physician-assisted suicide has been legal since 1997 under Measure 16, the Oregon Death with Dignity Act, 125 patients used lethal prescriptions provided legally by their physicians during the first five years of the act, representing less than 0.1 percent of the total annual deaths in the state.

Scientific Models of Suicide

Contemporary scientific understandings of the nature of suicide, primarily in the narrower sense, tend to fall into three groups: the "medical" model; the "cry-for-help," "suicidal career," or "strategic" model; and the "sociogenic" model.

THE MEDICAL MODEL. This model, heavily influential throughout most of the twentieth century, has understood suicide in terms of disease: If suicide is not itself a disease, then it is the product of disease, usually mental illness. Suicide is understood as largely involuntary and nondeliberative, the outcome of factors over which the individual has little or no control; it is something that "happens" to the victim. Studies of the incidence of mental illness in suicide often tacitly appeal to this model by attempting to show that mental illness—usually depression, less frequently other mental disorders—is always or almost always present in suicide. This invites the inference that the mental illness or depression "caused" the suicide.

More recent work presupposing the medical model has focused on biological factors associated with suicide, exploring among other findings decreases of serotonin in spinal fluid; drug challenges with fenfluramine; twin studies and other avenues of detecting heritable genetic patterns in families with multiple suicides; and environmental and disease exposures during pregnancy. While work to date remains provisional and in any case establishes correlations rather than causes, it nevertheless points to biological factors that may play a role in suicide.

THE CRY-FOR-HELP MODEL. A second model, developed in the pioneering work of Edwin S. Shneidman and Norman L. Farberow in the 1950s, understands suicide as a communicative strategy: It is a cry for help, an attempt to seek aid in altering one's social environment. Thus it is primarily dyadic, making reference to some second person (or less frequently, an institution or other entity) central in the suicidal person's life. In this view, it is the suicidal gesture that is clinically central; the completed suicide is an attempt that is (often unintentionally) fatal. While the cry for help is manipulative in character, it is also often quite effective in mobilizing family, community, or medical resources to assist in helping change the circumstances of the attempter's life, at least temporarily. Later theorists have developed related models that also interpret suicide attempts as strategic: The concept of suicidal careers interprets an individual's repeated suicide threats and attempts as a method of negotiating the world, though—as for the American poet Sylvia Plath (1932–1963)—an attempt in such a "career" may prove fatal.

THE SOCIOGENIC MODEL. Originally developed by the French sociologist Émile Durkheim (1858–1917) in his landmark work Suicide (1897), the sociogenic model sees suicide as the product of social forces varying with the type of social organization within which the individual lives. "It is not mere metaphor," Durkheim wrote, "to say of each human society that it has a greater or lesser aptitude for suicide, … a collective inclination for the act, quite its own, and the source of all individual inclination, rather than their result" (p. 299). In societies in which individuals are very highly integrated into the society and their behavior is rigorously governed by social codes and customs, suicide tends to occur primarily when it is institutionalized and required by the society (as, for example, in the Hindu practice of sati, or voluntary widow-burning); this is termed altruistic suicide. In societies in which individuals are very loosely integrated into the society, suicide is egoistic, almost entirely self-referential. In still other societies, Durkheim claimed, individuals are neither over-nor underintegrated, but the society itself fails to provide adequate regulation of its members; this situation results in anomic suicide, typical of modern industrial society. In Western societies of this sort, institutionalized suicide has been extremely rare but not unknown, confining itself to highly structured situations: the sea captain who was expected to "go down with his ship" and the Prussian army officer who was expected to kill himself if he was unable to pay his gambling debts.

Like the medical model, the sociogenic model considers suicide to be "caused," but it identifies the causes as social forces rather than individual psychopathology. Like the cryfor-help model, the sociogenic model sees suicide as a responsive strategy, but the responses are not so much matters of individual communication as conformity to social structures and reaction to the social roles a society creates.

Prediction and Prevention

Two principal strategies are employed to recognize the prospective suicide before the attempt: the identification of verbal and behavioral clues and the description of social, psychological, and other variables associated with suicide. Suicide prevention includes alerting families, professionals (especially those likely to have contact with suicidal individuals, such as schoolteachers), and the public generally to the symptoms of an approaching suicide attempt. They are trained to recognize and take seriously both direct warnings(e.g., "I feel like killing myself") and indirect warnings (e.g., "I probably won't be seeing you anymore") and behavior(e.g., giving away one's favorite possessions). They are also encouraged to be especially sensitive to these symptoms in those at highest risk, especially in males, those who are older, live alone, are alcoholic, have negative interactions with important others, are isolated, have poor or rigid coping skills, are less willing to seek professional help, have low religiosity, and have a history of previous suicide attempts—the last of these being a particularly at-risk group. Prevention strategies take a vast range of forms, from the befriending techniques developed by the Samaritans in England and the crisis hot lines widely used in the United States to involuntary commitment to a mental institution. Prevention strategies also include postvention, or post-occurrence intervention, for the survivors—spouse, parents, children, or important others—of a person whose suicide attempt was fatal, because such survivors are themselves at much higher risk of suicide, especially during the first year following the death.

These models of suicide and the associated forms of prediction and prevention are ubiquitous in contemporary medical and psychiatric practice. Yet although suicide has been treated largely as a medical or psychiatric matter, the conceptual, epistemological, and ethical problems it raises have reemerged in two central contexts: that of right-to-die issues in terminal illness and that of political phenomena such as self-sacrifice and suicide terrorism.

Conceptual Issues

The term suicide carries extremely negative connotations. There is little agreement, however, on a formal definition. Some authors count all cases of voluntary, intentional self-killing as suicide; others include only cases in which the individual's primary intention is to end his or her life. Still others recognize that much of what is usually termed suicide neither is wholly voluntary nor involves a genuine intention to die, such as suicides associated with depression or other mental illness. Many writers exclude cases of self-inflicted death that, while voluntary and intentional, appear aimed to benefit others or to serve some purpose or principle—for instance, the Greek philosopher Socrates (c. 470–399 b.c.e.), who drank the hemlock; Captain Lawrence Oates (1880–1912), thean English explorer who, after falling ill during the return trip from an expedition to the South Pole, deliberately walked out into a blizzard to allow his fellow explorers to continue without him; or the Buddhist monk Thich Quang Duc, who immolated himself in the streets of Saigon in June 1963 to protest the Diem regime during the Vietnam war. These cases are usually not called suicide, but self-sacrifice or martyrdom, terms with strongly positive connotations.

However, attempts to differentiate these positive cases from negative ones often seem to reflect moral judgments, not genuine conceptual differences. Conceptual and linguistic framing of a practice plays a substantial role in social policies; for example, supporters of physician-assisted suicide often use the term aid-in-dying as well as earlier euphemisms such as self-deliverance to avoid the negative connotations of suicide, while opponents insist on the more negative term suicide. The term suicide is not used in Oregon's Death with Dignity Act to describe the practice it makes legal, and indeed the statute stipulates: "Actions taken in accordance with this Act shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law" (Section 3.14). In contrast, the U.S. Supreme Court cases Washington v. Glucksberg and Vacco v. Quill (decided jointly in 1997) expressly considered the issue as one involving "suicide." Similarly, Palestinian militants attacking Israeli civilians have been called suicide bombers by their targets and by the Western press, but they are called martyrs by their supporters and those who recruit them for this role.

Cases of death from self-caused accident, self-neglect, chronic self-destructive behavior, victim-precipitated homicide, high-risk adventure, refusal of lifesaving medical treatment, and self-administered euthanasia—all of which share many features with suicide but are not usually termed such—cause still further conceptual difficulty. Consequently, some authors claim that it is not possible to reach a rigorous formal definition of suicide, and prefer a criterial or operational approach to characterizing the term, noting its varied, shifting, and often inconsistent range of uses. Nevertheless, conceptual issues surrounding the definition of suicide are of considerable practical importance in policy formation, affecting, for instance, coroners' practices in identifying causes of death, insurance disclaimers, psychiatric protocols, religious prohibitions, codes of medical ethics, and laws prohibiting or permitting assistance in suicide.

Suicide in the Western Tradition

Much of the extremely diverse discussion of suicide in the history of Western thought has been directed to ethical issues. The Greek philosopher Plato (c. 428–c. 348 b.c.e.) acknowledged Athenian burial restrictions—the suicide was to be buried apart from other citizens, with the hand severed and buried separately—and in the Phaedo, he also reported the Pythagorean view that suicide is categorically wrong. But Plato also accepted suicide under various conditions, including shame, extreme distress, poverty, unavoidable misfortune, and "external compulsions" of the sort that had been imposed on his teacher Socrates by the Athenian court when it condemned him to drink the hemlock. In the Republic and the Laws, respectively, Plato obliquely insisted that the person suffering from chronic, incapacitating illness or uncontrollable criminal impulses ought to allow his life to end or cause it to do so. Plato's pupil, the Greek philosopher Aristotle (384–322 b.c.e.) held more generally that suicide is wrong, claiming that it is "cowardly" and "treats the state unjustly." The Greek and Roman Stoics, in contrast, recommended suicide as the responsible, appropriate act of the wise man, not to be undertaken in emotional distress, but as an expression of principle, duty, or responsible control of the end of one's own life, as exemplified by Cato the Younger (95–46 b.c.e.), Lucretia (sixth century b.c.e.), and Seneca (c. 4 b.c.e.–65 c.e.).

Although Old Testament texts describe individual cases of suicide (Abimilech, Samson, Saul and his armor-bearer, Ahithophel, and Zimri), nowhere do they express general disapproval of suicide. The Greek-influenced Jewish general Josephus (c. 37–c. 100 c.e.), however, rejected it as an option for his defeated army, and clear prohibitions of suicide appear in Judaism by the time of the Talmud during the first several centuries c.e., often appealing to Genesis 9:5, "For your lifeblood I will demand satisfaction." The New Testament does not specifically condemn suicide, and mentions only one case: the self-hanging of Judas Iscariot after the betrayal of Jesus. There is evident disagreement among the early church fathers about the permissibility of suicide, especially in one specific circumstance: Eusebius of Caesarea(c. 260–c. 339), Ambrose (339–397), Jerome (c. 347–c.419), and others all considered whether a virgin may kill herself in order to avoid violation.

While Christian values clearly include patience, endurance, hope, and submission to the sovereignty of God, values that militate against suicide, they also stress willingness to sacrifice one's life, especially in martyrdom, and absence of the fear of death. Some early Christians (e.g., the Circumcellions, a subsect of the rigorist Donatists) apparently practiced suicide as an act of religious zeal. Suicide committed immediately after confession and absolution, they believed, permitted earlier entrance to heaven. Rejecting such reasoning, Augustine (354–430) asserted that suicide violates the commandment "Thou shalt not kill" and is a greater sin than any that could be avoided by suicide. Whether he was simply clarifying earlier elements of Christian faith or articulating a new position remains a matter of contemporary dispute. In any case, it is clear that with this assertion the Christian opposition to suicide became unanimous and absolute.

This view of suicide as morally and religiously wrong intensified during the Christian Middle Ages. Thomas Aquinas (c. 1225–1274) argued that suicide is contrary to the natural law of self-preservation, injures the community, and usurps God's judgment "over the passage from this life to a more blessed one" (Summa theologiae 2a 2ae q64 a5). By the High Middle Ages the suicide of Judas, often viewed earlier as appropriate atonement for the betrayal of Jesus, was seen as a sin worse than the betrayal itself. Enlightenment writers began to question these views. The English statesman Thomas More (1478–1535) incorporated euthanatic suicide in his Utopia (1516). In his Biathanatos (1608, published posthumously in 1647), the English poet John Donne (1572–1631) treated suicide as morally praiseworthy when done for the glory of God—as he claimed was the case for Christ. The Scottish philosopher and historian David Hume (1711–1776) mocked the medieval arguments, justifying suicide on autonomist, consequentialist, and beneficent grounds.

Later thinkers such as the French writer Madame de Staël (Anne-Louise-Germaine, née Necker, the baroness Staël-Holstein, 1766–1817) and the German philosopher Arthur Schopenhauer (1788–1860) construed suicide as a matter of human right—although Mme. De Staë subsequently reversed her position. Throughout this period, other thinkers insisted that suicide was morally, legally, and religiously wrong: Among them, the English evangelist and founder of methodism John Wesley (1703–1791) said that suicide attempters should be hanged, and the English jurist William Blackstone (1723–1780) described suicide as an offense against both God and the King. The German philosopher Immanuel Kant (1724–1804) used the wrongness of suicide as a specimen of the moral conclusions the categorical imperative could demonstrate. In contrast, the Romantics tended to glorify suicide, and the German philosopher Friedrich Nietzsche (1844–1900) insisted that "suicide is man's right and privilege" (Nietzsche, p. 210).

Although religious moralists have continued to assert that divine commandment categorically prohibits suicide, that suicide repudiates God's gift of life, that suicide ruptures covenantal relationships with other persons, and that suicide defeats the believer's obligation to endure suffering in the image of Christ, the volatile discussion of the moral issues in suicide among more secular thinkers ended fairly abruptly at the close of the nineteenth century. This was due in part to Émile Durkheim's insistence (1897) that suicide is a function of social organization, and also to the views of psychological and psychiatric theorists, developing from the French physician Jean Esquirol (1772–1840) to the Austrian neurologist Sigmund Freud (1856–1939), that suicide is a product of mental illness. These new "scientific" views reinterpreted suicide as the product of involuntary conditions for which the individual could not be held morally responsible. The ethical issues, which presuppose choice, reemerged only in the later part of the twentieth century, stimulated primarily by discussions in bioethics of terminal illness and other dilemmas at the end of life.

Suicide and Martyrdom in Religious Traditions

The major monotheisms, Judaism, Christianity, and Islam, all repudiate suicide, though in each martyrdom is recognized and venerated. Judaism rejects suicide but venerates the suicides at Masada, where in May of the year 73 c.e. some 960 Jews trapped in a fortress built on a high rock plateau killed themselves rather than be taken prisoner by the Romans, and accepts kiddush hashem, self-destruction to avoid spiritual defilement. At least since the time of Augustine, Christianity has clearly rejected suicide but accepts and venerates martyrdom to avoid apostasy and to testify to one's faith. Islam also categorically prohibits suicide but at the same time defends and expects martyrdom to defend the faith. Yet whether the distinction between suicide and martyrdom falls in the same place for Judaism, Christianity, and Islam is not clear. Judaism appears to accept self-killing to avoid defilement or apostasy; Christianity teaches passive submission to death when the faith is threatened but also celebrates the voluntary embrace of death in such circumstances; some Islamic fundamentalists support the political use of suicide bombing, viewing it as consistent with Islam and its teachings of jihad, or holy war, though others view this as a corruption of Islamic doctrine. Thus while all three traditions revere those who die for the faith as martyrs and all three traditions formally repudiate suicide, at least by that name, the practices they accept may be quite different: Christians would not accept the mass suicide at Masada; Jews do not use the suicide-bombing techniques of their Islamic neighbors in Palestine; and Muslims do not extol the passive submission to death of the Christian martyrs, appealing on Koranic grounds to a more active self-sacrificial defense of the faith.

Non-Western Religious and Cultural Views of Suicide

Many other world religions hold the view that suicide is prima facie wrong, but that there are certain exceptions. Still others encourage or require suicide in specific circumstances. Known as institutionalized suicide, such practices have included the sati of a Hindu widow, who was expected to immolate herself on her husband's funeral pyre; the seppuku or hara-kiri (suicide by disembowelment) of traditional Japanese nobility out of loyalty to a leader or because of infractions of honor; and, in traditional cultures from South America to Africa to China, the apparently voluntary submission to sacrifice by a king's retainers at the time of his funeral in order to accompany him into the next world. Eskimo, Native American, and some traditional Japanese cultures have practiced voluntary abandonment of the elderly, a practice closely related to suicide, in which the elderly are left to die, with their consent, on ice floes, on mountaintops, or beside trails.

In addition, some religious cultures have held comparatively positive views of suicide, at least in certain circumstances. The Vikings recognized violent death, including suicide, as guaranteeing entrance to Valhalla (the central hall of the afterlife). Some Pacific Islands cultures regarded suicide as favorably as death in battle and preferable to death by other means. The Jains, and perhaps other groups within traditional Hinduism, honored deliberate self-starvation as the ultimate asceticism and also recognized religiously motivated suicide by throwing oneself off a cliff. On Mangareva, members of a traditional Pacific Islands culture also practiced suicide by throwing themselves from a cliff, but in this culture not only was the practice largely restricted to women, but a special location on the cliff was reserved for noble women and a different location assigned to commoners. The Maya held that a special place in heaven was reserved for those who killed themselves by hanging (though other methods of suicide were considered disgraceful), and they recognized a goddess of suicide, Ixtab. Many other pre-Columbian peoples in the western hemisphere engaged in apparently voluntary ritual self-sacrifice, notably the Aztec practice of heart sacrifice, which was generally characterized at least during some historical periods by enhanced status and social approval. The view that suicide is intrinsically and without exception wrong is associated most strongly with post-Augustinian Christianity of the medieval period, surviving into the present; this absolutist view is not by and large characteristic of other cultures.

Contemporary Ethical Issues

Is suicide morally wrong? Both historical and contemporary discussions in the Western tradition exhibit certain central features. Consequentialist arguments tend to focus on the damaging effects a person's suicide can have on family, friends, coworkers, or society as a whole. But, as a few earlier thinkers saw, such consequentialist views would also recommend or require suicide when the interests of the individual or others would be served by suicide. Deontological theorists in the Western tradition have tended to treat suicide as intrinsically wrong, but, except for Kant, are typically unable to produce support for such claims that is independent of religious assumptions. Contemporary ethical argument has focused on such issues as whether hedonic calculus of self-interest—weighing pleasures and pains, or benefits against harms—in which others are not affected, provides an adequate basis for an individual's choice about suicide; whether life has intrinsic value sufficient to preclude choices of suicide; and whether any ethical theory can show that it would be wrong, rather than merely imprudent, for the ordinary, nonsuicidal person, not driven by circumstances or acting on principle, to end her life.

Epistemological Issues

Closely tied to conceptual issues, the central epistemological issues raised by suicide involve the kinds of knowledge available to those who contemplate killing themselves. The issue of what, if anything, can be known to occur after death has, in the West, generally been regarded as a religious issue, answerable only as a matter of faith; few philosophical writers have discussed it directly, despite its clear relation to theory of mind. Some writers have argued that because we cannot have antecedent knowledge of what death involves, we cannot knowingly and voluntarily choose our own deaths; suicide is therefore always irrational. Others, rejecting this argument, instead attempt to establish conditions for the rationality of suicide. Others consider whether death is always an evil for the person involved, and whether death is appropriately conceptualized as the cessation of life. Still other writers examine psychological and situational constraints on decision making concerning suicide. For instance, the depressed, suicidal individual is described as seeing only a narrowed range of possible future outcomes in the current dilemma, the victim of a kind of tunnel vision constricted by depression. The possibility of preemptive suicide in the face of deteriorative mental conditions such as Alzheimer's disease is characterized as a problem of having to use the very mind that may already be deteriorating to decide whether to bear deterioration or die to avoid it.

Public-Policy Issues

It is often, though uncritically, assumed that if a person's suicide is rational, it ought not to be interfered with or prohibited. This assumption, however, raises policy issues about the role of the state and other institutions in the prevention of suicide.

RIGHTS AND THE PREVENTION OF SUICIDE. In the West, both church and state have historically assumed roles in the control of suicide. In most European countries, ecclesiastical and civil law imposed burial restrictions on the suicide as well as additional penalties, including forfeiture of property, on the suicide's family. European attitudes and legal sanctions concerning suicide were translated into colonial societies as well, for example in India, Africa, and various Pacific Islands. In England, suicide remained a felony until 1961, and in Canada until 1971. Suicide has been decriminalized in most of the United States and in England, primarily to facilitate psychiatric treatment of suicide attempters and to mitigate the impact on surviving family members; in most U.S. states, however, assisting another person's suicide is a violation of statutory law, case law, or recognized common law. In Germany assisting a suicide is not illegal, provided the person whose death it will be is competent and acting voluntarily; in the Netherlands, physician-assisted suicide is legal under the same guidelines as voluntary active euthanasia: In Switzerland, assisted suicide is legal if it is done without self-interest on the part of the assister; and in Belgium, physician-performed voluntary active euthanasia is legal but physician-assisted suicide is not. Ongoing ferment characterizes the legal status of physician-assisted suicide in many countries.

Building on Shneidman and Farberow's early work, suicide-prevention strategies have been enhanced by considerable advances in the epidemiological study of suicide, in the identification of risk factors, and in forms of clinical treatment. Suicide-prevention professionals welcome increased funding for education and prevention measures targeted at youth and other populations at high risk of suicide. Nevertheless, philosophers are increasingly alert to the more general theoretical issues these strategies raise, for example, the effect of high false-positive rates on the right to avoid unjustified coercion. Restrictions to prevent suicide—such as involuntary incarceration in a mental hospital or suicide precautions in an institutional setting—typically limit liberty, but because the predictive measures of suicide risk that are available are neither perfectly reliable nor perfectly sensitive, they identify some fraction of persons as potential suicides who would not in fact kill themselves and fail to identify others who actually will. There are two distinct issues here. First, how great an infringement of the liberty of those erroneously identified is to be permitted in the interests of preventing suicide by those correctly identified? Second and more generally, can restrictive measures for preventing suicide be justified at all, even for those who will actually go on to commit suicide? Civil rights theorists are generally disturbed by the first of these problems, libertarians by the second.

Although U.S. law does not prohibit suicide, suicide has not been recognized as a right. There has been considerable pressure from right-to-die groups in favor of recognizing a broad right to self-determination in terminal illness not only by refusal of life-prolonging treatment but also by bringing about one's own death. In the Washington v. Glucksberg and Vacco v. Quill cases, the U.S. Supreme Court ruled unanimously that there was no constitutional right to assisted suicide, though the Court's ruling did not prohibit states from establishing laws that would legalize it. Cases such as these, however, tend to conflate the notion of a negative right to assistance in suicide, which would prohibit interference when a willing physician wished to provide assistance to a patient, with the far more controversial notion of a positive right to assistance in suicide—something that would give patients a claim to be provided with help from physicians when they sought it.

Other rights issues raised by suicide include, for example, freedom of expression. When Hemlock Society president Derek Humphry's Final Exit—a book addressed to the terminally ill that provided explicit instructions on how to commit suicide, including lethal drug dosages—was published in the United States in 1991 and sold over half a million copies, its publication was protected on the grounds of freedom of expression; yet in several other countries, including France and Australia, Final Exit was banned. More recent controversy surrounds web sites that provide explicit how-to information about suicide, including how to do so using readily available materials, and internet chat rooms that encourage or dare visitors to kill themselves.

PHYSICIAN-ASSISTED SUICIDE. Although issues of the permissibility of suicide generally have been the focus of sustained historical discussion, contemporary public-policy debate tends to focus on a narrower, specific issue: that of physician-assisted suicide, usually coupled with the question of voluntary active euthanasia. There are two principal arguments advanced for the legalization of these practices. First, claims about autonomy appeal to a conception of individuals as entitled to control as much as possible the course of their own dying. To restrict the right to die to the mere right to refuse unwanted medical treatment and so be allowed to die, this argument holds, is an indefensible truncation of the more basic right to choose one's death in accordance with one's own values. Thus, advance directives, such as living wills and durable powers of attorney, "do not resuscitate" (DNR) orders, and other mechanisms for withholding or withdrawing treatment, are inadequate to protect fundamental rights. Second, arguments for the legalization of physician-assisted suicide, usually together with arguments for voluntary euthanasia, involve an appeal to what is variously understood as mercy or nonmaleficence. Because not all terminal pain can be controlled and because suffering encompasses an even broader, less controllable range than pain, it is argued, it is defensible for a person who is in irremediable pain or suffering to choose death if there is no other way to avoid it.

Two principal arguments form the basis of the opposition to legalization of these practices. The first is that killing (in both suicide and euthanasia) is simply morally wrong, and hence wrong for doctors to facilitate or perform. The second argument is that legalization would invite a "slippery slope" leading to involuntary killing. The slippery slope argument contends, among other things, that permitting assistance in suicide or the performance of euthanasia would make killing "too easy," so that doctors would turn to it for reasons of bias, greed, impatience, or frustration with a patient who was not doing well; that it would set a dangerous model for disturbed younger persons who were not terminally ill; and that, in a society marked by prejudice against the elderly, the disabled, racial minorities, and many others, and motivated by cost considerations in a system that does not guarantee equitable care, "choices" of death that were not really voluntary would be imposed on vulnerable persons. Suicide in these circumstances would become a matter of social expectation or imperative. The counterargument for legalization replies that more open attitudes toward suicide would reduce psychopathology by allowing more effective counseling, and that by bringing practices that have always gone on in secrecy out into the open—and hence under adequate control—legalization would provide the most substantial protection for genuine patient choice.

Data from the Netherlands, where physician-assisted suicide and voluntary active euthanasia have been legally tolerated since the mid-1980s and are now legal, and from Oregon, where physician-assisted suicide became legal in 1997, do not support claims about a slippery slope, though full legalization is comparatively recent in both. In both only a very small fraction of patients who die actually die with physician assistance. Most are patients with cancer: 75 percent in the Netherlands, 79 percent in Oregon. Even so, of patients with cancer, the vast majority of those who die in either the Netherlands or Oregon do not die with this form of assistance. There is no evidence of disparate impact on groups of patients understood as vulnerable—the elderly, the poor, people with disabilities or with developmental delays, and others, although prior to the development of the protease inhibitors, was high for people with AIDS. Pain has not been the central issue; rather, most patients who have elected physician assistance in dying have done so, according to family members, physicians, and hospice caregivers, to avoid deterioration and loss of control over their circumstances. In Oregon, for example, the most frequently reported concerns by patients who died in 2001 included loss of autonomy (94%), decreasing ability to participate in activities that make life enjoyable (76%), and loss of control of bodily functions (53%); inadequate pain control and the financial implications of treatment were mentioned by just 6 percent each.

Particularly relevant to public-policy discussions is the contention of some contemporary writers that suicide will become "the preferred way of death" because it allows control over the time, place, and circumstances of dying. Others claim that as pain control in terminal illness improves, interest in physician-assisted euthanatic suicide will disappear. These may seem to be mere predictive claims. But in the technologically developed nations, where the epidemiologic transition in causes of death now means that the majority of the population will not die of parasitic and infectious disease, as was the case in all societies until the middle of the nineteenth century and is still the case in many less developed nations, but will die of late-life degenerative diseases with prolonged downhill courses, these claims may seem to harbor quite different normative visions of the roles people may—and should—play in their own deaths. One now faces a death that is comparatively predictable and prolonged, often perceived as burdensome to oneself and to those one loves.

Several particularly contentious issues have been raised in view of these facts. One concerns the question of whether a person can have a "duty to die." Some theorists have argued that as the burdens and costs of terminal care increase, both to the patient and to the family, a person becomes obligated to end his life; other commentators find this claim repugnant, an example of the kind of thinking that would fuel a slide down the slippery slope. Resolution of this issue rests on whether an individual's preferences and personal sense of concern for and obligation to family or others can be disentangled from social expectations about costs and savings.

Another issue of growing philosophical concern is that of suicide in old age, for reasons of old age alone rather than illness that accompanies old age. Despite extensive discussion among the Stoics of this matter—they held it to be a reasonable choice—and despite the prospects of vastly extended life expectancies of people in advanced industrial societies, such matters as preemptive suicide to avoid the deterioration of old age have been very little discussed.

Nor has the issue of altruistic suicide, not only in order to spare healthcare costs or other burdens for family members or others, but also in situations such as political protest and military strategy, received adequate philosophical analysis. In situations in which individuals committing suicide believe themselves to be acting for the common good, even at extreme personal sacrifice, is suicide—though it might be labeled with such euphemisms as martyrdom or heroism—morally acceptable or even praiseworthy? Such issues will form the basis for some of the many ethical challenges concerning suicide to be faced in future years.

margaret pabst battin (1995)

revised by author

SEE ALSO: Aging and the Aged: Old Age; Autonomy; Death; Dementia; Emotions; Human Rights; Life, Quality of; Life Sustaining Treatment and Euthanasia; Medical Codes and Oaths; Medical Ethics, History of Europe; Mental Illness: Conceptions of Mental Illness; Mental Institutions, Commitment to; Natural Law; Pain and Suffering; Pastoral Care and Healthcare Chaplaincy

BIBLIOGRAPHY

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Baechler, Jean. 1979. Suicides, tr. Barry Cooper. Oxford: Basil Blackwell.

Barraclough, Brian M. 1992. "The Bible Suicides." Acta Psychiatrica Scandinavia 86(1): 64–69.

Battin, Margaret Pabst. 1982. Ethical Issues in Suicide. Englewood Cliffs, NJ: Prentice-Hall.

Battin, Margaret Pabst. 1994. The Least Worst Death: Essays in Bioethics on the End of Life. New York: Oxford University Press.

Battin, Margaret Pabst, and Maris, Ronald W., eds. 1983. "Suicide and Ethics." Special issue of Suicide and Life-Threatening Behavior 13(4).

Battin, Margaret Pabst, and Mayo, David J., eds. 1980. Suicide: The Philosophical Issues. New York: St. Martin's Press.

Battin, Margaret P.; Rhodes, Rosamond; and Silvers, Anita, eds. 1998. Physician-Assisted Suicide: Expanding the Debate. New York: Oxford University Press.

Beauchamp, Tom L. 1996. Intending Death: The Ethics of Assisted Suicide and Euthanasia. Upper Saddle River, NJ: PrenticeHall.

Brock, Dan W. 1993. Life and Death: Philosophical Essays in Biomedical Ethics. Cambridge, Eng.: Cambridge University Press.

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Daube, David. 1972. "The Linguistics of Suicide." Philosophy and Public Affairs 1(4): 387–437.

Donne, John. 1982. Biathanatos, ed. Michael Rudick and Margaret Pabst Battin. New York: Garland.

Droge, Arthur J., and Tabor, James D. 1992. A Noble Death: Suicide and Martyrdom among Christians and Jews in Antiquity. San Francisco: HarperCollins.

Durkheim, Émile. 1951. Suicide: A Study in Sociology, tr. John A. Spaulding, ed. George Simpson. New York: Free Press.

Emanuel, Linda L., ed. 1998. Regulating How We Die: The Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide. Cambridge, MA: Harvard University Press.

Fedden, Henry Romilly. 1938. Suicide: A Social and Historical Study. London: Peter Davies.

Hardwig, John. 1997. "Is There a Duty to Die?" Hastings Center Report 27(2): 34–42.

Hume, David. 1777 (reprint 1963). "Of Suicide." In Essays: Moral, Political, and Literary, ed. T. H. Green and T. H. Grose. London: Oxford University Press.

Humphry, Derek. 1991, 1996, 2002. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Eugene, OR: National Hemlock Society. 2nd edition, New York: Dell. 3rd edition, New York: Delta.

Humphry, Derek, with Wickett, Ann. 1978. Jean's Way. London: Quartet Books.

Kant, Immanuel. 1980. Lectures on Ethics, tr. Louis Infield. Indianapolis, IN: Hackett.

Kant, Immanuel. 1983. Ethical Philosophy: The Complete Texts of the Grounding for the Metaphysics of Morals, and Metaphysical Principles of Virtue, Part II of the Metaphysics of Morals, tr. James W. Ellington. Indianapolis, IN: Hackett.

Kant, Immanuel. 1993. The Critique of Practical Reason, tr. Lewis White Beck. 3rd edition. New York: Macmillan.

Landsberg, Paul-Louis. 1953. The Experience of Death; The Moral Problem of Suicide, tr. Cynthia Rowland. New York: Philosophical Library.

Maris, Ronald W.; Berman, Alan L.; and Silverman, Morton M. 2000. Comprehensive Textbook of Suicidology. New York: Guilford Press.

Minois, George. 1999. History of Suicide: Voluntary Death in Western Culture, tr. Lydia G. Cochrane. Baltimore: Johns Hopkins University Press.

Murray, Alexander. 1998. Suicide in the Middle Ages, vol. 1: The Violent against Themselves. Oxford: Oxford University Press.

Nietzsche, Friedrich. 1953 (1881). The Dawn of Day (Morgenrote), p. 210. Stuttgart: Kroner Verlag.

Perlin, Seymour, ed. 1975. A Handbook for the Study of Suicide. Oxford: Oxford University Press.

Prado, Carlos G. 1990. The Last Choice: Preemptive Suicide in Advanced Age. Westport, CT: Greenwood.

Putnam, Constance E. 2002. Hospice or Hemlock? Searching for Heroic Compassion. Westport, CT: Praeger.

Quill, Timothy E. 1996. A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life. Balti-more, MD: Johns Hopkins University Press.

Seneca, Lucius Annaeus. 1920. "Letter on Suicide" and "On the Proper Time to Slip the Cable." In Ad Lucilium Epistulae Morales, tr. Richard M. Gummere. London: W. Heinemann.

Shneidman, Edwin S., ed. 1976. Suicidology: Contemporary Developments. New York: Grune and Stratton.

Shneidman, Edwin S., and Farberow, Norman L., eds. 1957. Clues to Suicide. New York: McGraw-Hill.

Sprott, Samuel E. 1961. The English Debate on Suicide: From Donne to Hume. La Salle, IL: Open Court.

Thomasma, David C.; Kimbrough-Kushner, Thomasine; Kimsma, Gerrit K.; et al., eds. 1998. Asking to Die: Inside the Dutch Debate about Euthanasia. Dordrecht, Netherlands: Kluwer.

van der Maas, Paul J.; van der Wal, Gerrit; Haverkate, Ilinka; et al. 1996. "Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990–1995." New England Journal of Medicine 335(22): 1699–1705.

INTERNET RESOURCES

McIntosh, John L. 2003. "Recent Suicide Statistics." Available from <http://www.iusb.edu/˜jmcintos/>.

Onwuteaka-Philipsen, Bregje D.; van der Heide, Agnes; Koper, Dirk; et al. 2003. "Euthanasia and Other End-of-Life Decisions in the Netherlands in 1990, 1995, and 2001," The Lancet 361. Available from <http:/image.thelancet.com/extras/03art3297webpdf>.

Oregon Department of Health Services. "Death with Dignity Act." Available from <http://www.dhs.state.or.us/publichealth/programs.cfm>.

van der Heide, Agnes; Deliens, Luc; Faisst, Karin; et al., on behalf of the EURELD consortium. 2003. "End-of-life Decision-Making in Six European Countries: Descriptive Study." The Lancet Available from <http://image.thelancet.com/extras/03art3298web.pdf>.

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Suicide

SUICIDE

To many people, suicide—intentional self-murder—is an asocial act of a private individual, yet sociology grew out of Durkheim's argument ([1897] 1951) that suicide rates are social facts and reflect variation in social regulation and social interaction. The concept of suicide derives from the Latin sui ("of oneself") and cide ("a killing"). Shneidman (1985) defines "suicide" as follows: "currently in the Western world a conscious act of self-induced annihilation best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution." Several conceptual implications follow from this definition.

Although suicidal types vary, there are common traits that most suicides share to some extent. (Shneidman 1985). Suicides tend to

  • Seek a solution to their life problems by dying
  • Want to cease consciousness
  • Try to reduce intolerable psychological pain
  • Have frustrated psychological needs
  • Feel helpless and hopeless
  • Be ambivalent about dying
  • Be perceptually constricted and rigid thinkers
  • Manifest escape, egression, or fugue behaviors
  • Communicate their intent to commit suicide or die
  • Have lifelong self-destructive coping responses (sometimes called "suicidal careers")

Completed suicides must be differentiated from nonfatal suicide attempts, suicide ideation, and suicide talk or gestures. Sometimes one speaks of self-injury, self-mutilation, accident proneness, failure to take needed medications, and the like—where suicide intent cannot be demonstrated—as "parasuicide." The most common self-destructive behaviors are indirect, such as alcoholism, obesity, risky sports, and gambling. There are also mass suicides (as in Jonestown, Guyana, in 1978 and in Masada in A.D. 72–73) and murder suicides. Individual and social growth probably require some degree of partial self-destruction.

Although most suicides have much in common, suicide is not a single type of behavior. Suicidology will not be an exact science until it specifies its dependent variable. The predictors or causes of suicide vary immensely with the specific type of suicidal outcome. Suicidologists tend to recognize three to six basic types of suicide, each with two or three of its own subtypes (Maris et al. 1992, chap. 4). For example, Durkheim ([1897] 1951) thought all suicides were basically anomic, egoistic, altruistic, or fatalistic. Freud (1917 [1953]) and Menninger (1938) argued that psychoanalytically, all suicides were based on hate or revenge (a "wish to kill"); on depression, melancholia, or hopelessness (a "wish to die"); or on guilt or shame (a "wish to be killed"). Baechler (1979) added "oblative" (i.e., sacrifice or transfiguration) and "ludic" (i.e., engaging in ordeals or risks and games) suicidal types.


EPIDEMIOLOGY, RATES, AND PREDICTORS

Suicide is a relatively rare event, averaging 1 to 3 in 10,000 in the general population per year. In 1996 (the most recent year for which U. S. vital statistics are available), there were 31,130 suicides, accounting for about 1.5 percent of all deaths. This amounts to an overall suicide rate of 11.6 per 100,000. Suicide is now the ninth leading cause of death, ranking just ahead of cirrhosis and other liver disease deaths and just behind human immunodeficiency virus (HIV) deaths. Suicide also has been moving up the list of the leading causes of death in this century (Table 1).

Suicide rates in the United States vary considerably by sex, age, and race (Table 2). The highest rates are consistently observed among white males, who constitute roughly 73 percent of all suicides. White females account for about 17 percent of all suicides. American blacks, especially females, rarely commit suicide (except for some young urban males). Some scholars have argued that black suicides tend to be disguised as homicides or accidents. In general, male suicides outnumber female suicides three or four to one. Generally, suicide rates gradually increase with age and then drop off at the very oldest ages. Female suicide rates tend to peak earlier than do those of males. Note in Table 3 that from about 1967 to 1977, there was a significant increase in the suicide rate of 15- to 24- year-olds and that suicide rates among the elderly seem to be climbing again.

Typically, marrying and having children protect one against suicide. Usually suicide rates are highest for widows, followed by the divorced and the never-married or single. Studies of suicide rates by social class have been equivocal. Within each broad census occupational category, there are job types with high and low suicide rates. For example, psychiatrists have high suicide rates, but pediatricians and surgeons have low rates. Operatives usually have low rates, but police officers typically have high rates.

The predominant method of suicide for both males and females in 1992 was firearms (Table 4).

Table 1
Ten Leading Causes of Death in the United States, 1996 (total of 2,314,690 deaths)
rankcause of deathrate per 100,000no. of deaths (all causes)
source: data from u.s. national center for health statistics, 1998.
1disease of the heart276.4733,361
2malignant neoplasms203.4539,533
3cerebrovascular disease60.3159,942
4chronic obstructive pulmonary disease40106,027
5accidents35.894,943
6pnuemonia and influenza31.683,727
7diabetes mellitus23.361,767
8hiv infection11.731,130
9suicide11.630,903
10chronic liver disease and cirrhosis9.425,047


The second most common method among males is hanging, and among females it is a drug or medicine overdose. Females use a somewhat greater variety of methods than males do. Suicide rates tend to be higher on Mondays and in the springtime (Gabennesch 1988).

Prediction of suicide is a complicated process (Maris et al. 1992). As is the case with other rare events, suicide prediction generates many false positives, such as identifying someone as a suicide when that person in fact is not a suicide. Correctly identifying true suicides is referred to as "sensitivity," and correctly identifying true nonsuicides is called "specificity." In a study using common predictors (Table 5) Porkorny (1983) correctly predicted fifteen of sixty-seven suicides among 4,800 psychiatric patients but also got 279 false positives.

Table 5 lists fifteen major predictors of suicide. Single predictor variables seldom correctly identify suicides. Most suicides have "comorbidity" (i.e., several key predictors are involved), and specific predictors vary with the type of suicide and other factors. Depressive disorders and alcoholism are two of the major predictors of suicide. Robins (1981) found that about 45 percent of all

Table 2
Rates of Completed Suicide per 100,000 Population by Race and Gender, 1996
race and gender groupno. of suicidespercent of suicidesrate per 100,000
note: *includes american indian, chinese, hawaiian, japanese, filipino, other asian or pacific islander, and other.
source: data from centers for disease control, 1998.
white males22,5477320.9
white females5,30917.14.8
black males(1,389)(4.5)(11.4)
black females(204)(0.8)(2.0)
nonwhite males*2,4518.011.3
nonwhite females*5961.92.5
totals30,903100.011.6

completed suicides involved either depressed or alcoholic persons. Roughly 15 percent of all those with depressive illness and 18 percent of all alcoholics eventually commit suicide. Repeated depressive illness that leads to hopelessness is especially suicidogenic.

Nonfatal suicide attempts, talk about suicide or dying, and explicit plans or preparations for dying or suicide all increase suicide risk. However, for the paradigmatic suicide (older white males), 85 to 90 percent of these individuals make only one fatal suicide attempt and seldom explicitly communicate their suicidal intent or show up at hospitals and clinics. Social isolation (e.g., having no close friends, living alone, being unemployed, being unmarried) and lack of social support are more common among suicides than among controls. Suicide tends to run in families, and this suggests both modeling and genetic influences. Important biological and sociobiological predictors of suicide have been emerging, especially low levels of central spinal fluid serotonin in the form of 5-HIAA (Maris 1997).


HISTORY, COMPARATIVE STUDIES, AND SOCIAL SUICIDOLOGISTS

The incidence and study of suicide have a long history and were fundamental to the development of sociology. The earliest known visual reference to suicide is Ajax falling on his sword (circa 540 b.c.). Of course, it is known that Socrates (about 399 b.c.) drank hemlock. In the Judeo-Christian scriptures there were eleven men (and no women) who died by suicide, most notably Samson, Judas, and Saul. Common biblical motives for suicide were revenge, shame, and defeat in battle. Famous suicides in art history include paintings of Lucretia stabbing herself (after a rape), Dido, and work by Edvard Munch and Andy Warhol.

Suicide varies with culture and ethnicity. Most cultures have at least some suicides. However, suicide is rare or absent among the Tiv of Nigeria, Andaman islanders, and Australian aborigines and relatively infrequent among rural American blacks and Irish Roman Catholics. The highest suicide rates are found in Hungary, Germany, Austria, Scandinavia, and Japan (Table 6). The lowest rates are found in several South American, Pacific Island, and predominantly Roman Catholic countries, including Antigua, Jamaica, New Guinea, the Phillipines, Mexico, Italy, and Ireland.

The sociological study of suicide started with Durkheim ([1897] 1951) and has continued to the present day primarily in the research and publications of the following sociologists: Short, (1954), J.P. Gibbs (1964), J.T. Gibbs (1988), Douglas (1967), Maris (1969, 1981), Phillips (1974), Phillips et al. (1991), Stack (1982), Wasserman (1989), and Pescosolido and Georgianna (1989). It is impossible in an encyclopedia article to do justice to the full account of the sociological study of suicide. For a more complete review, the reader is referred to Maris (1989).

Durkheim ([1897] 1951) claimed that the suicide rate varied inverely with social integration and that suicide types were primarily ego-anomic. However, Durkheim did not operationally define "social integration." Gibbs and Martin (1964) created the concept of "status integration" to correct this deficiency. They hypothesized that the less frequently occupied status sets would lead to lower status integration and higher suicide rates. Putting it differently, they expected status integration and suicide rates to be negatively associated. In a large series of tests from 1964 to 1988, Gibbs confirmed his primary hypothesis only for occupational statuses, which Durkheim also had said were of central importance.

Table 3
Rates of Completed Suicide per 100,000 Population by Year and Age in the United States
 year
age*19571967197719871992
note: suicide not reported for individuals under 5 years of age.
source: data from centers for disease control, 1995.
5–140.20.30.50.70.9
15–244.07.013.612.912.9
25–348.612.417.715.414.6
35–4412.816.616.815.015.1
45–5418.019.518.915.914.7
55–6422.422.419.416.614.9
65–7425.019.820.119.416.6
75–8426.821.021.525.823.1
>8526.322.717.322.121.9
total9.810.813.312.712.0



Short (Henry and Short 1954) expanded Durkheim's concept of external and constraining social facts to include interaction with social psychological factors of "internal constraint" (such as strict superego restraint) and frustration-aggression theory. Short reasoned that suicide rates would be highest when external restraint was low and internal restraint was high and that homicide rates would be highest when internal restraint was low and external restraint was high.

A vastly different sociological perspective on suicide originated with the work of enthnomethodologist Douglas. Douglas, in the tradition of Max Weber's subjective meanings, argued that Durkheim's reliance on official statistics (such as death certificates) as the data base for studying suicide was fundamentally mistaken (Douglas 1967). Instead, it is necessary to observe the accounts or situated meanings of individuals who are known to be suicidal, not rely on a third-party official such as a coroner or medical examiner who is not a suicide and may use ad hoc criteria to classify a death as a suicide. There are probably as many official statistics as there are officials.

Maris (1981) extended Durkheim's empirical survey of suicidal behaviors, but not just by measuring macrosocial and demographic or structural variables. Instead, Maris focused on actual interviews ("psychological autopsies") of the intimate survivors of suicides (usually their spouses) and compared those cases with control or comparison groups of natural deaths and nonfatal suicide attempts. Maris claimed that suicides had long "suicidal careers" involving complex mixes of biological, social, and psychological factors.

Phillips (1974) differed with Durkheim's contention that suicides are not suggestible or contagious. In a pioneering paper in the American Sociological Review, he demonstrated that front-page newspaper coverage of celebrity suicides was associated with a statistically significant rise in the national suicide rate seven to ten days after a publicized suicide. The rise in the suicide rate was greater the longer the front-page coverage, greater in the region where the news account ran, and higher if the stimulus suicide and the person supposedly copying the suicide were similar. In a long series of similar studies, Phillips et al. (1991) expanded and documented the suggestion effect for other types of behavior and other groups. For example, the contagion effect appears to be especially powerful among teenagers. Nevertheless, contagion accounts only for a 1 to 6 percent increase over the normal expected suicide rates in a population.

Table 4
Percent of Completed Suicides in 1987 and 1992 by Method and Gender
 gender
 male %female %
method1987199219871992
note: *includes gases in domestic use (e951), other specified and unspecified gases and vapors (e952.8–952.9), explosives (e955.5), unspecified firearms and explosives (e955.9), and other specified or unspecified means of hanging, strangulation, or suffocation (e953.8–953.9).
source: data from national center for health statistics, 1995.
firearms (e955.0–955.4)64.06539.839
drugs/medications (e950.0–950.5)5.225.0
hanging (e953.0)13.5169.414
carbon monoxide (e952.0–952.1)9.612.6
jumping from a high place (e957)1.83.0
drowning (e954)1.12.8
suffocation by plastic bag (e953.1)0.41.8
cutting/piercing instruments (e965)1.311.41
poisons (e950.6–950.9)0.61.0
other*2.5183.245
totals100.0100.0100.099.0

Phillips's ideas about contagion dominated the sociological study of suicide in the 1980s. Works by Stack (1982), Wasserman (1989), Kessler and Strip (1984), and others have produced equivocal support for the role of suggestion in suicide (Diekstra et al. 1989). Wasserman (1989) feels that the business cycle and unemployment rates must be controlled for. Some have claimed that imitative effects are statistical artifacts. Most problematic is the fact that the theory of imitation in suicide is underdeveloped.

The most recent sociologist to study suicide is the medical sociologist Pescosolido. She has claimed, contrary to Douglas, that the official statistics on suicide are acceptably reliable and, as Gibbs said earlier, are the best basis available for a science of suicide. Her latest paper (Pescosolido and Georgianna 1989) examined Durkheim's claim that religious involvement protects against suicide. Pescosolido and Georgianna find that Roman Catholicism and evangelical Protestantism protect one against suicide

Table 5
Common Single Predictors of Suicide
source: Maris et al. 1992, chap. 1.
1.depressive illness, mental disorder
2.alcoholism, drug abuse
3.suicide ideation, talk, preparation, religion
4.prior suicide attempts
5.lethal methods
6.isolation, living alone, loss of support
7.hopelessness, cognitive rigidity
8.older white males
9.modeling, suicide in the family, genetics
10.work problems, economics, occupation
11.marital problems, family pathology
12.stress, life events
13.anger, aggression, irritability, 5-hiaa
14.physical illness
15.repetition and comorbidity of factors 1–14, suicidal careers



(institutional Protestantism does not) and that Judaism has a small and inconsistent protective effect. Those authors conclude that with disintegrating network ties, individuals who lack both integrative and regulative supports commit suicide more often.


ISSUES AND FUTURE DIRECTIONS

Much of current sociological research on suicide appears myopic and sterile compared to the early work of Durkheim, Douglas, and Garfinkel. Not only is the scope of current research limited, there is very little theory and few book-length publications. Almost no research mongraphs on the sociology of suicide were written in the 1980s. Highly focused scientific journal articles on imitation have predominated, but none of these papers have been able to establish whether suicides ever were exposed to the original media stimulus. Since suicide does not concern only social relations, the study of suicide needs more interdisciplinary syntheses. The dependent variable (suicide) must include comparisons with other types of death and

Table 6
Suicide Rates per 100,000 Population in 62 Countries, 1980–1986
 countryrate
source: world health organization data bank, latest year of reporting as of july 1, 1988.
1.hungary45.3
2.federal republic of germany43.1
3.sri lanka29.0
4.austria28.3
5.denmark27.8
6.finland26.6
7.belgium23.8
8.switzerland22.8
9.france22.7
10.suriname21.6
11.japan21.2
12.german democratic republic19.0
13.czechoslovakia18.9
14.sweden18.5
15.cuba17.7
16.bulgaria16.3
17.yugoslavia16.1
18.norway14.1
19.luxemborg13.9
20.iceland13.3
21.poland13.0
22.canada12.9
23.singapore12.7
24.united states12.3
25.hong kong12.2
26.australia11.6
27.scotland11.6
28.netherlands11.0
29.el salvador10.8
30.new zealand10.3
31.puerto rico9.8
32.uruguay9.6
33.northern ireland9.3
34.portugal9.2
35.england and wales8.9
36.trinidad and tobago8.6
37.guadeloupe7.9
38.ireland7.8
39.italy7.6
40.thailand6.6
41.argentina6.3
42.chile6.2
43.spain4.9
44.venezuela4.8
45.costa rica4.5
46.ecuador4.3
47.greece4.1
48.martinique3.7
49.colombia2.9
50.mauritius2.8
51.dominican republic2.4
52.mexico1.6
53.panama1.4
54.peru1.4
55.philippines0.5
56.guatemala0.5
57.malta0.3
58.nicaragua0.2
59.papua new guinea0.2
60.jamaica0.1
61.egypt0.1
62.antigua and barbuda

violence as well as more nonsocial predictor variables (Holinger 1987).

A second issue concerns methods for studying suicide (Lann et al. 1989). There has never been a truly national sample survey of suicidal behaviors in the United States. Also, most suicide research is retrospective and based on questionable vital statistics. More prospective or longitudinal research design are needed, with adequate sample sizes and comparison or control groups. Models of suicidal careers should be analyzed with specific and appropriate statistical techniques such as logistic regression, log-linear procedures, and event or hazard analysis. Federal funds to do major research on suicide are in short supply, and this is probably the major obstacle to the contemporary scientific study of suicide.

Most studies of suicide are cross-sectional and static. Future research should include more social developmental designs (Blumenthal and Kupfer 1990). There is still very little solid knowledge about the social dynamics or "suicidal careers" of eventual suicides (Maris 1990). For example, it is well known that successful suicides tend to be socially isolated at the time of death, but how they came to be that way is less well understood. Even after almost a hundred years of research the relationship of suicide to social class, occupation, and socioeconomic status is not clear.

A major issue in the study of suicide is rational suicide, active euthanasia, the right to die, and appropriate death. With a rapidly aging and more secular population and the spread of the acquired immune defiency (AIDS) virus, the American public is demanding more information about and legal rights to voluntary assisted death (see the case of Nico Speijer in the Netherlands in Diekstra et al. 1989). The right to die and assisted suicide have been the focus of a few recent legal cases (Humphry and Wickett 1986; Battin and Maris 1983). Rosewell Gilbert, an elderly man who was sentenced to life imprisonment in Florida for the mercy killing of his sick wife, was pardoned by the governor of Florida (1990). However, in 1990, the U.S. Supreme Court (Cruzon v. the State of Missouri) ruled that hospitals have the right to force-feed even brain-dead patients. The Hemlock Society has been founded by Derek Humphry to assist those who wish to end their own lives, make living wills, or pass living will legislation in their states (however, see the New York Times, February 8, 1990, p. A18). Of course, the state must assure that the right to die does not become the obligation to die (e.g., for the aged). These issues are further complicated by strong religious and moral beliefs.

Should society help some people to die, and if so, who and in what circumstances? All people have to die, after all, so why not make dying free from pain, as quick as is desired, and not mutilating or lonely? One cannot help thinking of what has happened to assisted death at the other end of the life span, when help has not been available, in the case of abortion. Women often mutilate themselves and torture their fetuses by default. The same thing usually happens to suicides when they shoot themsleves in the head in a drunken stupor in a lonely bedroom or hotel room. Obviously, many abortions and most suicides are not "good deaths."

Euthanasia is not a unitary thing. It can be active or passive, voluntary or involuntary, and direct or indirect. A person can be against one type of euthanasia but in favor of another. "Active euthanasia" is an act that kills, while "passive euthanasia" is the omission of an act, which results in death. For example, passive or indirect euthanasia could consist of "no-coding" terminal cancer or heart patients instead of resuscitating them or not doing cardiopulmonary resuscitation after a medical crisis.

"Voluntary euthanasia" is death in which the patient makes the decision (perhaps by drafting a living will), as opposed to "involuntary euthanasia," in which someone other than the patient (e.g., if the patient is in a coma) decides (the patient's family, a physician, or a nurse).

"Direct euthanasia" occurs when death is the primary intended outcome, in contrast to "indirect euthanasia," in which death is a by-product, for example, of administering narcotics to manage pain but secondarily causes respiratory failure.

All the types of euthanasia have asssociated problems. For example, active euthanasia constitutes murder in most states. It also violates a physician's Hippocratic oath (first do no harm) and religious rules (does all life belong to God?) and has practical ambiguities (when is a patient truly hopeless?).

Passive euthanasia is often slow, painful, and expensive. For example, the comatose patient Karen Anne Quinlan lived for ten years (she survived even after the respirator was turned off) and seemed to grimace and gasp for breath. Her parents and their insurance company spent thousands of dollars on what proved to be a hopeless case. The U.S. Supreme Court ruled in Cruzan (1990) that hospitals cannot be forced to discontinue feeding comatose patients.

In a case in which the author served as an expert, Elizabeth Bouvia, a quadriplegic cerebral palsy patient in California, sued to avoid being force-fed as a noncomatose patient. Her intention was to starve herself to death in the hospital. The California Supreme Court upheld Bouvia's right to refuse treatment, but others called the court's decision "legal suicide."

A celebrated spokesperson for euthanasia in the form of assisted suicide has been Derek Humphry, especially in his best-selling book Final Exit (1996). Rational assisted suicide (Humphry assisted in his first wife's death and in the death of his father-in-law), even for the terminally ill within six months of death, has proved highly controversial, particularly to Catholics and the religious right. Basically, Humphry has written a "how-to" book on the practicalities of suicide for the terminaly ill.

His preferred rational suicide technique is to ingest four or five beta-blocker tablets and 40 to 60 100-mg tablets of a barbituate (perhaps in pudding or Jell-O), taken with Dramamine (to settle the stomach), vodka (or one's favorite whiskey), and a plastic bag over the head loosely fixed by a rubber band around the neck. Humphry recommends against guns (too messy), cyanide (too painful), hanging (too graphic), jumping (one could land on another person), and other mutilating, violent, painful, or uncertain methods.

One of the big questions about Final Exit is its potential abuses, for example, by young people with treatable, reversible depression. Having the lethal methods for suicide described in such vivid, explicit details worries many people that suicide will become too easy and thus often will be inappropriate. Yet Humphry shows that it is hard to get help with self-deliverance without fear of penalties. He argues that laws need to be changed to permit and specify procedures for physician-assisted suicide for the terminally ill under highly controlled conditions.

A few states have undertaken such reforms to permit legal assisted death. For example, Initiative 119 in the fall of 1991 in Washington and Proposition 161 in the fall of 1992 in California would have provided "aid in dying" for a person if (1) two physicians certified that the person was within six months of (natural) death (i.e., terminally ill), (2) the person was conscious and competent, and (3) the person signed a voluntarily written request to die witnessed by two impartial, unrelated adults. Both referenda failed by votes of about 45 percent in favor and 55 percent against.

Humphry waged a similar legal battle in Oregon, first as president of the Hemlock Society and later as president of the Euthanasia Research and Guidance Organization (ERGO) and the Oregon Right to Die organization. On November 4, 1994, Oregon became the first state to permit a doctor to prescribe lethal drugs expressly and explicitly to assist in a suicide (see Ballot Measure 16). The National Right to Life Committee effectly blocked the enactment of this law until-1997, when the measure passed overwhelmingly again. On March 25, 1998, an Oregon woman in her mid-eighties stricken with cancer became the first known person to die in the United States under a doctor-assisted suicide law (most, if not all, of Dr. Jack Kervorkian's assisted suicides have probably been illegal).

Physician-assisted suicide has been practiced for some time in the Netherlands. On February 10, 1993, the Dutch Parliment voted 91 to 45 to allow euthanasia. To be eligible for euthanasia or assisted-suicide in the Netherlands, one must (1) act voluntarily, (2) be mentally competent, (3) have a hopeless disease without prospect for improvement, (4) have a lasting longing (or persistent wish) for death, (5) have assisting doctor consult at least one colleague, and (6) have written report drawn up afterward.

The Dutch law opened the door for similar legislation in the United States, although the U.S. Supreme court seems to have closed that door shut in Washington and New York. Box 1 discusses reviews of Dr. Herbert Hendin's Seduced by Death, which opposes physician-assisted death the United States and the Netherlands. While the idea of legal assisted suicide will remain highly controversial and devisive, it is quite likely that bills similar to Oregon's Measure 16 will pass in other states in the next decade. A key issue will be safeguards against abuses (for example, Hendin argues that physicians in the Netherlands have decided on their own in some cases to euthanize patients).


THE DUTCH CASE

The following are excerpts from reviews of Dr. Herbert Hendin's Seduced by Death, Doctors, Patients, and the Dutch Cure (Norton 1997). See Suicide and Life-Threatening Behavior 28:2, 1998.

On June 26, 1997, the United States Supreme Court handed down a unanimous decision on physician-assisted suicide. All nine justices concurred that both New York and Washington's state bans on the practice should stand.

The picture [Hendin paints in the Netherlands] is a frightening one of excessive reliance on the judgment of physicians, a consensual legal system that places support of the physician above individual patient rights in order to protect the euthanasia policy, the gradual extension of practice to include administration of euthanasia without consent in a substantial number of cases, and psychologically naive abuses of power in the doctor-patient relationship.

[For example:] Many patients come into therapy with sometimes conscious but often more unconscious fantasies that cast the therapist in the role of executioner . . . It may also play into the therapist's illusion that if he cannot cure the patient, no one else can either." (Seduced by Death, p. 57)

Samuel Klagsburn, M.D., says of Hendin's argument: "He is wrong . . . suffering needs to be addressed as aggressively as possible in order to stop unnecessary suffering."

Hendin claims that in the Netherlands, "despite legal sanction, 60% of [physicianassisted suicide and death] cases are not reported, which makes regulation impossible."

Hendin goes on to argue that "a small but significant percentage of American doctors are now practicing assisted suicide, euthanasia, and the ending of patients' lives without their consent." But one also has to wonder: what about all those patients being forced to live and suffer without the patients' consent?

Dr. Hendin is, after all, the former Executive Director and current Medical Director of the American Foundation for Suicide Prevention. What would really be news is if Hendin came out in favor of physician-assisted death. Certainly, there are abuses of any policy. But is that enough of a reason to fail to assist fellow human beings in unremitting pain to die more easily? Death is one the most natural things there is and often is the only relief.

One of the most controversial advocates of physician-assisted suicide ("medicide") has been Dr. Kervorkian (Kevorkian 1991). Public awareness of assisted suicide and whether it is rational has foused largely on Kervorkian, the "suicide doctor." As of early 1999, Kervorkian had assisted in over 100 suicides.

Initially, with Janet Adkins, Kervorkian used a suicide machine, which he dubbed a "mercitron." This machine provided a motor-driven, timed release of three intravenous bottles; in succession, they were (1) thiopental or sodium pentathol (an anesthetic that produces rapid unconsciousness), (2) succinycholine (a muscle paralyzer like the curare used in Africa use in poison darts to hunt monkeys), and (3) postassium chloride to stop the heart. The metcitron was turned on by the would-be suicide. Because of malfunctions in the suicide machine, almost all of Kervorkian's suicides after Atkins were accomplished with a simple facial mask hooked up to a hose and a carbon monoxide cannister, with the carbon monoxide flow being initiated by the suicide. For most nonnarcotic users or addicts, 20 to 30 milligrams of intravenous injected morphine would cause death.

All of Kervorkian's first clients were women, and most were single, divorced, or widowed. Almost all were not terminally ill or at least probably would not have died within six months. The toxicology reports at autopsy (by Frederick Rieders; the author spoke with Dr. Dragovic, the Oakland County, Michigan, medical examiner to obtain these data) showed that only two of the eight assisted suicides had detectable levels of antidepressants in their blood at the time of death. It could be concluded that Kervorkian's assisted suicides were for the most part not being treated for depressive disorders.

Given Kervorkian's zealous pursuit of active euthanasia, one suspects that at least his early assisted suicides were not adequately screened or processed, for example, in accordance with the Dutch rules (above) or other safeguards. Strikingly, Hugh Gale is reputed to have asked Kervorkian to take off the carbon monoxide mask and terminate the dying process and perhaps was ignored by Kervorkian.

It is difficult to be objective about assisted suicide. Paradoxically, Kevorkian may end up setting euthanasia and doctor-assisted suicide back several years. Not only has he lost (1991) his Michigan medical license (he was a pathologist) and been charged with murder (after videotaping the dying of an assisted suicide for a television program), but Michigan and many other states (including South Carolina) have introduced bills to make previously legal assisted suicide a felony, with concurrent fines and imprisonment.

These new laws may have a chilling effect on both active and passive euthanasia, even in the case of legitimate pain control ("palliative care") previously offered to dying patients by physicians and nurses. For example, in Michigan it is now a felony to assist a suicide. People who want self-deliverance from their final pain and suffering will be more likely to mutilate themselves, die alone and disgraced, and feel generally abandoned in their time of greatest need.

Kervorkian needs to be separated from the issue of assisted suicide. However, the issue of physician-assisted suicide or death itself is not silly and transitory.

Everyone has to die eventually, and many people will suffer machine-prolonged debilitating illness and pain that diminishes the quality of their lives. Suicide and death and permanent annnihilation of consciousness (if there is no afterlife) are effective means of pain control. This refers primarily to physical pain, but psychological pain also can be excruciating. Pain cannot always be controlled short of death. Most narcotics risk respiratory death. Furthermore, narcotics often cause altered consciousness, nightmares, nausea, panic, long periods of disrupted consciousness and confusion, and addiction.

Pain control technology is progressing rapidly (e.g., spinal implant morphine pumps). There are hospices that encourage the use classic painkilling drinks such as Cicely Saunder's "Brompton's cocktail" (a mixed drink of gin, Thorazine, cocaine, heroin, and sugar). It is also possible to block nerves or utilize sophisticated polypharmacy to soften pain.

However, some pain is relatively intractable (e.g., that from bone cancer, lung disease with pneumonia, congestive heart failure in which patients choke to death on their own fluids, gastrointestinal obstructions, and amputation). A few physicians have made the ludricrous death-in-life proposal to give hopeless terminally ill patients general anesthesia to control their pain. People do always get well or feel better. Sometimes they just need to die, not be kept alive to suffer pointlessly. Anyone deserves to be helped to die in such instances.


references

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Blumenthal, Susan J., and David J. Kupfer, eds. 1990. Suicide over the Life Cycle: Risk Factor Assessment, and Treatment of Suicidal Patients. Washington, D.C.: American Psychiatric Press.

Diekstra, René F. W., Ronald W. Maris, Stephen Platt, Armin Schmidtke, and Gernot Sonneck, eds. 1989 Suicide and Its Prevention: The Role of Attitude and Imitation. Leiden: E.J. Brill.

Douglas, Jack D. 1967 The Social Meanings of Suicide. Princeton, N.J.: Princeton University Press.

Durkheim, Emile. (1897) 1951 Suicide. New York: Free Press.

Freud, Sigmund (1917) 1953 "Mourning and Melancholia." In Standard Edition of the Complete Works of Sigmund Freud. London: Hogarth Press.

Gabennesch, Howard 1988 "When Promises Fail: A Theory of Temporal Fluctuations in Suicide." Social Forces 67:129–145.

Gibbs, Jack P., and W. T. Martin 1964 Status Integration and Suicide. Eugene: University of Oregon Press.

Gibbs, Jewelle Taylor, ed. 1988 Young, Black, and Male in America: An Endangered Species. Dover, Mass.: Auburn House.

Henry, Andrew F., and James F. Short 1954 Suicide and Homicide. New York: Free Press.

Holinger, Paul C. 1987 Violent Deaths in the United States: An Epidemiological Study of Suicide, Homicide, and Accidents. New York: Guilford.

Humphry, Derek 1996 Final Exit. New York: Dell.

——, and Ann Wickett 1986 The Right to Die: Understanding Euthanasia. New York: Harper & Row.

Kessler, Ronald C., and H. Stripp 1984 "The Impact of Fictional Television Stories on U.S. Fatalities: A Replication." American Journal of Sociology 90:151–167.

Kervorkian, Jack 1991 Prescription Medicine. Buffalo, N.Y.: Prometens.

Lann, Irma S., Eve K. Mościcki, and Ronald W. Maris, eds. 1989 Strategies for Studying Suicide and Suicidal Behavior. New York: Guilford.

Maris, Ronald W. 1969 Social Forces in Urban Suicide. Chicago: Dorsey.

—— 1981. Pathways to Suicide: A Survey of Self-Destructive Behaviors. Baltimore: Johns Hopkins University Press.

—— 1989. "The Social Relations of Suicide." In Douglas Jacobs and Herbert N. Brown, eds., Suicide, Understanding and Responding: Harvard Medical School Perspectives, Madison, Conn.: International Universities Press.

—— 1990. The Developmental Perspective of Suicide." In Antoon Leenaars, ed., Life Span Perspectives of Suicide. New York: Plenum.

—— 1997 "Suicide." In Renato Pulbecco, ed., Encyclopedia of Human Biology.

——, Alan L. Berman, John T. Maltsberger, and Robert I. Yufit, eds. 1992 Assessment and Prediction of Suicide. New York: Guilford.

Menninger, Karl 1938 Man against Himself. New York: Harcourt, Brace.

Pescosolido, Bernice A., and Sharon Georgianna 1989 "Durkheim, Suicide, and Religion: Toward a Network Theory of Suicide." American Sociological Review 54:33–48.

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Pokorny, Alex D. 1983 "Prediction of Suicide in Psychiatric Patients." Archives of General Psychiatry 40:249–257.

——, Katherine Lesyna, and David T. Paight 1991 "Suicide and the Media." In Ronald W. Maris, et al., eds., Assessment and Prediction of Suicide. New York: Guilford.

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Ronald W. Maris

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Suicide