Suicide - huji.ac.ilpluto.huji.ac.il/~msheyd/files/suicide-proofs.pdf · suicide principally from the point of view of the agent. On this level, suicide has no specifically moral

Chapter 13

Suicide

Sidney Bloch and David Heyd

Suicide is undoubtedly the most demanding clinical situation encountered by psychia-trists. An estimated one million people die by their own hand each year. For example,the rate for China is about 300,000 per annum; 5,000 suicides occur in England everyyear, nearly 4,000 in Canada, 2200 in Australia, and 31,000 in the US (1). And as thenumber of attempted suicides is up to 50 times greater than that of fatal suicides,(depending on the study cited) every psychiatrist inevitably deals with suicidalpatients and their families. While the incidence makes suicide impossible to ignore, itsnature makes it difficult to confront—psychologically and ethically (2).

Suicide differs in four principal ways from other clinical situations in psychiatry thatgenerate ethical dilemmas. First, most psychiatric problems involve the adjustment ofthe right means to a given end that is shared by both clinician and patient; by contrastsuicide focuses on the end itself, about which the two groups may hold contradictorypositions. The psychiatrist’s task then becomes one to persuade the patient to changehis most basic desires and attitude to life.

Second, the conflict between the psychiatrist’s values and his patient’s goals is deeperthan an incidental disagreement. The value of life as an end in itself is not only sharedby most people, but also considered the most fundamental value. Accordingly, suicidethreatens our deepest convictions about the ‘sanctity of life’ (We should hasten tomention that the concept of ‘rational suicide’ has been invoked by some commentators,which suggests other views of life’s sanctity (3).) We will return to this theme whenpresenting various clinical situations below. Third, it is exceedingly difficult to ridourselves of this sense of threat, because the phenomenon of suicide is logically andethically puzzling. Justifying the value of life and the purported moral duty to go onliving is problematic. Our belief in the value of life is further offended by the relativefailure to prevent suicide, either through treatment or social changes; suicide is disturbingly ubiquitous—across cultures and ages. And the optimism felt after successful prevention in individual cases is offset by others under professional care,who nevertheless take their own lives.

Final, the suicide rate among psychiatrists is substantially higher than that in thegeneral population, which makes them feel vulnerable when they treat a suicidalpatient. In other spheres of clinical work, psychiatrists can remain more detached.

Methodological difficulties also abound. A range of definitions and a plethora ofsynonymous terms pervade the field (‘suicide,’ ‘self-killing,’ ‘self-poisoning,’ ‘deliberateself-harm,’ ‘attempted suicide,’ ‘para-suicide,’ etc.). The fact that suicide is the denial of a value, and not just the act of terminating life, makes its definition value-laden,

13-Bloch&Green-Chap-13 8/2/08 6:11 PM Page 229

that is, to say not purely descriptive. The language of suicide reflects this: for example, the lack of a specific word for it in the Bible, Augustine’s emotive phrase‘self-murder,’ and the use of objectively scientific terms. ‘Suicide’ itself is a relativelynew (17th-century) term whose function was to replace the more incriminatory ‘self-homicide’ (4).

On the other hand, ethical analysis cannot ignore scientific theories about thenature of suicide, namely descriptive studies in the medical and social sciences. Boththe way suicide is conceptualized and our approach to the question of the right to intervene depend on these studies, especially whether suicide is a form of mentalillness or a rational choice, and whether it reflects a pure intention to die or a ‘cry forhelp.’ Furthermore, any analysis of voluntariness, a condition of suicide, partlydepends on our theory of human behaviour, including criteria to distinguish betweenan impulsive act under conditions of stress and a reasoned choice based on the consideration of alternative courses of action.

This interdependence of descriptive and normative factors is both theoretically andclinically salient and will become clearer when we cover major views about suicide inWestern thought and its clinical dimension. In the philosophical discussion we willsee that difficulties in refuting the ‘rationality’ of suicide are considerable, but morallyjustifiable intervention remains possible (see page XXXX).

The philosophical point of view: the value of lifeThat life has value, indeed is the greatest value, and is taken for granted. Being such anobvious ‘good,’ it requires no justification. Not surprisingly, any questioning of life’svalue is usually regarded as a sign of crisis, or even of ‘illness.’

Yet, the persistence of suicide challenges the obviousness of life’s value. On the onehand, it proves that the drive to preserve life is not always sufficiently powerful to over-ride other drives. On the other hand, it forces us to admit that most people go on livingnot as a result of a well-grounded conclusion of reasoning. This may not disturb us aslong as we are not confronted by a person’s preference for death over life. Besides thetragedy of death itself, the absence of rational justification is perhaps the main cause ofthe shattering impression suicide leaves on us. In a more existentialist vein we can saythat the tragedy of suicide is not only the victim’s but also that of the survivors, sincethe act lays bare the absurdity of life. As Camus put it: ‘There is but one truly seriousphilosophical problem and that is suicide. Judging whether life is or is not worth livingamounts to answering the fundamental question of philosophy’ (5).

Most cultures have linguistically powerful tools for expressing the special value of life:the inalienable right to life, respect for life, sanctity of life, reverence for life and dignityof life. These terms are typically vague, often expressing deep beliefs, fears and taboosrather than rationally formulated conceptions (6). But beyond the awesome terminolo-gy, the main philosophical hurdle in justifying the value of life lies in a symmetrybetween the choices of life and death. The prolongation of life does not mean the short-ening of death, and cutting life short does not imply having more of the other state(death). Therefore, even if we could assign ‘values’ to life and death, they would beincommensurable. How can we compare the state of conscious experience with thecomplete loss of personal identity? We are reminded here of the Epicurean argument

SIDNEY BLOCH AND DAVID HEYD230


qkreader

rationality’ of suicide are possible (see page XXXX).

qkreader

AQ: Please update this cross reference.

that we should never fear death or regard it as an evil, since as long as we live death is notwith us, and when we die we are not there to suffer it. We have no scale of values bywhich we could choose between existence and non-existence. This perplexity is reflectedin the difficulty to conceive one’s own death. Indeed, Freud was convinced that we cannever imagine ourselves dead, and that if we try, we always remain as spectators (7).

One attempt to avoid the perplexing logical asymmetry of the values of life anddeath is by shifting the emphasis from life as such to the good life; that is, what carriesvalue is the good life—pleasant, happy, virtuous, and so forth—not sheer biologicallife. Thus, assuming any scale of values, not only can we compare the value of differ-ent lives, but we can also declare certain lives as not worth living at all. This argumentunderlies the ostensibly ‘rational’ case of suicide. For instance, King Saul kills himselfto avoid shame; the terminally ill patient opts for voluntary euthanasia to spare herselfpain; Socrates drinks poison to avoid the immoral life of an outlaw; Captain Oatessees no value in his life if it risks that of his companions; the ideologically driven ter-rorist blows himself up to promote his cause; and the religious martyr dies in ordernot to violate divine command. In all these examples, consideration of quality of liferather than the comparative value of life versus death leads to the suicidal decision.

The problem of the incommensurability of the values of life and death is circum-vented only at the price of introducing other controversial moral or theological val-ues. Ascribing value to life rather than to life of a certain quality has the advantages ofuniversality and independence of subjective belief. Moreover, proponents of the qual-ity-of-life theory have to concede that life is a necessary condition to the worthwhilelife, and therefore has indirect value. These remarks pertain to our approach to sui-cide because they have far-reaching ethical implications. As we shall see below, thereare good reasons to prevent a person from committing suicide even if she sincerelybelieves that her life has lost all value. These reasons appeal to the value of life itself,from which a new meaning might be created. In other words, even if philosophicallyspeaking only the meaningful life is valuable, life itself should be morally respectedand enhanced as the only way to attain that meaningfulness.

This last point suggests that the person considering suicide and the psychiatrist donot share the same outlook. For the person, the question is that of the meaning of life,the subjective assessment of its value for him. For those who judge his decision to takehis life, the question is whether it is rational or irrational. Thus far, we have consideredsuicide principally from the point of view of the agent. On this level, suicide has nospecifically moral meaning because morality is concerned with the guiding principles of‘the game of life,’ whereas suicide is a decision to opt out of the game. The decision todie lies beyond the reach of moral arguments. But the view of others is the ethical oneon which we should focus—by considering the major ethical approaches to suicide inthe history of Western thought and then by examining the moral dilemma of those whoare in a position of responsibility in the face of a person’s intent to kill himself.

Major ethical approaches towards suicidein Western thoughtThe Biblical approach to suicide is mentioned only as a curious exception and indeedthere is no specific term for it (8). Throughout the Old Testament there are only five

SUICIDE 231


cases—King Saul, his slave, Samson, Achitofel and Zimri—and in their stories anymoral condemnation (or praise) is conspicuously absent. Death by one’s own hand isdescribed as a natural concomitant to another legitimate intention such as avoidingtorture by the enemy, loyalty to the King and wreaking revenge. The New Testamentdescribes Judas Iscariot hanging himself with similar neutrality.

Suicide played a more prominent role in Greek and Roman society. It was approved,even praised, under certain conditions. Aristotle (9), however, claims that killing oneself is ‘contrary to the right rule of life’ and unjust to the state; thus the state is jus-tified in taking punitive measures against the suicidal person and her family. A similarextension of the meaning of suicide can be traced in Socrates’ (10) argument that self-annihilation is unjust towards the gods since a person is only the custodian of alife given by them.

The Romans considered suicide mainly from the agent’s point of view, concludingthat it was not morally wrong. In Seneca’s words, ‘mere living is not a good, but livingwell. Accordingly, the wise man will live as long as he ought, not as long as he can’ (11);trouble, lack of peace of mind or misfortune are sufficient reasons to suicide. Likeother Stoics, Seneca also values the ultimate exercise of freedom, which characterizesour choice of one of the ‘many exits’ from life. Dying is typically depicted as a liberat-ing event. In this kind of freedom, says Pliny, we are superior even to the gods. Andindeed the occurrence of suicide in Rome was widespread, with no legal sanctionagainst it.

The rise of Christianity as a persecuted religion led to acts of suicide, which werejustified as martyrdom. The Church responded by banning self-killing formally in the6th century. Augustine (12) interpreted the sixth commandment prohibiting murderas also applying to killing oneself; indeed, the latter is the gravest sin under all circum-stances (with the exception of a definite command of God as in Samson’s case).The most systematic argument against suicide in medieval Christianity is that ofThomas Aquinas (13th century) (13):

1. Suicide violates the natural law according to which ‘everything naturally keepsitself in being’ and which prescribes self-love;

2. It violates the moral law since it harms the community of which the suicidal person is a member; and

3. It violates the divine law that assigns the right to take life to God alone.

The first reason is self-regarding; the second and third consider others and are typically moral. The second reason is utilitarian, the assumption being that suicidehas undesirable consequences for society. The first and third reasons are absolutist,that is, to say derived from general rules in a non-contingent manner. Suicide isdeemed a triple sin—against oneself, society and God.

This condemnation of suicide had a long-range effect on European attitudes.A more tolerant view only emerged during the Renaissance. Montesquieu (14), forexample, sharply criticized anti-suicide laws as unjust. No person is obliged to workfor society when he has become weary of life, since the relationship between them isbased on reciprocity, and the laws of the state have authority only on those who go on living. The first bold and systematic challenge to Thomas’s reasoning came after



a long delay; the Scottish philosopher David Hume (15) critically considers his threereasons against suicide, although in reverse order to Thomas:

1. If God governs the world in every detail, suicide must also conform to his laws anddoes not encroach on his power. And if suicide is a disturbance of the naturalorder, so must be any act of saving life from natural destruction, and this is absurd.

2. Suicide does not harm society in that death absolves a person from all duties,which are binding only as long as he benefits from society. Indeed, suicide may reduce the burden borne by society (e.g., a very ill person who consumes considerable health care resources) and even be laudable.

3. Suicide is not necessarily against the agent’s interests. Misery, sickness, and misfortune can lead to life not being worth living. The fact that people commitsuicide despite the ‘natural horror of death’ proves that it is not unnatural in somecases.

The German moral philosopher, Immanuel Kant (16), at about the same time supported an absolute prohibition of suicide using rational argument. He appealed toits inherent inconsistency: we cannot improve our lot by destroying ourselves; suicideis self-defeating. We have a duty to ourselves to choose life rather than death.Kant showed that the maxim ‘From self-love I make it my principle to shorten my lifeif its continuance threatens more evil than it promises pleasure’ could never become a‘universal law of nature.’ This is due to the fact that the function of self-love is ‘the furtherance of life,’ and it would contradict itself if it led to its annihilation.

Both Hume and Kant, although holding contradictory views on suicide, reflect thetendency, starting from the Renaissance onwards, to discuss it on a purely moral level,and not regard it as a sin. This change facilitated two noteworthy developments: theintroduction of state laws in which suicide and attempted suicide were construed ascrimes and a new interest in their scientific study. In a 17th-century study, RobertBurton suggests a causal link between depression (‘melancholy’) and suicide, andinterestingly regards it as a mitigating factor in our moral judgment of those who are‘mad, beside themselves for the time … deprived of reason, judgement’ (17).This attempt at scientific understanding was crowned in 1897 by the pioneering workof the French sociologist Emil Durkheim. His is a descriptive account of a social phe-nomenon which avoids value judgment either by way of assumption or conclusion.Although Durkheim uses the terms ‘altruistic’ and ‘egoistic’ to typify suicides of dif-ferent types, he does not mean to praise the first and to condemn the second. He ismerely analysing motives and their relation to social forces (18). If there are any nor-mative implications, they consist of a criticism of society rather than blame of theperson, who is regarded as a victim of social change or the loss of religious affiliation.

Developments in psychiatry in the 20th century contributed to the uncoupling ofmorality with suicide. Given his commitment to a life instinct, Freud was puzzled bythe phenomenon of suicide. He posited that thoughts of suicide are ‘murderousimpulses against others’ turned upon the self (19). Later, he supplemented this ideawith the concept of a ‘death instinct,’ a wish for a return to an inorganic state.Psychiatry then sought to develop effective treatment of potential suicides and to carefor the bereaved relatives of actual suicides.

SUICIDE 233


Historically, this is a radical shift. Instead of a post hoc judgment—theological,moral or legal—an effort to diagnose and prevent supplants discouragement of sui-cide through threats (of worldly or divine punishment). Treating replaces preachingand suicide is medicalized. This has notable ethical implications as we shall see whenwe discuss intervention. At this stage, we may note that in both psychological andsociological attitudes to suicide, the person who suicides is absolved from any moralresponsibility.

This more ‘liberal’ position is not only a function of growing medical interest. Withthe weakening of religious belief, scepticism prevails about the possibility of justifyingthe value of life and questions arise about the traditional criteria of the valuable life.According to the Existentialists, meaningfulness is derived from a purely subjectivechoice rather than from any objective norms. More value is placed on autonomy thanin previous times, and as—according to many—a woman has a right over her body inthe case of abortion, so must society respect the right to opt out of life. This is not easily applied to cases in the psychiatric clinic and is incompatible with views held bymost practitioners.*

Finally, advances in medicine, particularly in cancer treatments that extend the lifeexpectancy of patients, have triggered public debate on the ethics of physician-assistedsuicide (PAS) (20). Unlike ‘voluntary euthanasia,’ in which the patient asks the doctorto kill her, in PAS the patient is the direct agent of the act which can accordingly becategorized as suicide. The ethical challenge underlying this practice is awesome sincePAS is typically sought in circumstances in which suicide is arguably rational. A fewsocieties like the Netherlands, Belgium and the State of Oregon in the US have legalized PAS and some theoreticians regard it as a right (21).

Such legislation imposes an extra burden on the psychiatrist who inevitably has totake the role of arbiter when the conditions of a rational suicide are satisfied.The decision is marred by many difficulties such as the characterization of autonomy,persistence of intention, quality of life and authenticity of choice. This forces psychia-trists to assume a ‘judgmental’ role, which may contradict the basic ethos of the profession (22). In that respect, a reluctance to assume responsibility in otherwise justified cases of PAS resembles the resistance some doctors have felt regarding theexpectation they should play an explicit role in euthanasia.

Clinical aspectsAs we suggested above, the attempt to strip suicide of any moral overtones is reflectedin modern definitions, a necessary starting-point to consider clinical aspects.According to Durkheim, the term is appropriately applied to cases of death resultingdirectly from an act of the victims themselves, which they know will produce this outcome (18, p. 44). This definition encompasses circumstances that we do not


* For a clear and relatively concise overview of the various philosophical views about suicidethroughout the ages, see Michael C. Suicide. In: Edward NZ, editor. The StanfordEncyclopedia of Philosophy Summer 2007 edition. http://plato.stanford.edu/archives/sum2007/entries/suicide/.


ordinarily label ‘suicide,’ such as religious martyrdom, self-sacrifice of soldiers andpolitically derived hunger-strikes. Durkheim requires only the agent’s knowledge ofhis resulting death and only an indirect causal link with his action. Yet, we usuallydescribe as suicide only cases involving a wish to die, carried out actively by the agentas the result of a specific decision. Beauchamp’s (23) definition is more useful in theclinico-ethical context: a person commits suicide if she intentionally brings about herown death, she is not coerced in any way by others and death is caused by conditionsarranged by the person to bring about her own death.

The snag is how to assess intention. As in the doctrine of ‘Double Effect,’ an intentional act may have two effects—one intended, the other unintended, thoughforeseen. For example, terminating a pregnancy may result in saving the woman’s lifeand in the death of the fetus but only the first outcome is desired; the second is seen asa necessary and undesirable means. We should take care in applying this distinctionbetween intended result and reluctant acceptance of secondary effects, because directintentions may lie beyond conscious awareness and intentions claimed as primarymay not in fact be so. For example, ‘suicidal’ intention may underlie heavy smoking ordrinking, dangerous sports like motor-racing and heroic altruistic actions. No lessclear is the observation that expression of suicidal intent is, in many instances, a cryfor help, a wish to gain sympathy, a desire to take revenge, or a hope to be relievedfrom distress and so forth. The distinction, therefore, between direct and obliqueintention is not academic and influences whether a case should be classified as ‘suicide’ and the moral justification to intervene.

We tend to feel more confident in labeling a case as suicide when it is active ratherthan passive, egoistic rather than altruistic in motivation, conscious rather thanunconsciously determined and likely to lead to certain death rather than a gamblewith life. However, the active–passive distinction is criticized as morally and psycho-logically irrelevant. Durkheim’s inclusion of both egoistic and altruistic forms ofsuicide seems valid psychiatrically, at least in some cases (24); unconsciously intendeddeath may be more effective in causing death than expressed suicidal intention; final-ly, the ‘suicidal attempt’ commonly referred to since the 1990s as ‘deliberate self-harm’is no less meaningful a suicidal behaviour than the case of completed suicide,although there are reasons to distinguish between them (25). Theoretical and clinicalstudies therefore cast doubt on a view of suicide as only the first sort of case in each ofthe above pairs. Yet, our moral intuition about the right to intervene in a potentiallysuicidal act is still based on that natural tendency rather than on sophisticated philosophical and clinical views: we do not usually feel morally bound to intervene inthe case of a patient who refuses to comply with treatment (passive suicide), or in anextravagant and ‘irrational’ act of heroism or hunger-strike (altruistic suicide), in aheavy drinker’s life-threatening habit (unconscious suicide) or in a game of Russianroulette (‘probable’ suicide).

The crucial issue clinically is the association between suicide and mental illness.Is suicide itself a disorder? Is it always linked to mental illness? There are theoreticaldifficulties in defining both mental illness and suicide, and obstacles to empiricalresearch in the form of unreliable sources of information and methodology used in‘psychological autopsies’ (reports of failed suicides, of surviving relatives, of doctors,

SUICIDE 235


of coroners, etc.). Then, suicide is linked with other factors such as age, sex, maritalstatus, place of residence, physical condition, family history, social class and even with‘cosmological’ factors such as the season. Methodologically, if we take cases of suicidein a suicide-prone group (elderly men living on their own in big cities), we might end up with different results regarding the weight of mental illness as a contributoryfactor than if we studied another group in a different context.

Despite the above complexities, the research findings are persuasive. Two classicalstudies come to mind. Barraclough and his colleagues (26) in their thorough exami-nation of suicide in England found that of 100 cases, 93 were judged to be mentally illby a panel of three psychiatrists, each of whom independently reviewed all availableevidence. A similar level of disorder was found in a notable American study of134 completed suicides (27,28).

In the British study, two-thirds of the patients in the sample were diagnosed as suffering from depressive illness; the next sizeable group were cases of alcoholism (15 per cent). The strong link between suicide and depression has been found by sev-eral investigators. In follow-up studies, there is a consistent finding that about 15 per cent of people with moderate to severe depression will die by suicide.

Other pertinent findings are that: completed suicide is commonly preceded by oneor more attempts; the risk is high in patients immediately following discharge fromhospital; suicide occurs among inpatients of psychiatric wards (29); most suicidesgive warning signals; and a substantial proportion consult their family doctor or psychiatrist in the weeks preceding the act.

These findings support the notion that suicide-proneness can be predicted with adegree of confidence (30). This is pivotal in the ethics of prevention since it is a well-known principle that we ought to do only what we can do: in this case, intervene onlywhen we know we can identify those at risk and stand a good chance of preventingdeath (31).

Prevention can assume various forms. The family doctor’s recognition of early signsof deep depression, the Samaritans and other lay organizations’ response to a crisis,effective psychiatric treatment and social measures to promote mental health aresome means to reduce the suicide rate (32–36). However, it remains questionablewhether such measures can prevent suicide in the long run and on a large scale, orwhether the basic cause, and hence also cure, lies on a social rather than psychologicallevel (37).

If we accept that the ability to prevent suicide is feasible and a clear associationbetween suicide and mental illness exists in a large proportion of cases, are there stillmoral grounds to intervene? Involuntary admission to hospital and enforced drug orelectroconvulsive treatment, particularly in psychotically depressed patients may beindicated. The risk prevails of erroneously imposing treatment on a person who is notin fact contemplating suicide, or on someone who wishes to die but is definitely notmentally ill.

Moreover, as we shall see below, it is by no means obvious whether intervention isjustified, even if we assume that suicide virtually always points to mental illness;or that intervention is always wrong, even if suicide is considered as the rational,voluntary act of a ‘healthy’ person.



The ethics of psychiatric intervention and suicideFor psychiatrists, the ethics of suicide revolves around the justification of an interven-tion policy: general prevention of potential suicidal acts and applying life-savingmeasures to people who have made attempts on their lives, as well as the role in certain jurisdictions of assisting someone to suicide in special circumstances.

The dilemma of whether to intervene preventively is intensified by the fact thatwhatever we do, a price must be paid. This dilemma is presented schematically inTable 13.1.

Let us consider four clinical cases in our consideration of the issue of intervention:

Case AA 65-year-old widower insists on learning the truth about his prognosis. Two yearshave passed since his first symptoms led to the discovery of cancer of the colon. Now,with widespread metastases, he is fully aware that the outlook is grave. He has weeksor months left to live. Throughout his life he has been an advocate of voluntaryeuthanasia, and concludes now that he does not wish to battle futilely. He wouldrather die ‘with dignity’ and in his full senses than in excruciating pain requiring mas-sive doses of opiate drugs. He is also steadfast in his conviction that it would be unfair

SUICIDE 237

Table 13.1

Intervention Non-intervention

Taking the patient’s decision as irrational, Take the patient’s decision as authentic, impulsive, distorted by mental illness. deliberate, clear-headed and rational.

On the assumption that her decision is On the assumption that her decision isreversible, (i.e., she may change her mind irreversible, (i.e., there is no evidenceabout killing herself), certain steps, which that she will change her mind) noare also reversible (e.g., the psychiatrist ends steps are taken, thus irreversibly lettingwhat appears to be unhelpful treatment), her commit suicide (the psychiatrist takesare taken to prolong her life. no action).

Paternalism: forcing the patient to act Respect for the patient’s autonomy andrationally as an expression of care for liberty to kill herself as to take any otherher real interests. decision, even if it seems irrational to us.

Care for the patient’s family, who usually ask Take the patient’s side rather than that offor intervention. her family. Priority of her freedom over

the family’s interests.

The price: forcing her to act against her will, The price: missed opportunities, the infiniteprolongation of her mental and physical loss involved in death, possibility of themisery, serious loss of liberty. most ‘tragic mistake.’

Underlying assumption: the instinctive drive Underlying assumption: ‘nothing in life isto save other people’s lives plus the as much under the direct jurisdiction ofprofessional duty and practice of doctors to each individual as are her own persondo so. and life’ (Arthur Schopenhauer)


qkreader

AQ: Please provide the caption for Table 13.1.

qkreader

Table 13.1

to saddle his only daughter with his problems. He knows he can no longer fend forhimself and that his only options are to be admitted to a hospice or to move in withhis daughter’s family. Both prospects are unacceptable to him. He has always beenproud of his self-reliance, and will not easily forgo it now. He talks candidly about hiswish to die—through his own hand. His plan is to collect a sufficient number ofsleeping pills to enable him to die decently.

Case BA 35-year-old married woman and mother of three young children has been feelingutter despair since the tragic death in a domestic fire of her youngest child eightmonths earlier. During this period, her sense of loss has escalated to the point whereshe now believes that she must join ‘the baby in heaven.’ She has always been a devoutRoman Catholic, now more so than ever. Her belief is strong that the deceased childneeds her whereas the three living children can be cared for by her husband and relatives. She is convinced that she is to blame for the tragedy; she should not have leftthe child unattended. There is absolutely no point in continuing to live her life when‘Paul needs me.’ She tried to hang herself on the day of consultation but her husband,close to breaking point because of his wife’s insistence on being reunited with Paul,managed to intercede. He has no doubt that she will succeed in killing herself unlesscomprehensive help can be provided. On the other hand, as a practising Catholichimself, he can appreciate his wife’s sentiments to be reunited with the baby.

Case CA 40-year-old housewife and mother of three teenage children presents with apathy,withdrawal and self-neglect over several weeks. She has lost interest in her family andfriends, wakes at about 2 a.m. each morning and cannot return to sleep, and has lost 5 kg in weight. She has developed the unshakeable belief that she is worthless, has lether husband and children down, and deserves to die. She feels quite helpless and seesno future for herself. She suffered a similar episode three years previously for whichshe was treated as an inpatient with antidepressant medication. She made a goodrecovery then and had felt content and cheerful until the onset of her present state.

Case DA 60-year-old retired teacher and mother of two adult children feels physically unwelland is diagnosed as suffering from the side-effects of long-term treatment with lithium. During the course of her admission to a general hospital to investigate thephysical problem she shows features of depressed mood; these become so severe as torequire her transfer to a psychiatric unit. There, her pessimism, lack of energy, insom-nia and, more particularly, her intense suicidal thoughts, lead to a decision to applyelectroconvulsive therapy (ECT). She responds reasonably well but the improvementis short-lived. ECT is resumed, again with evidently good results. Periods of homeleave follow, with the anticipation that recovery is almost complete and dischargeimminent. By this time she has spent six months in a hospital. The depression however,soon recurs, this time more severely and also more frustratingly to herself, her family,



and the staff. A doubt begins to develop as to whether the condition is treatable.A third course of ECT is instituted, in conjunction with antidepressants. Because thepatient is constantly preoccupied with ways of ‘ending it all,’ her status of voluntaryadmission is converted into a compulsory one. This drastic step is supplemented by‘constant observation,’ even to the point of supervising her toiletries. Immense concern prevails about the patient’s safety following her disappearance for 36 hours.Found by the police, she explains how she is ‘longing for death’ and feels ‘utterly desperate.’ Another course of ECT begins but the staff are confused about perseveringwhen after nine months it is obvious that the patient is determined to die. They are allthe more bewildered in the face of her repeated requests for advice on how she canaccomplish her goal, and the spurning of her family’s concern.

Two months later sees a mounting desperation in all the protagonists, culminatingin the patient’s attempt to asphyxiate herself. Saved from death, she repeatedlyexpresses the wish to die, but also joins in ward activities and even exhibits a dryhumour. Exactly one week later she is discovered in the bathroom with a plastic bagover her head. A determined effort to resuscitate her proves to no avail. The one-yearsaga is at an end, save for the profound feelings of loss in the bereaved family and ofdistress in the medical and nursing staff.

One final point needs to be stressed. The patient had been successfully treated forepisodes of depression 32, 26 and 20 years previously, and in the intervening periodshad led a reasonably contented life in her various roles of wife, mother and teacher.

Let us now ethically analyse the four cases:Case A can be confidently categorized as a ‘rational suicide’ (38). Most doctors wouldrespect the patient’s wish ‘to die with dignity,’ although they might find it psychologically (and legally) difficult to co-operate actively in his suicide. No psychiatristwould consider forced hospitalization for such a person. In terms of our earlier discus-sion, we can assume that the patient’s decision to die is deliberate, authentic and, in alllikelihood, irreversible. The family might well be relieved rather than distressed. Forcinghim to continue to live means prolongation of despair, pain and loss of dignity. (See thecase of the author Arthur Koestler below for another illustration of a rational suicide)

Case C is common in practice and characterizes a class of suicides caused bydepression. Psychiatrists would suspect that her wish to die is not rational and sincere,and that her thinking has been distorted by reversible causes. Previous treatmentproved helpful, and it can be assumed that therapy for the present state will be equal-ly effective. Deprivation of liberty will be temporary and reasonably short. There ismuch hope that in applying therapy she will be relieved of her sense of helplessnessand be helped to see that her interests and those of her family are better served by hercontinuing to live.

Case B which is undoubtedly more problematic in ethical terms. Her wish to diecan be labeled as irrational only on the grounds of rejecting her religious convictions.The suicidal wish she expresses is not irrational in being impulsive, lacking delibera-tion, ambiguous or distorted by mental illness. Even her close relatives, who stand to‘lose’ from her decision, sympathize with her reasoning. On the other hand, the psychologically astute observer would ascribe her desperate decision to profound

SUICIDE 239


grief over the death of her child, and conclude that her despair can be relieved withtreatment. How far should the psychiatrist intervene?

Case B shows that blend of sound reasoning (at least from the agent’s point of view)and non-rational motives; it is a complex which resists disentanglement. The area inthe spectrum of cases lying between type-A and type-C is ‘grey’ and ethically indeter-minate; and no recipe for solving the dilemma of intervention can be readily offered.A methodological remark may however prove useful.

There is an asymmetry between the two horns of the dilemma of intervention,because of the irreversibility of the act of suicide, and correspondingly of the decisionnot to intervene. This source of asymmetry—temporal in nature—is not often considered by philosophers who discuss the ethics of suicide in the abstract. But it iscrucial clinically, such as in case D. The irreversibility of non-intervention places a burden of moral responsibility on the psychiatrist. By contrast, a decision to inter-vene can always be reversed, if shown to be erroneous. The responsibility for an irreversible act is even more challenging given that the decision is often taken underconditions of considerable uncertainty: is the suicidal intention final, authentic,rational, and will the person be grateful if saved?

Case D is particularly demanding for the treating psychiatrist in this context, forunlike Cases A and C, the issue is not the rationality and authenticity of the suicidalperson’s choice, but rather the chance of success of intervening. The quandary is notwhether to force treatment on someone who does not want it but whether to forcetreatment on someone who is, for all practical purposes, untreatable. If the suicidalcondition is indeed incurable, the only point in hospitalizing, that is, detaining, thepatient is to compel her to live.

On the basis of earlier remarks regarding the dependence of the value of life on theidea of a valuable life, we can seriously doubt the legitimacy of compulsion. However,the question whether a condition is untreatable is a matter of professional judgmentrather than of moral judgment. And as all clinical judgment is prone to error, the psychiatrist wards off responsibility by continuing to apply treatment despite accept-ance of its inefficacy. Although this strategy is perfectly understandable, we shouldrecognize the vast difference between an heroic effort to save the life of a ‘hopeless’case (such as a victim of a serious motor car accident) and the struggle against an‘untreatable’ patient with a mental illness set on a suicidal course. The slightest chanceof a ‘miraculous’ cure in the first case justifies the policy of ‘never giving up.’ A simi-larly slender chance in the second cannot justify violating the patient’s autonomy andcreating much distress in enforcing treatment.

However, in cases such as A, B and C, this responsibility over a potentially irreversible decision under conditions of uncertainty suggests a ‘policy of postpone-ment.’ We are justified in asking or even forcing potential suicides to reconsider, togive themselves a second chance, or to defer a final decision lest there be changed cir-cumstances. This policy is sounder than non-intervention because intervention itselfis reversible. If further study shows that suicide is ‘rational’ and authentic, or treat-ment fails to alter the person’s frame of mind, or the person persists in his wish to killhimself regardless of change of circumstances—then there is always the option of let-ting him carry out his intentions. Although there is no good reason to argue that



paternalistic regard for the person’s interests, and those of his family, is in principlemore important than respect for his autonomy and liberty, the reversibility of thedecision to intervene makes violation of autonomy less weighty. Only in extremecases such as a person with paraplegia who can be technically prevented from killinghimself indefinitely, can we question the moral legitimacy of prevention.

Assisting suicide Throughout the previous section, our focus was on the question of the moral justifi-cation of preventing suicide. Although our remit in this chapter does not extend to thesubject of euthanasia, the controversial issue of the psychiatrist’s role to assist or atleast abet a patient to commit suicide requires serious attention. The circumstances ofCase D point to the potential relevance of the issue, while the following well docu-mented cases, those of Elizabeth Bouvia and Dr Chabot, demonstrate its complexity.

Elizabeth BouviaMs Bouvia, a 26-year-old woman with incapacitating cerebral palsy, declared herselfas suicidal on her voluntary admission to the psychiatric service of a Californian general hospital in September 1983. She both refused nourishment and sought acourt order preventing the staff from force-feeding her. Her wish to die was the resultof a belief that her future prospects were bleak.

The Court ruled in favor of the hospital on the grounds that while Ms Bouvia wascompetent to decide, the requirement of the common good overrode respect for herautonomy. Concluding that: ‘… society’s interest in preserving life and the medicalprofession’s obligation to do so outweighed her right to self-determination’, the judgereferred to the ‘devastating’ effects that assisting suicide would have on other patientsand others afflicted with handicaps (39).

Most commentators concur with the decision (as we do) although arguments differ. For example, Bursztajn et al. (40) adopt an empirical approach, namely that‘physical illness alone, per se, is rarely a cause of suicidality.’ Rather, it is the associatedswirl of emotional feelings, especially depression, which clouds judgment.Intervention in the form of a ‘therapeutic cooling-off period’ (at least six months)provides an opportunity to alleviate or ameliorate the depression. This positionresembles our policy of postponement. Bursztajn and his colleagues also contend thatthe autonomous patient is a myth, and that a person, like Ms Bouvia, who presents tothe hospital in a distressed state is likely to be calling for professional help because sheis ambivalent about her decision to die.

Alan Stone (41) has criticized this analysis, claiming that the patient’s mental state isirrelevant. Following the Bursztajn argument, the Court should have found Bouviaincompetent and forced her doctors to intervene. For Stone, hospitals and doctors arenot duty-bound to passively abet the suicide of a patient, competent or incompetent,who is not terminally ill; and, conversely, patients have no right to compel their doctorsto participate, even passively, in their suicide. He would wish to dispel a double mythby adding to the original myth of the autonomous patient the one of the ‘omniscientand omnipotent psychiatrist.’

SUICIDE 241


A third argument concerns the common good, and comes closest to the gist of theCourt’s decision in the Bouvia case. Kane (42) has asserted that her plea could not bebased merely on an appeal to the right to self-determination. Even if a person shouldhave the freedom to commit suicide, ‘… it does not follow that the civic communityhas the responsibility to assist anyone in that act of suicide.’ Kane asked rhetoricallyabout the freedom of the doctors, nurses and hospital staff, if the judge had orderedtheir collaboration in Ms Bouvia’s suicide. Most of them would have been forced toviolate their codes of ethics and to act against their conscience. We end up in thedilemma of having to respect the liberty of both patient and professional staff. Even ifpersonnel could have been found to assist in the suicide, their collaboration wouldstill have had detrimental effects on the broader community, including the rest of thestaff, other patients and society as a whole. In the final analysis, Kane argues for theprimacy of the common good, which must override private interest.

Dr Boudewijn ChabotEven more ethically intriguing is the Chabot case (43). In 1991, Dr BoudewijnChabot, a Dutch psychiatrist, was consulted by Hilly Bosscher, a 50-year-old retiredsocial worker. The consultation was quite extraordinary: Mrs Bosscher wanted Dr Chabot to assist her to commit suicide. Her story was tragic. Three men hadplayed a role in her life: her ex-husband had abused her physically, a feature of hisalcohol abuse, one son had died by his own hand, the other had lost a battle againstcancer.

Dr Chabot got to know his patient well over several months and concluded that shewas not suffering from any diagnosable psychiatric disorder. Moreover, her contactwith reality was consistently intact. Notwithstanding, he recommended antidepres-sants and psychotherapy. Her response was emphatic: since life had no meaning forher, she sought help to achieve a foolproof and painless suicidal death. Having consulted several professional colleagues (none of whom interviewed Mrs Bosscher),Dr Chabot gave the ‘patient’ a lethal drink in her own home.

The legal repercussions are noteworthy. In view of the significance of the case, theDutch Supreme Court became involved and ruled that Dr Chabot was guilty of assistingin a suicide, but also concluded that he had adhered to the guidelines on euthanasiaand assisted suicide set by the country’s Medical Association by judging Mrs Bosscherto be a suitable candidate: she had suffered dreadfully, been mentally competent,and sought to die without any sign of external duress or coercion. Given these circumstances, Dr Chabot was permitted to continue his psychiatric career.

The Chabot case raises new issues in physician-assisted suicide. One factor whichusually serves as part of the justification for professional cooperation with suicidalplans (as well as with requests for euthanasia) is the irreversibility of the conditionfrom which the patient is suffering. In the present case, Mrs Bosscher is experiencingprofound grief, which can be expected to persist for an extended period. On the otherhand, it is not necessarily an irreversible (let alone deteriorating) condition, and onecannot judge her situation as ‘hopeless.’ This by no means implies that there is norational basis for suicidal choice, since the severe pain of the present may outweighthe prospects of a better future; but it does impose a special ethical constraint on the



psychiatrist who is expected to consider seriously the long-term interests of hispatients.

Another element in the case is the absence of any medically defined syndrome,usually the principal grounds for a medical intervention. Unlike all the cases discussedabove, that of Mrs Bosscher deals with a person whose emotional distress is not linkedto either a physical or a mental illness. It is noteworthy that Dr Chabot himselfemphasizes in his report that he did not consider himself as a doctor and the womanas a ‘patient’ in the circumstances. If that is true, it is not clear why a psychiatristshould assist in the act of suicide? Should not physician-assisted suicides be limited,by their very definition, to circumstances in which the relationship between the twoparties is of a ‘medical’ nature, which is involving the attempt of a doctor to help hispatient who is suffering from a clearly defined syndrome?

One could argue (as has been done in the debate on abortion and euthanasia) thateven if actively causing death is morally justified under certain conditions, it shouldnot be the function of physicians, whose primary professional role is to save life(44,45). Psychiatrists, according to this view, should not be expected to serve as ‘executioners,’ mercy killers, sympathetic relievers of intolerable pain. They should co-operate with requests for help to suicide only when the basis for these are associatedwith a pathological (non-curable and irreversible) condition. Although many warn-ings of the threat of a ‘slippery slope’ are overstated it seems that the Chabot case,due to its qualitative distinction from other cases of PAS, calls for particular ethicalcaution.

It should be noted that the court did not recognize Chabot’s defense of ‘necessity,’namely the existence of an irresolvable conflict between the duty to preserve life andthe duty to do everything possible to relieve the patient from unbearable suffering.And, indeed, since the case involved a non-somatic and non-terminal condition, thedoctor could not be sure that there was absolutely no prospect of treatment or improvement. The question of evidence becomes crucial in such cases, and theDutch court noted that Chabot failed to get a second expert opinion based on a thor-ough examination of his patient before making his decision to provide Mrs Bosscherwith the means for her self-inflicted death. As has been noted by commentators onthe case, a psychiatrist should be sensitive and wary about the possibility of bothtransference and counter-transference processes in the relationship with patients,processes which could mar the psychiatrist’s assessment of the actual condition of thepatient (46).

Legislation by the Dutch parliament in 2001 has dispelled the need to appeal to the‘necessity defence’ in cases of PAS by decriminalizing euthanasia. According to thenew law doctors are permitted to assist in acts of suicide as long as certain strict con-ditions of care and oversight are satisfied. However, it seems that psychiatric cases, likeChabot’s, remain unclear according to the new law which is confined to terminally illpatients afflicted with continuing and intolerable pain and other physical symptoms,who freely, competently and repeatedly request that their lives be ended because oftheir suffering (47). These circumstances differ fundamentally from those obtainingin the psychiatric context dealt with in this chapter, and arguments advanced againstassisting a ‘psychiatric suicide’ are likely to prevail (47–51).

SUICIDE 243


Suicide ‘pacts’Although not actually a case of psychiatric ethics since it did not involve, directly orindirectly, the participation of a psychiatrist, it nevertheless challenges the professionin a profound way by highlighting the rare situation in which the choice to end one’s life is fully autonomous, voluntary and rational in one member but not in theother, of a pair of people who suicide. In 1999, David Cesarini brought the ‘doublesuicide’ of Arthur Koestler and his wife Cynthia (in 1983) to public attention in hisscholarly biography of the famous author (52). Koestler had been a fervent believerthroughout his life in the right to die in dignity and active in associations which pro-moted voluntary euthanasia. When his condition deteriorated due to the combinedeffects of Parkinson’s disease and leukemia, the writer wrote a clear and unambiguousletter explaining his suicide plan. The carefully formulated note justifies the act in acompelling way which would be hard to challenge, at least not on the basis of psycho-logical factors such as impaired clarity of mind, incompetence in terms of being ableto reflect on the implications of alternative decisions regarding continuing to live,whim or external or internal pressure. Consider the penultimate paragraph comprisinghis suicide note:

I wish my friends to know that I am leaving their company in a peaceful frame of mind,with some timid hopes for a depersonalized after-life beyond the confines of space, time,and matter, and beyond the limits of our comprehension. This ‘oceanic feeling’ has oftensustained me at difficult moments, and does so now, while I am writing this (52, p. 548).

However, the news that his wife had joined Koestler’s suicide (they were both founddead in the same room) aroused strong public responses and raised doubts about theauthenticity of her decision. Being young (49 at her death) and healthy, was Cynthia’schoice of death ‘autonomous’? Was she not unduly influenced by her husband’s decision? An analysis of her suicide note raises the possibility that Koestler did not try todissuade her from her decision. Her note indeed is confused and far from unambiguouslike that of her spouse. For example, she explicitly declares that the idea of a double sui-cide has never appealed to her and that she fears both death and the act of dying. In thesame breath she mentions her inability to live without her husband even though shefeels she is the bearer of ‘certain inner resources.’ So although neither Koestler nor hiswife violated any law, and did nothing wrong in the sense of harming other people, wedo not hold the same view regarding the ethical justification of the two suicidal choices.

Ethics and research on people who are suicidal(see Chapter 15)The ethics of research in the field of suicidality is ethically sensitive since its subjectscommonly are severely depressed or have other major mental illnesses (53). In studieswith such people, those presenting with a past history of attempted suicide are commonly excluded due to the risk of completed suicide in them and to the liabilityof the investigator. In a typical randomized trial in psychiatry, active treatment mightnot be administered. However, studies that aim specifically at reducing suicidal



behaviour cannot obviously be undertaken with such exclusion clauses. Another keyfactor that impedes research on suicide is the lack of specificity of risk factors leadingto accurate identification of a high risk group (54).

The total exclusion of patients with suicidal tendencies from studies of depressionand other mental illness is considered by some as unfair to this population (andtherefore unethical) since they are then barred from potential benefits derived fromthe research (on the other hand, the notion of a general right to take part in medicalresearch is controversial). Moreover, the lack of new knowledge that results from a continuing policy of exclusion prolongs the dilemma of not being well placed toprevent future suicides. We land up in a paradoxical position of being immobilizedscientifically in the face of conditions with potentially fatal outcomes.

Given these circumstances, research on suicidal people should be allowed from anethical point of view but with the caveat that robust safeguards are instituted. Extracaution in selecting suitable subjects is obvious. More detailed informed consent,including advanced directives and family members’ participation in the process, iscritical especially when decision-making capacity is buffeted by fluctuations in theseverity of the associated mental illness. An effective plan of risk management shouldinclude close monitoring and supervision, the ability to provide emergency treat-ment, and a detailed and explicit protocol to determine withdrawing a subject (55).

Respect for confidentiality is another aspect of research ethics that has special relevance in the domain of suicide. Two examples spring to mind. Given that thosewho have attempted suicide are at risk of repeating the behaviour and repeaters are atrisk of killing themselves, one pivotal public health research strategy is to follow upcases systematically. The snag is how to achieve this without violating the right ofthese people to privacy and yet making the data collection a worthwhile endeavour(56). Remedies are not readily at hand. Neither are they available for another tradi-tional investigatory approach, namely the ‘psychological autopsy’ (The two classicstudies we commented on in the section on the link between suicide and mental ill-ness (26,27) are examples of this type of investigation). In such work, the researchersinterview family members, friends, acquaintances, work colleagues and relevant oth-ers to glean as much information as they can about the person who has suicided. Thisis complemented by a search of all pertinent documents—medical files, work recordsand the like. The goal is to build up as detailed a biography as possible about thedeceased and in so doing to learn what underlay his decision to kill himself. EmilioMordini (personal communication, November 2007) highlights the many ethicalchallenges in conducting a psychological autopsy. Respect for the memory of thedeceased is pre-eminent in that a person who has not provided consent is strippedbare, as it were, and regard for his dignity imperiled. In the pursuit of as many detailsof the research subject as possible, the effect on the interviewees is unpredictable.We are inviting family and friends who related to the deceased in ways which couldstill be painful and distressing to reveal potentially intimate aspects of themselves andothers, and by so doing revive or aggravate unresolved emotional harms. Yet anothermatter is maintaining confidentiality. Given that this mode of research is qualitativein nature, the emergent data may be recognizable if it is not disguised. Yet a ‘thick’disguise may invalidate the study and lead to incorrect conclusions (see Chapter 11).

SUICIDE 245


As can be ascertained from even this brief account, the tension between gainingnew knowledge in the field of suicide through the conduct of systematic research andrespecting the principles underlying ethical research is beset with problems.Ultimately, it is a tension that has to be handled with exquisite sensitivity and care butthen it could be argued that all research in psychiatry should be approached in thisway given the marked vulnerability of mentally ill people.

ConclusionIn turning to the question of suicide in a psychiatric framework, we may conclude, aswe have advocated in previous editions of Psychiatric Ethics, by stating that it is betterto err on the side of preserving life than on the side of letting it be lost. Although philosophical considerations may show that valid arguments preferring life overdeath are not readily available and that our bias for life cannot be given strict rationalgrounds, we should remember that the potentially suicidal person may, deep in hisheart, harbor that irrational preference.

References1. Diekstra R. The epidemiology of suicide and parasuicide. Archives of Suicide Research

1996;2:1–29, 1996. See also: Wasserman D, Cheng O, JiangG. Global suicide rates amongyoung people aged 15–19. World Psychiatry 2005;4:114–20 and Sakinofsky I. The currentevidence base for the clinical care of suicidal patients: Strengths and weaknesses. CanadianJournal of Psychiatry 2007;52(6 Suppl 1):7S–20. For further details on prevalence, seewww.who.int/mental_health/prevention/suicide/country_reports

2. Battin M. Suicide. In: Post S, editor. Encyclopedia of bioethics. New York: Macmillan; 2004.p. 2475–83. See also by the same author: Ending life: Ethics and the way we die. New York:Oxford University Press; 2005.

3. Kleespies P, Hughes D, Gallacher F. Suicide in the medically and terminally ill:Psychological and ethical considerations. Journal of Clinical Psychology 2000;56:1153–71.

4. Daube D. The linguistics of suicide. Philosophy and Public Affairs 1972;1:415–7; See alsoFairbairn GJ. Suicide, language, and clinical practice. Philosophy, Psychiatry andPsychology 1998;5:157–69.

5. Camus A. The myth of Sisyphus. Harmondsworth: Penguin; 1975. p. 11,12.

6. For a detailed analysis of the various aspects of the valuation of life, see Kleinig J. Valuinglife. Princeton, NJ: Princeton University Press; 1991. See also: Nagel T. Death. In: Rachels J,editor. Mortal problems. New York: Harper and Row; 1975. p. 403.

7. Freud S. Thoughts on war and death. Standard ed. London: Hogarth; 14:289,290.

8. Koch H. Suicides and suicide ideation in the Bible: An empirical survey. Acta PsychiatricaScandinavica 2005;112:167–72. See also: Koch H. Hostile traits in Bible suicides. ActaPsychiatrica Scandinavica 2006;113:237,238.

9. Aristotle. Nichomachean Ethics. Oxford: Oxford University Press; 1925. p. 1138a.

10. Plato. Phaedo. The dialogues of Plato. Oxford: Clarendon Press; 1953. p. 62b,62c (vol 1).

11. Seneca. Epistle 70. In: Loeb, editor. Epistulae morales. London: Heinemann; 1925 (vol II).

12. Augustine. The city of God. Harmondsworth: Penguin; 1972 (Book I, Chs 17–27).

13. Thomas Aquinas. Summa Theologica. New York: Benziger; 1947 (II, ii, Q. 64, Art. 5).

14. Montesquieu, Baron de. Persian letters, No. 76. Harmondsworth: Penguin; 1973.



qkreader

Freud S.

qkreader

AQ: Please provide the year of publication.

qkreader

Aristotle. Plato.

qkreader

AQ: Please provide the year of publication.

15. Hume D. On suicide. In: Green TH, Grose TH, editors. Essays. London: Longman; 1882. p.406–14 (vol 4); see also Lester D. Can suicide be a good death? Death Studies 2006;30:511–27for the argument that suicide can be defined as potentially appropriate as well as potentiallyrational; and Feldman D. Can suicide be ethical? A utilitarian perspective on the appropri-ateness of choosing to die. Death Studies 2006;30:529–38 who offers a critique of Lester’sposition using a utilitarian perspective, namely that an act is good or not dependent on howit affects the individual as well as others—emotionally, interpersonally and economically.

16. Kant I. Groundwork of the metaphysic of morals. In: Paton J, editors. The moral law.London: Hutchinson; 1948. p. 89. Cf. Lectures on ethics. New York: Harper and Row; 1963.p. 148–54. See Brassington I. Killing people: What Kant could have said about suicide andeuthanasia but did not. Journal of Medical Ethics 2006;32:571–4 for an argument againstthe Kantian position.

17. Burton R. Anatomy of melancholy. London: Nonesuch Press; 1925. p. 224–6.

18. Durkheim E. Suicide: a study in sociology. London: Routledge and Kegan Paul; 1952.

19. Freud S. Mourning and melancholia, Standard ed. London: Hogarth; 1957. 14:239–60.

20. Kopelman LM, deVille KA, editors. Physician-assisted suicide: What are the issues?Dordrecht: Kluwer; 2001. For a strong view against the practice from a psychiatric point ofview, see Barbara AO. Protecting psychiatric patients and others from the assisted-suicidemovement. Westport, CT: Praeger; 2002. Olevitch is particularly concerned about the ‘slippery slope effect’ and the spill-over of the practice of assisted suicide to illegitimateforms of involuntary euthanasia and the abuse of psychiatric power.

21. Dworkin R, et al. Assisted suicide: the philosophers’ brief. New York Review of Books;March 27, 1997. This is a text, presented as an ‘amicus curiae,’ to the US Supreme Court bysix prominent moral philosophers.

22. Zaubler TS, Sullivan MD. Psychiatry and physician-assisted suicide. Psychiatric Clinics ofNorth America 1996;19:413–27.

23. Quoted in Rachels J. The end of life. Oxford: Oxford University Press; 1986. p. 81.

24. Robertson M. Books reconsidered: Emile Durkheim, Le suicide. Australasian Psychiatry2006;14:365–8.

25. Goldney R, Beautrais A. Suicide and suicidal behaviour. In: Bloch S, Singh B, editors.Foundations of clinical psychiatry, Melbourne: Melbourne University Press; 2007. p. 523–37.

26. Barraclough B, Bunch L, Nelson B, et al. A hundred cases of suicide: clinical aspects. BritishJournal of Psychiatry 1974;125:355–73.

27. Robins E, Murphy GE, Wilkinson RH, et al. Some clinical considerations in the preventionof suicide based on a study of 134 successful suicides. American Journal of Public Health1959;49:888–98.

28. Robins E. The final months: a study of the lives of 134 persons who committed suicide.New York: Oxford University Press; 1981.

29. Hunt IM, et al. Suicide in current psychiatric in-patients: A case-controlled study: theNational Confidential Inquiry into Suicide and Homicide. Psychological Medicine2007;37:831–7.

30. Martin G, Rozanes P, Pearce C, et al. Adolescent suicide, depression and family dysfunction.Acta Psychiatrica Scandinavica 1995;92:336–44.

31. Mann J, Waternaux C, Haas G, et al. Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry 1999;156:181–9.

32. Isometsa E, Henriksson M, Hillevi M, et al. Suicide in major depression. Acta PsychiatricaScandinavica 1994;151:530–6.

SUICIDE 247


qkreader

Dworkin

qkreader

Dworkin R, March 27, 1997.

qkreader

AQ: Please provide the names of at least 3 authors.

qkreader

Hunt IM,

qkreader

AQ: Please provide the names of at least 3 authors

33. Morgan H. Suicide prevention and ‘The Health of the Nation’. Psychiatric Bulletin1993;17:135,136.

34. Depression and suicide: are they preventable? Lancet 1992;340:700,701.

35. Garland A, Zigler E. Adolescent suicide prevention. American Psychologist 1993;48:169–82.See also: Brent D, Mann J. Familial pathways to suicidal behavior-understanding and preventing suicide among adolescents. New England Journal of Medicine 2006;355:2719–21and Fortune S, Clarkson H. The role of child and adolescent mental health services in suicide prevention in New Zealand. Australasian Psychiatry 2006;14:369–73.

36. Forum: Prevention of suicide worldwide. World Psychiatry 2004;3:147–62. A series of com-mentaries on an article by Bertolote JM. on Suicide prevention: at what level does it work?(p. 147–51) by experts from different countries, including the developing world.

37. Goldney R. Suicide prevention: a pragmatic review of recent studies. Crisis2005;26:128–40.

38. Motto J. A psychiatric perspective on rational suicide: 24 points of view. Contemporaryperspectives on rational suicide. Philadelphia: Brunner/Mazel; 1999. p.121–5. See also:Suicide in the medically and terminally ill: Psychological and ethical considerations.Journal of Clinical Psychology 2000;56:1153–71.

39. Bouvia v. County of Riverside. No. 159780, Supreme Court, Riverside County, CA, Tr.1238-1250, 16 December 1983. For an account of Elizabeth Bouvia and three other cases ofdisability in the US who requested asistance in dying, and the concept of rational depression inherent in each situation, see Gill C. Depression in the context of disability andthe “right to die”. Theoretical Medicine Bioethics 2004;25:171–98.

40. Bursztajn H, Gutheil TG, Warren MJ, et al. Depression, self-love, time and the ‘right’ to suicide. General Hospital Psychiatry 1986;8:91–5.

41. Stone A. Response to the article by Bursztajn H, et al. ‘Depression, self-love, time and the‘right to suicide’. General Hospital Psychiatry 1986;8:97–9.

42. Kane FI. Keeping Elizabeth Bouvia alive for the public good. Hastings Center Report1985;15:5–8.

43. Sheldon T. Judges make historic ruling on euthanasia. BMJ. 1994;309:7–8; Dutch argue thatmental torment justifies euthanasia. BMJ 1994;308:431,432. Also see: Hendin H. Assistedsuicide, euthanasia, and suicide prevention: the implications of the Dutch experience.Suicide and Life-Threatening Behaviour 1995;25:193–204 and Burgess S, Hawton K.Suicide, euthanasia, and the psychiatrist. Psychology, Psychiatry, Philosophy 1998;5:113–56.

44. Battin M. Assisted suicide: can we learn from Germany? Hastings Center Report1992;22:44–9. (Battin provides an account of the role of the non-medical German Societyfor Humane Dying in facilitating suicide; it was established in 1980).

45. Zaubler T, Sullivan M. Psychiatry and physician-assisted suicide. Psychiatric Clinics ofNorth America 1996;19:413–27.

46. For a good description and critical analysis of the case, see Griffiths J. Assisted suicide inthe Netherlands: The Chabot case. Modern Law Review 1995;58:232–47.

47. Stone A. Psychiatry’s undiscovered country. American Journal of Psychiatry1994;151:953–5.

48. Hendin H, Klerman G. Physician-assisted suicide: the dangers of legalisation. AmericanJournal of Psychiatry 1993;150:143–5.

49. Report of the House of Lords Select Committee on medical ethics. London: HMSO; 1994.

50. Report of the Committee on physician-assisted suicide and euthanasia. Suicide and Life-Threatening Behaviour 1996;26(Suppl):1–19.



qkreader

Bursztajn H,

qkreader

AQ: Please provide the names of at least 3 authors.

51. Gostin L. Deciding life and death in the courtroom. Journal of the American MedicalAssociation 1997;278:1523–8.

52. For an ethically sensitive account of the suicide of Arthur Koestler and his wife Cynthia,including the letters left by both, see Cesarani D. Arthur Koestler: The homeless mind.New York: Free Press; 1999. p. 542–50.

53. Mishara B, Weisstub D. Ethical and legal issues in suicide research. International Journal ofLaw and Psychiatry 2005;28:23–41.

54. Stoff D, Mann J. Suicide research. Overview and introduction. Annals of the New YorkAcademy of Sciences 1997;836:1–11.

55. Pearson J, Stanley B, King C, et al. Intervention research with persons at high risk for suicidality: safety and ethical considerations. Journal of Clinical Psychiatry 2001;25:17–26.

56. Goldsmith S, Pellmar T, Kleinman A, et al., editors. Reducing suicide. A national imperative. Washington, DC: National Academies Press; 2002. p. 388,389.

SUICIDE 249



Documents

Suicide - huji.ac.ilpluto.huji.ac.il/~msheyd/files/suicide-proofs.pdf · suicide principally from the point of view of the agent. On this level, suicide has no specifically moral