Macmillan Encyclopedia of Death and Dying. Ed. Robert Kastenbaum. Vol. 2. New York: Macmillan Reference USA, 2002.
Indirect Suicide (Brian L Mishara)
Suicide, perhaps the most obvious type of avoidable death at any age, is an intentional act that quickly results in death. However, there is a wide range of indirect suicidal behaviors in which death results gradually rather than immediately, and in which the degree of intentionality is less obvious than in an overt suicide attempt.
Defining Indirect Suicidal Behavior
Robert Kastenbaum and Brian Mishara, in their discussion of the concept of premature death and its relationship to self-injurious behavior, suggested that behaviors that shorten life are varied in form and widespread. They recognized that in one sense all human behavior affects a person’s life expectancy. Some obvious examples of potentially life-shortening behavior include smoking cigarettes, taking risks when driving, and ignoring doctors’ orders. On the other hand, life span can be prolonged by exercising regularly, eating well, using care when crossing the street, and driving an automobile in good condition equipped with air bags while always wearing a seat belt.
Indirect suicidal behavior is thus a matter of probabilities rather than certainties. Not taking one’s heart medication or crossing the street carelessly will certainly increase the probability of a premature death. However, the timing of the occurrence of a subsequent heart attack is unknown; some people cross recklessly and live a long life, while others are hit by a car and die the first time they are not careful. Similarly, smoking cigarettes is clearly associated with a reduction in life expectancy, and most people know this, including smokers. However, as many smokers will point out, there is usually a case of a person someone knows who has smoked for decades and lived to old age.
Suicides are often deemed indirect where there is no immediate and clearly identifiable intentionality. The pioneer suicidologist Edwin Shneidman spoke of “subintentioned death” and “indirect suicide” (1981, p. 234). He felt that orientations toward death, or “toward cessation,” fall into four categories, which include intentioned, subintentioned, unintentioned, and contraintentioned. Suicide is by definition generally considered to be intentioned. Accidental deaths are unintentioned, and his category of “contraintention” includes people who feign death and threaten death. He specifies four groups of persons who have subintentional orientations. First, there is the “death-chancer” who gambles with death by doing things that leave death “up to chance.” Suicidal behavior in which there appears to be a calculated expectation for intervention and rescue are examples of this form of subintentional suicidal behavior.
The “death-hasteners” are individuals who unconsciously aggravate a physiological disequilibrium to hasten death. Death-hasteners may engage in a dangerous lifestyle, such as abusing the body, using alcohol or drugs, exposing themselves to the elements, or not eating a proper diet.
The “death-capitulators,” by virtue of some strong emotion, play a psychological role in hastening their own demise. These people give in to death or “scare themselves to death.” Shneidman includes in this category voodoo deaths and other deaths in which psychosomatic illness and higher risk of complications (e.g., high blood pressure and anxiety) increase the probability of an early death.
Shneidman’s fourth and final category is the “death-experimenter,” who does not wish consciously to end his or her life but who appears to wish for a chronically altered or “befogged” state of existence. This includes alcoholics and barbiturate addicts.
Interpretations by Freud and His Followers
Although Freud did not discuss indirect suicide, he developed the concept of the death instinct later in his life. It was his student Karl Menninger who elaborated on the concept of a death instinct, Thanatos, which he viewed as being in constant conflict with the opposing force of the life instinct, or Eros. According to Menninger, there is an inherent tendency toward self-destruction that may, when not sufficiently counterbalanced by the life instincts, result in both direct and indirect self-destructive behavior.
Norman Farberow expanded upon Menninger’s theory and developed a classification system for what he called “indirect self-destructive behavior.” Farberow felt that direct and indirect self-destructive behaviors differ in many ways. The impact of indirect self-destructive behaviors is most often long-term and frequently permanent, so that only the results are clearly apparent. Unlike direct suicidal behavior, indirect self-destructive behavior is not linked to a specific precipitating stress; hence this behavior is not sudden or impulsive. Unlike completed suicides and suicide attempts, indirect self-destructive behavior does not entail a threat to end one’s own life; nor does it involve clear messages that indicate a death wish. Indirect self-destructive people are generally self-concerned and unable to invest much of themselves in a relationship with significant others. They are often alone and have limited social support systems. In contrast, the suicide attempts of the direct self-destructive are often related to the loss of a significant other.
Studies of Other Species
Humans are the only species who engage in intentional self-destructive behavior. Philosophers generally limit the possibility of voluntary and intentional self-destruction to the human race. Nevertheless, self-initiated behaviors that result in harm and death do occur in other species. These behaviors, while obviously self-destructive, do not have the characteristic of conscious decisionmaking that is unique to humans. Nevertheless, they may ultimately result in injury or death. Researcher Jacqueline Crawley and her colleagues present a review of ethological observations of self-sacrificing deaths in some animal species—usually in defense of territory. Parental behavior may be at the core of many altruistic behaviors, with parents in many species performing some forms of self-sacrifice for the survival of their offspring.
When environmental conditions become stressful for animals, such as for those confined in zoos, self-mutilation and refusal to eat may result. Similarly, pets that are boarded at a kennel or have lost masters to whom they were very much attached may refuse to eat or may mutilate themselves. Crawley speculates that similar dynamics may explain the increased incidence of self-destructive behavior in humans who are imprisoned. More humane care in institutional settings can result in an elimination of self-destructive behaviors in animals. Crawley speculates that greater nurturing and caring behavior may similarly reverse many of the stress-related, self-injurious behaviors in humans.
Indirect suicidal behavior has been studied in several populations. For example, researchers Carol Garrison and colleagues conducted a survey of a community sample of 3,283 American youths in the range of twelve to fourteen years of age. They determined that 2.46 percent of males and 2.79 percent of females engaged in “nonsuicidal physically self-damaging acts” (Garrison 1993, p. 346). Those who engaged in these behaviors had more suicidal ideation, were more likely to have been suffering from a major depression, and had more frequently experienced recent misfortunes.
The researcher Yeates Conwell and his collaborators found that although suicide is rare in nursing homes, indirect self-destructive behaviors, such as refusing to eat or not taking life-sustaining medications, are commonplace. Reviews by McIntosh, Hubbard, and Lester suggest that more elderly persons may die from indirect suicide than from direct suicidal behavior.
Larry Gernsbacher, in his book The Suicide Syndrome, speaks of individuals who engage in what he calls “a suicidal lifestyle.” He includes in this category alcoholics and drug addicts. These behaviors are considered to be expressions of unconscious suicidal motivations. Gernsbacher asks, “What better way for him to express his self-hatred than to destroy himself with alcohol? How could he more effectively express his vindictiveness than to inflict on those about him the consequences of his addiction? What better way to express his hopelessness than to drown his life in drink?” (1988, p. 175).
In The Many Faces of Suicide: Indirect Self-Destructive Behavior, Farberow presents chapters by different authors on a wide variety of indirect suicidal behavior. The contributors discuss physical illnesses “used against the self,” including self-destructive behavior in diabetics, “uncooperative” patients, self-destructive behavior in hemodialysis patients, spinal cord injury, and coronary artery illness. Several chapters are concerned with drug and alcohol abuse and their relationship to indirect self-destructive dynamics. Hyperobesity and cigarette smoking are also analyzed as possible ways of increasing the probability of a shortened life. Similarly, gambling, criminal activities, and deviance are judged forms of indirect suicides. Criminals and delinquents often put themselves in situations where there is a high risk of a premature death. Finally, a variety of stress-seeking and high-risk sports activities draw on unconscious or sub-conscious motivations to risk death or to test one’s ability to master death.
It may be that direct intentional acts that result in death (i.e., completed suicides) constitute only a small proportion of the various human behaviors that result in premature death. Perhaps these behaviors are, as Freud and Menninger hypothesized, the result of an intrinsic human proclivity to self-destruction that is locked in constant combat with an inherent motivation to preserve life at all costs. Perhaps indirect suicidal behavior is simply part of one’s cultural baggage, with different societies encouraging or condoning certain forms of risky and dangerous activities, such as engaging in high-risk sports or having unprotected sex with a high-risk partner. Perhaps, as several research studies indicate, indirect suicidal behavior may be linked to treatable depression, stressful life events, and more obviously identifiable suicidal thoughts and intentions.
It is clear that indirect suicidal behaviors can decrease when the surrounding environment improves; for example, offering patients better treatment in a nursing home. Research in the twenty-first century indicates that it is important to be aware of indirect suicidal behavior and to understand it as a signal of treatable problems. Such vigilance cannot only improve lives, it can save them as well.
Murder-Suicide (Marc S Daigle)
The relationship between suicidal behavior and other forms of violence is not always clear. In the case of murder-suicide (or homicide-suicide), however, the two acts are directly associated. The typical definition of “murder-suicide” is “homicide followed within a week by the perpetrator’s suicide.”
In most cases, there is an intimate relationship between perpetrator and victim. Murder-suicide is uncommon, ranging in rate from 0.05 per 100,000 inhabitants in Scotland or New Zealand to 0.55 in Miami. According to the descriptive typology proposed by Nock and Marzuck, it falls into four main categories: spousal/consortial murder-suicide, filicide-suicide, familicide-suicide, and extrafamilial murder-suicide. Spousal/consortial murder-suicide is the most common type in Western countries. Committed primarily by males acting out of morbid jealousy and/or revenge, it usually occurs when the victim attempts to end the relationship, often in the context of verbal violence. In the United States, males perpetrate 57 percent of simple spousal homicides but 90 percent of spousal murder-suicides. The reason for this imbalance is that for women, spousal homicide is a desperate means of deliverance from an abusive relationship, whereas for men it is often a way to maintain control over their partner unto death. Compassion can sometimes motivate murder-suicide among spouses or cohabitants, especially in cases involving the frail and elderly. These “altruistic” mercy killings often assume the semblance of informal suicide pacts.
Filicide-suicide—killing one’s own children before killing oneself—is the most common form of murder-suicide committed by women in Japan. Globally, women commit most filicides, but men are more likely to commit suicide after filicide. If a woman’s victim is an infant who is less than six months old, the perpetrator usually suffers from serious postpartum depression or psychosis. Often such filicidal mothers view their infants as extensions of their own tortured psyches and hence claim the altruistic motive of rescuing their children from future emotional torments.
Even less common is familicide-suicide, in which the perpetrator kills all family members before committing suicide. In extrafamilial murder-suicide, the victims can be related to the perpetrator but not by consanguinity. It is the rarest form of murder-suicide but the one with the highest social toll per incident.
Most types of murder-suicide involve morbid forms of attachment between perpetrator and victim, especially when the relationship is threatened with dissolution, and/or impulsive personality traits. Depression, too, is a common factor in murder-suicide, as it is in simple suicide, although most depressives are not suicidal or homicidal. Murder-suicide is one of two special types of dyadic (paired) death, the other being the suicide pact. Alan Berman developed a more psychodynamic typology of murder-suicide that covers both types, classifying them according to four categories: erotic-aggressive, unrequited love, dependent-protective, and symbiotic.
Murder-suicide is hard to predict and prevent because of its rarity and apparent suddenness. Among various psychiatric treatments, the most successful preventive approach involves diffusing the intensity of the spousal relationship.
Physician-Assisted Suicide (Robert Kastenbaum)
Physician-assisted death did not begin with the 1993 government-sanctioned process in the Netherlands, nor with the first such acknowledged action by the pathologist Jack Kevorkian in the United States. The practice of ending the life of a suffering patient was so well established by the fifth century B.C.E. that opponents were motivated to mount a strenuous counterattack. The Hippocratic oath offered a landmark definition of the physician’s responsibilities. Included was the key statement: “I will give no deadly medicine to anyone if asked, nor suggest any such counsel.” In modern times, this controversial practice has become most commonly known as physician-assisted suicide. Some forensic experts and prosecuting attorneys, however, classify these deaths as homicides. The neutral term, physician-assisted death, leaves the question of whether the practice is actually homicide open for consideration.
History of Physician-Assisted Death/Suicide
There is no way of knowing how many physicians have abided by this stricture and how many have lent death a hand through the centuries. Concerned about possible consequences, physicians who have assisted death generally have not spoken openly of these actions. It is clear, however, that some physicians have been easing some patients toward death. These deaths have not necessarily occurred immediately after a medical intervention. Often the preference has been for a medication that reduces respiration or other vital functions in a gradual manner. If this technique functions as intended the patient drifts into a drowsy, painless state of mind until passing away.
In “mercy killings,” as these actions have sometimes been described, it is usually assumed that the patient was (a) dying, (b) suffering severely, and (c) asking urgently for the relief. In practice, though, each of these conditions can be difficult to assess. For example, was this person of sound mind in making the request, or was judgment clouded and confused? Were there ways to relieve this person’s suffering short of death? How accurate was the diagnosis and prognosis—was this person actually on a nonreversible terminal trajectory?
Furthermore, the medical interventions have not always proven effective. In twenty-first-century medical practice a patient is sometimes given medication to reduce agitation. There can be the unfortunate effect of a terminally ill person continuing to experience pain but now being unable to move or communicate. Even the passive form of euthanasia—withdrawing treatment rather than making a direct intervention—can fail. This was demonstrated, for example, in the landmark case of Karen Ann Quinlan, a young woman who never regained consciousness after lapsing into a coma in 1975. More than a year later a court ruled that she could be disconnected from the ventilator. It was assumed that she would then die almost immediately. However, the young woman remained in a persistent vegetative state for another ten years. Although this episode predated the emergence of the assisted death movement in the United States, it demonstrates that medical expertise in ending a life cannot be taken for granted.
Physician-assisted suicide entered the spotlight of public opinion in the 1980s as this practice was given a limited form of judicial acceptance in the Netherlands. Jack Kevorkian became the central figure in physician-assisted death in the United States in the 1990s. Many other nations have also been wrestling with this controversy. The Parliament of the Northern Territory of Australia, for example, approved assisted suicide in 1996, but a year later was overturned by the Australian Senate, which forbade all its territories from passing any such measures. Although significant cultural differences exist in response to the assisted death issue, the practice itself and the basic controversy can be identified by focusing on events in the Netherlands and the United States.
Physician-Assisted Death as an Alternative to Prolonged Suffering
Advances in health care have raised expectations. Many life-threatening conditions, such as smallpox, have been prevented by public health measures; others respond to skillful treatment. Nevertheless, dying people often have experienced uncontrolled pain and other distressing symptoms. A growing number of critics placed blame on the medical profession for isolating and neglecting the dying person, who reminded doctors of their still-limited ability to restore health. One major response was the development of the hospice or palliative care movement, in which relief of pain and provision of comfort were the top priorities. The other major response was the attitude conveyed by such phrases as “death on demand,” “right to die,” and “deliverance.” The Hemlock Society and other organizations not only argued the case for suicide but provided information on how to proceed. Suicide and suicide attempts had already become decriminalized. Although religious and moral sanctions remained in place, there was increasing public toleration for a terminally ill person who sought to avoid further suffering by suicide.
Physician-assisted death came out of the shadows as some patients requested and some physicians proved willing to lend a hand. Why could not people who were resolved to end their lives do so for themselves? Two factors were certainly involved and another factor probable: (1) In some terminal conditions the individual did not have the physical ability to take his or her own life (e.g., an advanced stage of Lou Gehrig’s disease); (2) some people were concerned that their suicide attempts would fail and only increase their suffering, and thus medical expertise was needed; and (3) case studies suggest that some people felt the need for approval and authorization from a physician, thereby releasing them from any moral hesitation. The basic need was for relief both from current suffering and from the prospect of additional suffering throughout the terminal phase of life. Many patients and family members expressed the opinion that when physicians could no longer restore health and prevent death, they should provide relief from suffering.
Arguments For and Against Physician-Assisted Death
The liberty interest was often presented as the legal and philosophical foundation for assisted death. The Fourteenth Amendment to the U.S. Constitution includes a due process clause whose provisions have been affirmed by the courts in many decisions over the years. The chief justice of the Supreme Court concluded in Missouri v. Cruzan, “the choice between life and death is a deeply personal decision of obvious and over-whelming finality” (Baird 1989, p. 184) and therefore protected by the Fourteenth Amendment. Citizens have a right to autonomy that the state cannot overcome without proving a compelling interest for so doing.
A few arguments against physician-assisted death state that (1) religion and the state consider life to be sacred (this does comprise a compelling interest that overrides individual choice); (2) legalizing assisted death even in the most appropriate cases would push society down the “slippery slope” to large-scale abuse of this practice; (3) physicians would lose public trust if they are seen as executioners as well as healers; and (4) palliative care can prevent or reduce terminal suffering, therefore assisted death is not necessary. There are counterarguments to all of these; for example, claims that life is considered sacred are contradicted by some actions of church and state; the argument that effective regulations can prevent abuse of the assisted death option; and the position that not all terminal conditions can be significantly eased by palliative care.
Another controversy centers around the most appropriate term for this practice. Physician-assisted suicide, the most frequently used term, implies that the decisive action is taken by the patient. Critics say that this is an attempt to gloss over the truth: The physician prepares the materials and places them at the disposal of the patient. It is, therefore, not any kind of suicide, but something closer either to euthanasia or murder. (The Michigan coroner who investigated the deaths involving Kevorkian classified them as homicides.)
The Netherlands Experience
The world has been observing developments in the Netherlands since physician-assisted death first received a limited kind of toleration in the 1980s. A physician was found guilty for ending her mother’s life at her request. Her sentence was one week in prison. In 1984 the Dutch Supreme Court decided that physician-assisted death is acceptable if the following conditions are met: (1) The patient has been determined as incurably ill from a medical standpoint; (2) the patient’s physical or spiritual suffering is unbearable or serious to the patient; and (3) the patient has indicated in writing that he or she desires to terminate life or that he or she wants to be delivered from his suffering.
This ruling had an uneasy coexistence with other provisions of Dutch law that had been established a century before; specifically, the statement: “He who deliberately incites another to suicide, then assists him therein or provides him with the means is punished, if the suicide follows, with a prison sentence of at most three years or a fine of the fourth category” (Henk 2001, p. 9). The semi-approved practice of assisted death also had a divided response within both the health care community and the general public. After years of study and debate, the Dutch Parliament voted to legalize assisted death. Additional criteria were established: (1) The patient’s request must be determined to be voluntary, well-considered, and lasting (an advance directive or living will is acceptable); (2) a second physician must be consulted; (3) parental consent is required for people under the age of sixteen; and (4) the intervention itself must be in a medically approved manner. Physicians who function within the framework of these rules are free from criminal prosecution.
There remains heated controversy about the scope and manner in which physician-assisted death has been practiced in the Netherlands. About 2,000 cases of physician-assisted suicide are reported in the Netherlands, a small proportion of the approximately 135,000 total deaths. Advocates claim that there is no evidence that a slippery slope has developed because physicians are conscientiously following the guidelines. Opponents note that about half of the patients do not make an explicit request because they are no longer mentally competent or other reasons exist. Advocates reply that in these instances there is other basis for decision making (e.g., family request), and that the medical procedures shorten the patient’s life by only a few hours or days. Opponents also argue that there are many more cases than reported and that it is in these cases that abuse of the law occurs.
Assisted Death in the United States
Kevorkian has been the most prominent person in the assisted death movement in the United States since 1987. A critic of the medical establishment’s treatment of dying people, he promised to deliver them from their suffering and made himself available to all who might desire his services. In Prescription: Medicide (1991) Kevorkian listed the rules that he believed should be followed; they include calling for psychiatric consultation, calling for pain specialist consultation, allowing a twenty-four-hour waiting period after final request, conducting extensive patient counseling, and stopping the process if there is any sign that patient is ambivalent.
Surprisingly, perhaps, he expressed a strong emotional reaction against the specific act by which a person’s life is ended: “Performance of that repulsive task should now be relegated exclusively to a device like the Mercitron, which the doomed subject must activate. What is most important is that the participation of doctors or other health professionals now becomes strictly optional … A doctor no longer need perform the injection” (Kevorkian 1991, pp. 233-234). It seemed odd to speak of the dying person in both a melodramatic (“doomed”) and distant (“subject”) manner when his intent was to preserve human dignity. Critics also accused Kevorkian of trying to evade personal responsibility by replacing his own hand on the hypodermic needle with a device (also known as “the suicide machine”) that provided first a muscular relaxant, then a drug to halt the action of the heart.
Many testimonials were given in appreciation of Kevorkian’s services. He was described as a caring and sensitive person who had provided the blessing of pain relief. Public opinion was divided, but has moved toward increasing acceptance. In 1950 one-third of survey respondents agreed with the statement, “Physicians should be allowed to end the lives of patients with incurable diseases if they and their families requested it.” In the 1990s the approval rate increased to two-thirds.
Numerous attempts were made to find Kevorkian guilty of criminal behavior, but none succeeded until he provided a television news program with a video in which he gave a lethal injection to a man in an advanced stage of Lou Gehrig’s disease (amyotropic lateral sclerosis). The man and his family were grateful but, as Kevorkian had expected, he was found guilty of second-degree murder and sentenced to a term of ten to twenty-five years in prison. Kevorkian often said that he welcomed legal actions against him as a way of awakening the public and forcing a change in the system. Judge Jessica Cooper of Oakland County, Michigan, noted that Kevorkian was not licensed to practice medicine at the time he administered the lethal injection. It was also her opinion that the trial was more about Kevorkian’s defiance of the legal system than it was about the moral and political issues associated with euthanasia.
Research Perspective on Kevorkian’s Practice
Studies of Kevorkian’s practice of assisted death produced critical findings. Most of the people whose deaths were assisted by Kevorkian were not terminally ill. Most were not in severe pain. A gender bias encouraged death: In the general population, women are much less likely than men to commit suicide; most of Kevorkian’s patients were women who were depressed and dependent. This profile does not fit the population of terminally ill people, but it does fit the population of people who make nonfatal suicide attempts. The inference drawn was that Kevorkian attracted unhappy people who might otherwise have found other solutions to their problems. Kevorkian did not recognize or treat the depression that was experienced by many of the people who requested his services, nor was Kevorkian trained in palliative care and he provided little or no help in trying to reduce pain by methods other than death. Kevorkian functioned without adequate medical consultation. In fact, he violated all the rules that he himself proposed for assisted death in Prescription: Medicide (1991).
A 2000 study found that only one-fourth of Kevorkian’s patients were terminally ill, as compared with 100 percent of those who requested physician-assisted suicide since this procedure became legally accepted in Oregon. The researchers conclude that Kevorkian’s procedures did not provide adequate clinical safeguards to prevent the physician-assisted deaths of people who were not terminally ill.
Assisted suicide has often been criticized as an extreme and unnecessary measure that could be avoided in most instances by compassionate and informed care. Other physicians have perhaps criticized it most severely for presenting death as a treatment or therapy. The physician and scholar Thomas Szasz also observes, “a procedure that only a physician can perform expands the medicalization of everyday life, extends medical control over personal conduct, especially at the end of life, and diminishes patient autonomy” (Szasz 1999, p. 67).
Although Kevorkian’s influence should not be underestimated, the assisted death movement has taken other forms that incorporate due process, extensive consultation, and compliance with existing laws and regulations. Whatever the future might hold for assisted death it is more likely to be worked out through the ballot, legislative acts, and consensus.
Rational Suicide (Brian L Mishara)
The question of whether or not suicide can sometimes be rational is a controversial topic that has been the subject of considerable debate among mental health practitioners, scholars, and laypeople alike. Some suicides are obviously irrational, for example, when a schizophrenic man kills himself because he hears voices commanding him to do so. However, the possibility that some suicides may be rational can be debated on both philosophical and scientific grounds.
In 1964 the philosopher Jacques Choron defined rational suicide as being when there is no psychiatric disorder, there is no impairment of the reasoning of the suicidal person, and the person’s motives appear to be justifiable or at least understandable by the majority of contemporaries in the same culture or social group.
Choron’s first requirement that there is no psychiatric disorder eliminates the majority of suicides, since most persons who die by suicide suffer from a mental disorder, such as clinical depression, alcoholism, or drug abuse. Given these data, rational suicide, if it exists, is a phenomenon that can only characterize a small minority of suicides. Even the most vocal proponents of rational suicide exclude persons suffering from mental disorders. In his defense of the Hemlock Society’s support of rational suicide, the society director Derek Humphry stated in 1986 that there is another form of suicide called “emotional suicide or irrational self-murder.” The Hemlock Society view on emotional suicide is to prevent it when you can. The Hemlock Society, which supports rational suicide, specifically does not encourage any form of suicide “for mental health or unhappy reasons” (1986, pp. 172-176).
Even when the suicide victim does not suffer from a serious mental disorder, some suicides may still be irrational by any standard; for example, when the suicide victim is in a temporary state of extreme agitation or depression or his or her views of reality are grossly distorted by drugs or alcohol, or a man whose wife has just left him, has a loaded gun in his house, and then consumes great quantities of alcohol that distorts his judgment may become highly suicidal even though he was not suffering from a previous mental disorder. There still remains the question of whether or not some suicides can be considered rational.
The psychiatrist Ronald Maris has argued that suicide derives from one’s inability or refusal to accept the terms of the human condition. He argues that suicide may effectively solve people’s problems when non-suicidal alternatives may not do so. Although no suicide is ever the best alternative to the common human condition, for some individuals suicide constitutes an individual’s logical response to a common existential human condition.
The researcher and ethicist Margaret Battin, while admitting that no human acts are ever wholly rational, defines rational suicide in terms of the criteria of being able to reason, having a realistic worldview, possessing adequate information, and acting in accordance with a person’s fundamental interests. Battin indicates that meeting the criterion of “ability to reason” may be very difficult to establish because of research and anecdotal information indicating that persons who commit suicide often leave messages that are illogical and tend to refer to themselves as being able to experience the effects of their suicide after their death as if they were to continue to be alive.
One of the basic criteria for being able to act rationally is the ability to use logical processes and to see the causal consequences of one’s actions. It can be argued that many suicides do not accurately foresee the consequences of their actions. Furthermore, one can ask the philosophical question of whether or not it is possible to foresee the final consequence of suicide, which is to know what it is like to be dead. Battin suggests that when one imagines oneself dead, one generally imagines a view of one’s own dead body surrounded by grieving relatives or located in the grave, which presupposes a subject being around to have those experiences. This may be an indication that one does not accurately imagine death. However, Battin points out that two classes of suicides are not necessarily irrational: first, those with religious or metaphysical beliefs that include the possibility that one goes on to have humanlike experiences after death; and second, persons whose reputation and honor are of primary importance, such as the case of the Japanese suicide of honor by a samurai who had been disgraced.
There is also the question of what is considered rational decision making. According to Webster’s New World Dictionary of American Language, rationality is “exercising one’s reason in a proper manner, having sound judgement, sensible, sane; not foolish, absurd or extravagant; implying the ability to reason logically, as by drawing conclusions from inferences, and often connoting the absence of emotion.” This definition implies a degree of autonomy in the decision-making process, the presence of abilities to engage in logical and reasoned thought processes, and the absence of undue influence on the decision-making process by external factors. In a 1983 review of contemporary philosophical writings on suicide, the scholar David J. Mayo presented the definition that a rational suicide must realistically consider alternatives concerning the likelihood of realizing goals of fundamental interest to the person and then choose an alternative which will maximize the realization of those goals. More than a decade later Brian L. Mishara argued that the most important human decision making is more emotional than rational, including the most significant choices in life, such as whom a person marries and what career a person chooses. If important decisions have a predominantly emotional basis, what would lead one to expect that the paramount decision of ending one’s life could then be different and more rational? Those who argue for rational suicide generally insist that the act must occur when a person is experiencing interminable suffering. Mishara argued that in the presence of severe suffering true rational decision making is even less likely to occur; the emotions associated with the suffering compromise one’s ability to reason rationally.
Battin’s second criterion for rational decision making is that the decision is based upon a realistic view of the world. She points out that there are multiple worldviews that vary depending upon cultural and religious beliefs; what appears to be irrational for some is considered quite rational in other cultural contexts. Her third criterion, adequacy of information, may be questioned because of the effect of one’s emotional state on the ability to look for and see the full picture. Still the suicidal person’s actions cannot be seen to be more inadequately informed or less rational than in any other important moral choices.
Battin’s criterion of avoidance of harm is essentially the justification that organizations such as the Hemlock Society propose as their fundamental justification of rational suicide. They cite the cessation of the harm of unbearable suffering as the most common reason for suicide. The organization lists grave physical handicap that is so constricting that the individual cannot tolerate such a limited existence as a second reason. This justification goes against the Christian religious tradition that purports that pain and suffering may serve some constructive purpose of spiritual growth, has some meaning, or is part of God’s plan.
The decision to end one’s life when terminally ill is frequently construed as rational. The acceptance of ending life when extreme pain or handicap is experienced assumes that no relief for the pain is available and that the severe handicap may not be better tolerated. Derek Humphry defends people’s “right” to refuse to experience even a “beneficent lingering” and to simply choose to not continue to live any longer when they are terminally ill.
Battin’s final criterion of being in accordance with a person’s fundamental interest raises the question of whether one can actually satisfy any kind of personal interest by being dead (and not around to be satisfied). Nevertheless, some individuals have long-standing moral beliefs in which the decision to foreshorten life under certain difficult circumstances is clearly condoned as in their interest.
The concept of rational suicide may sometimes be confused with the concept of “understandable” suicide. David Clarke’s work suggests that the concepts of rationality and autonomy are less useful than the concepts of “understandability” and “respect” when considering the expressed wish to die. However, what an outsider considers to be understandable or respectful of a person’s wishes is not necessarily congruent with the suicidal person’s experience. In some situations, when outsiders often feel that a person would be “better off dead,” persons who actually experience those circumstances feel differently. For example, despite popular beliefs, very few persons who are suffering from terminal and severely disabling chronic illnesses actually consider or engage in behavior to end life prematurely.
Debates concerning rational suicide usually center around society’s obligations to provide easier access to suicide under certain circumstances. If one accepts the possibility of rational suicide, there is also an implicit moral acceptance of suicide under the circumstances in which rational suicides may occur. However, developing criteria for when a suicide can be considered rational is not an easy task. What constitutes unbearable suffering for one person may be an acceptable level of discomfort for another. Furthermore, individuals differ to the extent that rationality is an important component of their decision-making process. On what basis may one say that rational decision making is more justifiable than emotional decisions? Most suicidologists choose to try to prevent suicides that come to their attention, assuming that rational suicides, if they exist, are rare, difficult to identify, and merit interventions to challenge their reasoning.
Suicide Pacts (Janie Houle & Isabelle Marcoux)
A suicide pact is a mutual agreement between two or more people to die at the same time and usually at the same place. This is a rare phenomenon that occurs in less than 1 percent of suicides in the Western world. However, suicide pacts are a little more prevalent in the Eastern world where they represent approximately 2 to 3 percent of deaths committed by suicide. Because suicide pacts are rare, they are difficult to study. Despite their rarity and the fact that suicide pact victims generally choose nonviolent suicide methods, suicide pacts are generally lethal and the chances of survival are low.
Suicide Pact Commonalities
Suicide pacts have some common characteristics. The suicidal persons have a close and exclusive relationship, often free of significant bonds to family or friends. The isolation can be caused or exacerbated by a recent retirement, loss of work, disease, or social rejection—for example, two lovers or two friends who are not permitted to be together. The suicide pact is often triggered by a threat of separation of the dyad, death of one of them, or social and familial restrictions on seeing each other. The fear of losing the relationship with the other person motivates the majority of suicide pacts.
The dyad is generally composed of a dominant person who initiates the suicide pact and convinces a more submissive person to agree to this plan. The dominant member is usually the most suicidal member and the dependent person is the most ambivalent. In most cases, the male plays the dominating role. However, there are no indications that someone can become suicidal only due to the suggestion of another person.
Most suicide pacts use poisoning. This nonviolent method allows the synchronization of the deaths and, at the same time, allows the pact members to change their minds. It appears that when the pact is aborted it is frequently because the passive member changes his or her mind and saves the instigator, sometimes against his or her will. However, some researchers claim that the dependent member may ask the dominant one to kill him or her in order to not survive and be left alone.
The prevalence of mental disorders is lower in suicide pacts than in individual suicides. However, researchers have found that at least one member of the dyad usually suffers from depression, borderline or antisocial personality traits, or substance abuse. Physical diseases are frequently observed, particularly in older suicide pact victims. Often, at least one pact member has attempted previously or has been exposed to the suicide of a close relative. This has led some researchers to suggest that suicide pacts are related to suicide clusters (a series of suicides in the same community) because there is a contagion effect. Besides these commonalities, some important differences exist. Three types of suicide pacts can be identified: the love pact, the spouse pact, and the friendship pact.
The love pact. Generally the love pact occurs between two young lovers who are faced with the threat of separation as imposed by their parents or society. There are some cases of love pacts in the Western world, but this type of pact is particularly frequent in the Eastern world where there are strict rules concerning dowry and marriage. For example, in India and Japan many young people are forced to break off a love relationship to marry the person that their parents have chosen for them. Some of these young lovers view suicide as the only way that they can stay together. Lover suicide pacts are often also seen as rebellion against parental authority and linked to the intense guilt of giving priority to one’s own desires instead of respecting social conventions.
The spouse pact. Typically occidental, the spouse pact is the most prevalent. Generally it occurs between a husband and a wife, aged fifty or older, who are childless or not living with their children. At least one of them is likely to be physically ill. In most cases, there is interdependence and devotion to one another and the couple engages in a suicide pact because neither member wants to be separated by the other’s death. However, the members are sometimes motivated by the fear of chronic pain or fear of losing their physical and mental integrity because of old age. Usually, a dominant/ dependent relationship is present.
The friendship pact. The friendship pact has a lower prevalence. Usually it takes place between two or three adolescents of the same sex. This type of pact appears to be less planned and results in less lethality than adult suicide pacts. Attempters tend to share similar life stories; for example, they have been separated from their parents since childhood because of parental divorce or the death of a parent. As a result, adolescents see each other as a narcissistic double and this dynamic seems to be a mutual facilitator. In the days before the suicide members of the pact stay together almost all of the time, in isolation from the rest of society. This social withdrawal prevents them from seeking help. The dominant/dependent relationship seems to be less prevalent in the friendship pact.
Prevention of Suicide Pacts
Numerous risk factors associated with individual suicides are linked to suicide pacts. For this reason, it is important for health practitioners and loved ones to pay attention to general signs of suicide risk, such as major behavioral or emotional changes, sleeping or eating disorders, disposal of important possessions, loss of interest and energy, substance abuse, and hopelessness. One should also be watchful for signs of suicide pacts, such as the isolation of an older couple with a physical illness or emotionally unhealthy exclusive relationships in young friends. Moreover, the people who engage in suicide pacts often talk about their plans to family and friends.
Mental health practitioners suggest that one asks direct questions to verify suicide intentions and plans, such as, “Are you thinking of suicide?” “Did you plan your suicide (i.e., decide when, where, or how to do it)?” The more the suicide is planned, the more important it is to be direct and act quickly. One should be empathic and warm with a suicidal person, and try to find new solutions or alternatives to the person’s problems, and encourage him or her to seek professional help if needed. Finally, despite the fact that suicide pacts share a lot of characteristics with individual suicides and are a rare phenomenon, health practitioners believe that education programs on suicide prevention should incorporate information on suicide pacts and guidelines for preventing suicide pact behavior.
Theories of Suicide (David Lester)
Theories of suicide have been formulated mainly by psychologists and psychiatrists. This analysis began a century ago with Sigmund Freud’s psychoanalytic theory. Sociologists have since proposed theories, based upon the work of Émile Durkheim, that explain the variation in suicide rates over nations and over regions within those nations. These seminal theories are the foundation for more recent theories developed by suicidologists that account for both individual suicides and suicide rates within a society.
Early Theories of Individual Suicide
Suicide is an uncommon behavior, occurring in less than 50 out of every 100,000 people in nations with the highest suicide rate. Explaining and predicting such infrequent occurrences has proved to be very difficult. The major theories of personality and systems of psychotherapy have not addressed the etiology of suicide to any great extent, with the exception of Sigmund Freud’s psychoanalytic theory. Freud never considered the psychodynamics underlying suicidal behavior to any great extent. Brief mentions of suicidal behavior can be found throughout his writings, however, and in 1967 the psychiatrist Robert Litman attempted to document and synthesize these dispersed thoughts.
By 1910 Freud had recognized many clinical features of suicidal behavior: guilt over death wishes toward others, identification with a suicidal parent, refusal to accept loss of gratification, suicide as an act of revenge, suicide as an escape from humiliation, suicide as a form of communication, and the connection between death and sexuality.
The more systematic views began with his discussion of melancholia. The essential feature of suicidal behavior is that the person loses a loved object, and the energy withdrawn from this lost loved object is relocated in the ego and used to recreate the loved one as a permanent feature of the self, an identification of the ego with the lost object. Litman called this process ego-splitting.
Freud’s formulation is phrased in the more archaic version of his theory. In more modern terms, the person has already introjected some of the desires of the loved one. Children introject desires of their parents, and adults introject the desires of their lovers. In this way, it is as if part of one’s mind is also symbolic of one’s loved ones. Once this person is lost (e.g., by death or divorce), a person still possesses those introjected desires, and thus the lost loved one remains symbolically as part of the living person’s own mind. This process can lead to suicide when the person also harbors hostile wishes toward the lost object, for now one can turn this anger toward that part of one’s mind that is modeled upon and symbolizes the lost object.
A later development in Freud’s thought was the postulate of the existence of a death instinct, an instinctual drive toward death that is balanced by the life instinct. The death instinct is primarily masochistic, and the individual tries to externalize the instinct as aggression or sadism. However, when there are cultural forces opposing sadism, the instinct is turned back onto the self. In 1961 the psychoanalyst Samuel Futterman stressed that neither the life instinct nor the death instinct could really function independently of each other, but that they were always fused in variable amounts.
Litman pointed out that this later development moves to a very general level of discourse and focuses on the universal elements of humankind’s lot. Thus it is not clear how such a process can explain why some people kill themselves whereas others do not. At best, it provides a mere restatement of this fact. The earlier formulation was more heuristic in that it did propose a developmental process leading to suicide.
Freud’s Influence on Theorists
Freud’s postulate of a death instinct can be seen as aproduct of his era. Early in the twentieth century, every psychological theorist felt the need to explain why humans behaved at all. Therefore, they all proposed energy concepts in their theories. After Donald Hebb’s classic book The Organization of Behavior (1949), psychological theorists no longer felt it necessary to explain why humans behaved. Rather, the motivational question focused on why humans do one action rather than another.
Freud’s hypothesis of a death instinct had a great influence on thinking about suicide. For example, in 1938 the psychiatrist Karl Menninger suggested that suicidal motivation can be seen behind behaviors that at first glance are not obviously suicidal. Menninger noted that some people shorten their lives by choosing self-destructive lifestyles, such as alcohol or drug abuse, heavy cigarette smoking, and engaging in other destructive behaviors. He called such behaviors “chronic suicide.” He noted that some people appear to focus their self-destructive impulses on specific parts of their bodies, leaving their minds unimpaired. For example, a person may blind himself or lose an arm in an industrial accident. Menninger saw the death instinct as behind such behaviors, and he called them “focal suicide.”
The result of Menninger’s ideas has resulted in some interest on the part of suicidologists in indirect self-destructive behavior, as in Norman Farberow’s book The Many Faces of Suicide (1980), and other works on life-threatening behavior in general and the official journal of the American Association of Suicidology is called Suicide and Life-Threatening Behavior, indicating a broader focus than suicide per se.
Maurice Farber, a psychologist, proposed that the tendency to commit suicide is a function of the extent of the threat to acceptable life conditions experienced by the individual, the individual’s sense of competence, and therefore the individual’s degree of hope. Aaron Beck, a psychiatrist who has developed a system of counseling known as Cognitive-Behavioral Therapy for those suffering from depression and anxiety, and his associates later developed an inventory to measure hopelessness. Subsequent research has shown that hopelessness, which is one component of the syndrome of depression, is a much more powerful predictor of subsequent suicidal behavior than other components of the syndrome.
In 1996 Edwin Shneidman, the founder of the American Association of Suicidology, defined “lethality” as the likelihood of an individual committing suicide, while “perturbation” referred to the level of upset or distress that the individual was experiencing. Shneidman later called the subjective experience of perturbation “psychache.” Shneidman suggested that the way to reduce the lethality of individuals was to reduce their perturbation. He also proposed that all suicides share ten common qualities, which include the:
- Common purpose of seeking a solution;
- Common goal of cessation of consciousness;
- Common stimulus of unbearable pain;
- Common stressor of frustrated psychological needs;
- Common emotion of hopelessness-helplessness;
- Common cognitive state of ambivalence;
- Common perceptual state of constriction;
- Common action of escape;
- Common interpersonal act of communication of intention; and
- Common pattern of consistency of lifelong styles.
These preliminary theories have not been subjected to extensive empirical testing. Instead most psychological research on suicidal behavior is based on the simple additive effect of a variety of psychological and experiential factors, such as loss of parents through death, experience of sexual and physical abuse, low self-esteem, and depression.
Explaining Societal Suicide Rates
In contrast to the unpredictability of individual suicides, societal suicide rates are remarkably stable from year to year, and this stability makes it easier to account for societal differences.
In 1990 Hungarian sociologist Ferenc Moksony noted that one simple explanation of differences in suicide rates between nations is that the national populations differ in the proportion of those at risk for suicide. For example, typically in developed nations, suicide rates are highest in men, the elderly, and the divorced. Therefore, nations with a higher proportion of men, elderly, and divorced people will have a higher suicide rate. Societies may differ also in physiological variables (i.e., serotonin levels) and psychological/ psychiatric variables (i.e., levels of depression and anxiety).
Social causation theories. The most popular explanations of social suicide rates focus on social variables. These social variables may be viewed in two ways: as (1) direct causal agents of the suicidal behavior, or (2) indices of broader, more abstract, social characteristics which differ among nations.
The most important theory for choosing relevant variables is the one that the French sociologist Émile Durkheim proposed in 1897. Durkheim hypothesized that suicide rates were determined by the society’s level of social integration (that is, the degree to which the people are bound together in social networks) and the level of social regulation (that is, the degree to which people’s desires and emotions are regulated by societal norms and customs). Durkheim thought that this association was curvilinear, with very high levels of social integration and regulation leading to altruistic andfatalistic suicide, respectively, and very low levels of social integration and regulation leading to egoistic and anomicsuicide, respectively.
The sociologist Barclay Johnson suggested that the association is linear in modern societies, with suicide increasing as social integration and regulation decrease. Studies of nations have found that suicide rates are associated with such variables as the birth rate, female participation in the labor force, immigration, and the divorce rate.
Some investigators see these associations as suggesting a direct link between divorce or immigration and suicidal behavior. For example, divorce may be associated with suicide at the aggregate level because divorced people have a higher suicide rate than those with other marital statuses. Other investigators see the associations as suggesting that divorce and immigration are measures of a broader and more basic social characteristic, perhaps social integration, which plays a causal role in the suicides of everyone in the society. In this latter case, societies with a higher rate of divorce, for example, should have a higher rate of suicide for those in all marital statuses, and this has been confirmed in the United States.
The other major social causation theory of suicide was proposed in 1954 by social scientists Andrew Henry and James Short, who assumed that the basic target of aggression for a frustrated person would be the frustrating object. What inhibits this outward expression of aggression and results in the aggression being turned inward upon the self?
At the societal level, Henry and Short argued that the primary factor was the extent of the external restraints on people’s behavior. If these external restraints are strong, then frustrated individuals can blame others for their misery, and the outward expression of aggression (and, in the extreme, murder) is legitimized. On the other hand, if the external restraints on behavior are weak, then frustrated individuals can blame only themselves for their misery, and other directed aggression is not legitimized and must be inhibited, which increases the probability of the aggression being turned inward upon the self (and, in the extreme, resulting in suicide). Thus, in a multiethnic society such as America, the oppressed (namely, African Americans and Native Americans) may be expected to have higher rates of murder while the oppressors (European Americans) may be expected to have higher rates of suicide, a difference which is confirmed by crime and mortality rates.
Social stress. In 1969 the anthropologist Raoul Naroll proposed that suicide would be more common in members of a society who were socially disoriented; that is, in those who lack or lose basic social ties, such as those who are single or divorced. In this way Naroll’s theory resembles Durkheim’s theory. However, Naroll argued that because not all socially disoriented people commit suicide there must be a psychological factor that makes suicide a more likely choice when an individual is socially disoriented, and Naroll proposed that it was the individual’s reaction to “thwarting disorientation contexts.” These contexts involve a weakening of the individual’s social ties as a result of the actions of other people or oneself (but not as aresult of impersonal, natural, or cultural events). Being divorced by a spouse or murdering one’s spouse are examples of such contexts, while storm damage or losing a spouse to cancer are not. In thwarting disorientation contexts, some individuals commit protest suicide, which Naroll defined as voluntary suicide committed in such a way as to come to public notice. Societies differ in the extent to which they provide thwarting disorientation contexts, and so societies differ in their suicide rates.
Whereas Durkheim’s theory refers to more steady-state characteristics of a society, Naroll’s theory suggests the role of sudden and acute changes in a society: social stressors. Furthermore, Naroll’s theory is phrased in a way that permits its applications to individuals as well as to societies.
The theories of societal suicide rates have been formulated more precisely and logically than the theories of individual suicide and have generated more successful predictions. Research findings from the 1990s to the present have not invalidated their assumptions, and the theories seem to predict suicide rather than psychiatric disorder in general. Henry and Short’s theory has suggested that an appropriate comparison group for suicides would be murderers, a group that individual theories of suicide have ignored. The success of societal theories as compared to individual theories may be due in part to the relative stability (and therefore easier predictability) of social suicide rates as compared to the rarity and unpredictability of individual suicide.