The Complexities Behind the Act of Suicide

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Editor's note: For a comment from the Editor in Chief, as well as reader response(s) to this article, please scroll down.

I am a 78-year-old retiree, living in Australia. I notice that there have recently been a few articles about the contentious subject of suicide in Psychiatric Times. My first wife died from suicide about 40 years ago, and my second wife died 3 years ago after a short illness.

Some people do commit suicide, and this has surely happened since humans first walked the earth. This is not a treatise on the causes or possible reasons for suicide, but the complexities behind the act have puzzled me for many years. In particular our seeming abhorrence and our obvious dismay, regret, and great sadness that anyone should even contemplate the need to end their life, by whatever means has taxed my understanding and the meaning of my life.

What follows below is my considered opinion.

I ask the question-why is suicide considered such a bad thing? Now I am not advocating that anyone should commit suicide. I am just trying to pick apart the emotional clutter that accompanies this very personal and private act. The only answers I get are that it is a waste of a (usually) young person’s life; that they were loved; that they had unlimited potential, now never to be realized; that they had a future to live for . . . etc, etc.

This is partially correct but is not a real answer. The person concerned-the person now deceased-obviously had a different view of life. I am not discussing his or her view-I have no idea what that was. I am discussing our view-that of the outsider-the ones left behind.

Why are we “outsiders” (I deliberately use this word because we are “outside” that person’s inner world) affronted because someone considers living-in their current situation-to be so bad, so threatening, so limiting as to be not worthwhile continuing? Are we discomforted because this rejection, this dismissal of all we have striven for (in “our” world), may reflect poorly on us, those left behind, regarding the way we have organized the world? Are we disturbed by the confronting prospect of having to admit that we make mistakes and that the way in which the economy, our legal, welfare, and education systems are set up may actually cause distress, that we are not always fair or just in our dealings? Do we feel guilty that we have developed a financial system that promotes the massive imbalance between the very wealthy and the very poor and the disadvantaged?

We have to recognize that we are all, all, party to the ills of the world. We created them. If we look with even a modicum of insight, we should see in ourselves the cause of these shortcomings and see ourselves reflected in the eyes of the distressed. And we should be dismayed.

Is this why we consider suicide a “bad thing” and are so shocked when it occurs?

It is needful to remember that we, each one of us, have our own experiences of life. These are our own. No one can see the world through our eyes with the same imagery and emotional response. No one can see the world through our eyes with our life experiences and our interpretations of those experiences-these are our own.

So, I ask the question again-why is suicide considered such a bad thing? Obviously for the person concerned the prospect of death is more alluring than continuing living as currently experienced. What is “wrong” with that? It is their choice.

Then, for some to say that only God can decide when or where a person dies is surely a gross over assumption-how do they know? What special insight do they possess? Is it not possible, because (I assume) God gave us free will that God may have already decided to allow a person who wants to die, to die?

Furthermore, to declare (as some authority figures do) that most people who commit suicide suffer from a mental “illness” or disorder is surely wrong. It is also highly presumptuous on the part of the person making such a declaration-how do they ACTUALLY know! This is categorizing a person, who now has no recourse or ability to refute the presumption. This is putting a label on someone. And what about those “outsiders” left behind to live with the event-the family and friends?

Are they to be made to suffer further pain with the stigma provided by so called experts who provide the “knowledge” that their son, daughter, friend, brother, sister “must have been mentally deranged” to have committed such an act. This implies that no “normal” person would ever do such a thing! What about self-sacrifice when there is loss of life? Isn’t this an act of suicide? But if it saves the life of others it is considered “noble”! (“There is no greater love than this, that a man should lay down his life for his friends,” English King James Bible: John 15:13).

Research on completed suicides is notoriously difficult. It is always referring to an historic act-something that has already happened. Police, the coroner’s, autopsy, psychiatric and psychological, and counselling reports are analyzed and carefully combed through to try and establish some reason or motive for the suicide. This is fraught as it is impossible to know what was actually going through a person’s mind at the precise moment they took their own life. At that moment they made a choice. Why? We can never know.

Shall we now look at what suicide actually is? Someone taking his or her own life-right? It seems that the “act” is only considered suicide if it results in the quick death of the person concerned. But what about those who commit suicide in the “long term”? Those who drink or drug themselves to death over a number of years, what about them? They may suffer from abuse, or from unbearable pressures associated with their domestic arrangements or at work. They may determine that the easiest and most “socially acceptable” way of easing this pressure or pain, is to get drunk or to get “stoned” on a regular basis. It may take some time but in possibly 5 or 10 years they will be dead. The emotional (and economic) “cost” of this (“long-term suicide”) far exceeds that of any number of “quick” suicides.

To get back to the “mental illness or disorder” accusation. Disordered from what? What are these people supposed to be disordered from? From “normal”? As far as I can discover, there is no accepted definition of “normal.” Possibly those considered “disordered” react to life’s trials and tribulations differently from those around them. Are they wrong? Or are we “outsiders” just being intolerant and lacking in understanding or compassion? Maybe these people are just eccentric-God knows there are enough odd-ball people in the community! Some behavior may be considered maladaptive or possibly antisocial by “outsiders” but not by the people concerned-otherwise they wouldn’t act the way they do!

Similarly, why should anyone “live” according to another’s expectations?

The Scottish philosopher David Hume (1711-1776) wrote the essay, “Suicide,” wherein he said, “I believe that no man ever threw away Life while it was worth keeping.”

What follows is a warning relating to antidepressant drugs, with which you will be familiar:

US FOOD AND Drug Administration Product Information Warning

Patients with major depressive disorder, both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality), whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Although there has been a long-standing concern that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients, a causal role for antidepressants in inducing such behaviors has not been established. Nevertheless, patients being treated with antidepressants should be observed closely for clinical worsening and suicidality, especially at the beginning of a course of drug therapy, or at the time of dose changes, either increases or decreases.

Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse or whose emergent suicidality is severe, abrupt in onset, or was not part of the patient’s presenting symptoms.

From the above it is apparent that psychopharmaceutical medications are not always the answer! Finally, I give you a quote from the Indian sage Jiddu Krishnamurti (1895-1986), who said, “It is no measure of health to be well adjusted to a profoundly sick society.”

There we have it-in a nutshell!

From the Editor:

As anticipated, the commentary “The Complexities Behind the Act of Suicide” by Andrew Campbell-Watt in the March 2019 issues of Psychiatric Times generated a wide range of feedback. Our intent in publishing this commentary was to give voice to the author, a 78-year-old man who has reflected on the suicide of his first wife for over 40 years-a person deeply affected by a suicide who was compelled to share his personal perspective after deliberating on the meaning of suicide for decades after the loss of his wife. As clinical psychiatrists, understanding how individuals grieve, process, and in some cases make peace with the suicide of a loved one can only serve to enhance our own empathy for our patients and any person whose life has been impacted by suicide.

Many factors can shape a person’s understanding of the reasons, experiences, and circumstances that ultimately converge on an individual’s decision to take their own life. As Mr. Campbell-Watt states, often we will never know the personal deliberations that occurred in the moments before a completed suicide. As psychiatrists, it is our ethical and professional duty to intervene to prevent a person from suicidal actions. Often, days, weeks or months after our intervention to prevent a suicide the person involved is grateful for our intervention, especially when the circumstances, experiences, symptoms or substance abuse issues have been thoughtfully addressed and that great healer “time” has enacted its gift. However, this is not always the case, and a subset of individuals will continue to attempt suicide until they succeed.

Suicide is, indeed, a complex act. We encourage a healthy and respectful discussion on the many facets of suicide, some of which may invite us to explore beyond our personal beliefs and opinions. We will post follow-up letters to the editor to encourage this discussion and exploration.

John J. Miller, MD
Editor in Chief, Psychiatric Times

From Our Readers: Nancy B. Graham, MD

The commentary in the March, 2019 issue on suicide written by Andrew Campbell-Watt was profoundly disturbing to me as a psychiatrist. I do not know what professional or educational credentials Mr. Campbell-Watt possesses to qualify his writing knowledgeably on this topic in this newspaper. Obviously, much of our psychiatric work is devoted to deciding when people might be a danger to themselves and to try to prevent their suicides.  

He asks why suicide is such a bad thing. There are many reasonable answers to that question, but I suspect he would accept few of them.

First, suicide has been considered an evil, selfish act throughout thousands of years in all Judeo-Christian cultures. Only in so-called pagan cultures (e.g. the Greeks, the Romans, the Japanese samurai society) would suicide be an acceptable or even noble act.  

Next follows the reality that practicing psychiatrists have all seen suicidal patients stop wanting to die when their mental illness was treated or their social or emotional or physical needs were met. Many of our patients, after nearly dying from a suicide attempt, no longer have any wish to die. In fact, people who survived leaps off the Golden Gate Bridge have usually said they regretted their decision to die on the way down.   The wish to die is generally a transient wish linked to certain changing circumstances.

Third, Mr. Campbell-Watt does not consider the traumatic and permanently life–altering effect of suicide on the family and friends of the deceased. This act is never a solitary affair and grieving people are forever left with unanswered questions, never fully quenched pain, and a great hollow inside. Most patients who have tried to kill themselves have told me they weren’t thinking of their loved ones when they acted, because their pain was so great.   Is that not then, though understandable, a profoundly selfish act?  The rate of suicide, by the way, is greatly increased in the children of parents who killed themselves. What a wonderful legacy to give your kids!

He also conflates suicide and dying to save another life. Suicide is performed only to end one’s life-that is the purpose and method of “escape.” Sacrificing one’s life for another is NOT suicide. The person dying does not do the act to die but to save life. How different are the motivations though each person dies!

In the end suicide is exactly what the word means – “murder of self.”   Murder-just contemplate that word. How much better is the suffering person trying to murder himself than the one who murders another? He is taking a life he never gave himself and slaughtering that life, admittedly out of pain. But there is help for pain. Pain is a momentary thing, even if it lasts some years. All pain comes to an end naturally in time. If the sufferer endures the pain, he may be restored to health, partially or fully. As long as he lives, there is hope, yet suicide takes away hope. Even those who, as Mr. Campbell-Watt, puts it, commit “long-term suicide” by abusing their bodies still have the opportunity to change for the better and live a full life. Again, drug abuse or other destructive habits are not an active attempt to kill oneself but to feel better.

The commentary’s author does not mention that slippery ethical slope at the top of voluntary, adult suicide to the mud-slicked bottom of involuntary killing of various people. It’s not so far from there to “helping” the elderly, the chronically sick, the handicapped, the “deformed,” and the unwanted on to their reward. Ask the Netherlands how involuntary euthanasia is working out for them after they allowed voluntary suicide. Read about the patients who pin notes on their chests saying, “Do not kill me” when they go in the hospital. Follow the news stories about the babies and children whose parents decide they should die because of their poor health. Once it seems expedient for some people to move on, it is much easier to see how others should, too. 

Finally he asks why “anyone should live according to another’s expectations.” Killing oneself is not living at all and has nothing to do with others’ expectations.   Incidentally we all live according to some social expectations, and those who don’t end up in prison or dead; society dictates that we shall not rob others, we shall not rape others, we shall not kill others, we shall not abuse others. Those are very good rules. Total personal autonomy is not only antisocial and harmful-it is impossible.

Sincerely,
Nancy B. Graham, MD
Richmond, KY
April 6, 2019

From Our Readers: Alicia Vaughn

Dear Mr. Campbell-Watt,

I read your piece in Psychiatric Times with great interest. Many of the questions you raise have puzzled me, too. While I did find some of your ideas disturbing, Dr. Nancy Graham’s letter was equally troublesome, to me. Respectfully, may I suggest to both of you that Is suicide such a bad thing? is the wrong question? Is it wrong, evil, and selfish? only compounds the problem and obfuscates the way forward.

As someone who has lived with suicidal thoughts for much of my life, these questions have worked against my efforts to remain alive. Guilt and shame-and their unholy offspring, stigma-encouraged my parents to keep secret my first suicide attempts just as strong religious traditions in my part of the country continue to fuel the difficulties I face in managing my mental health issues.

You ask many questions about suicide but curiously, you leave the one area that would seem of most interest to readers of Psychiatric Times unexplored. Where I live, firearms, drugs and other means by which I could commit suicide are readily available. As long as I don’t disclose my intentions to anyone, ending my life is a relatively straightforward endeavor. It’s when I decide to try to stay alive, and begin to navigate the American health care system-a process euphemistically referred to as getting help-that complexities arise.

Perhaps it’s different, where you live, but the central issue in the United States is that if I commit suicide while in the care of a mental health professional, that person can be held liable for my death, a fact of which I’m sure not a single Psychiatric Times reader is unaware. It’s no surprise to me that among clinicians who assume those risks are countless “outsiders” who are decidedly “affronted” by the idea of suicide.

This peculiar dilemma and its infuriating collection of resultant complexities have shaped the psychiatric care available to me more than anything having to do with the “complexities behind the act” of suicide itself, or even my own needs, as a person experiencing suicidal thoughts.

Please picture this...I’m at a psychiatric clinic, sitting across from a caring, well-trained and experienced outpatient provider. The moment I utter the “s” word, all efforts to see my “circumstances [and] symptoms... thoughtfully addressed” as Dr. Miller describes, are immediately suspended to allow for thorough risk assessment. From this point forward, my relationship with my doctor will split its focus between the treatment of my symptoms and the management of the threat I pose to his or her livelihood. Every decision he or she makes now must balance what might be best for me against what can be defended in court.

So there we are, this doctor and I, in the same room, with the same goal: keep me from dying by suicide. To effect that outcome, what does this clinician really have to offer me?
He or she can try to alleviate the symptoms of my depression, but that may or may not affect my suicidal thoughts. What about drugs specifically developed to reduce the likelihood of suicide? There are none. What about this doctor’s specialized training in treating suicidal clients? There’s very little to be had, I’m told. Does he or she have access to a knowledge base of relevant research? What research is currently underway, I wonder, apart from that aimed at improving risk assessment so as to better indemnify those individuals who care for patients likely to succumb to suicide?

As far as I can tell, my outpatient provider has little choice but to rely on assumption, anecdote and personal experience in place of evidence-based medicine. The bewildering statements Dr. Graham offers throughout her letter: the wish to die is generally a transient wish... pain is a momentary thing... killing oneself has nothing to do with others’ expectations... evince the familiar dismissive, accusatory approach favored by the majority of my 28 years’ worth of health care providers.

While Dr. Graham’s truisms might not be true, they do make suicide is wrong easier to accept. Rolling them out again and again also makes it easier to convince me that attempting suicide means I’m petulant, short-sighted and selfish. Those three in turn justify the ever-present implication that a doctor’s duty includes the application of additional guilt and shame-maybe even a little intimidation-because the “standard of care” requires I be made to understand that suicide is wrong, lest attempts to investigate my motivations, validate my feelings or accept that ultimately, my personal autonomy in this context is absolute might be mistaken for approbation. To trade condemnation for productive efforts at meaningful change might accidentally reward me, the wrongdoer.

What I’m getting at is that getting help often proves far from helpful. The Is it so bad? / Is it wrong? debate devalues the humility required to ask the questions that need asking, and the courage required to answer them with enough honesty to facilitate actual improvement. Absent that humility, my doctor and I are left in a sadly adversarial situation, full of bullying and empty assurances (even if they’re born of genuine empathy for the worried human being charged with my care) that yes, I feel better now.

While I appreciate Dr. Graham’s sincere belief that her patients regret their actions, all she can really know is what they report to her, and if suicide is wrong is in the room, what they say might speak less of their genuine experience than of the guilt and shame engendered by her (hopefully) unspoken but plainly apparent contempt for those who, even “admittedly out of pain,” attempt to end their lives.

I’ve had 28 years to wonder why doctors resort to such negative tactics. I don’t know that I ever arrived at an answer, but at some point, that question turned into a different one: What is it reasonable for me to expect from someone who assumes the risk of treating me in return for (I kid you not) $60 per visit? Who in their right mind (pardon the expression) would accept that risk?

Once I arrived at those questions, it upset me less that most outpatient providers won’t accept me as a patient, not with my history of medically-serious attempts, multiple hospitalizations and failed medication trials. I understand now that the risk I represent is just too great.

I’ve also spent the last 28 years evaluating and re-evaluating the risk my family and I take, every time I seek help. How profoundly will another pointless hospitalization jeopardize our financial future? How likely is it that a doctor on my insurance company’s panel will have the training and experience to help me avert a sixth attempt instead of intensifying my feelings of helplessness?

It has been several years since my last serious struggle with suicidal thoughts. These days, I am not involved in any efforts to end my life. Should thoughts of suicide arise in the future, will I try to get help? Not if the resources available to me are the same ones available to me at the present time. The risk that such help will not prove helpful and that the cost will only add to the stressors driving my suicidal thinking is just too great.

I feel a great deal of empathy for you, Mr. Campbell-Watt; I can’t help but imagine that you are a lot like my own husband-hurt and confused, with as genuine a desire to understand your wife as my husband has to understand me. My suicide is not yet an historic act, however, and the questions which matter to me do so in an immediate and concrete way.

So I ask you, and Dr. Graham, Dr. Miller, and all Psychiatric Times readers: If it’s too risky for me to seek treatment, and too risky for psychiatrists to accept me as a patient, is that so bad? Is that wrong?

I think it is.

Sincerely,
Alicia Vaughn
April 19, 2019

Response from the author:

Re: The Complexities Behind the Act of Suicide

I have read with great interest the responses, so far published, to my original contribution to your publication. I am responding to clarify a few points. With our [Australian] health system (including mental health) there is none of the apparent adversarial attitude described so eloquently by Alicia Vaughn, who responded to my commentary. All health needs are very well addressed in Australia-including mental health needs. Our “Medicare” system is very generous.

Any patient with mental health issues, in the “public system” (with no private health insurance) may be referred by his health professional to any psychiatrist for up to 10 consultations, who may “bulk bill” (ie, charge a government set fee) or charge what he or she likes. The “gap” in any payment may be ultimately covered by the government-provided “safety net.”

Should a patient with mental health issues present him or herself at a public hospital emergency department (to my knowledge very few private hospitals have EDs) he or she will be charged accordingly: Medicare patients charged nothing; private health insurance patients invoiced for payment by their insurer.

Briefly summarized, since 1984 Australians have had the benefits of universal health care: Medicare. If one is a “public patient” attending a “public hospital,” treatment is free-no matter what. (For example, my second, late wife, endured many years of renal dialysis before receiving, over the years, two kidney transplants. We did not pay a cent apart from heavily subsidized medication-normally about $40.00 per prescription; pensioners only pay $7.00 per prescription.)

As I understand it, if a mental health patient attends a public hospital to see a psychiatrist (patients need to be referred by their physicians) the psychiatrist may “bulk bill.” If the patient is a pensioner and holds a government provided “Health Care Card” the patient will not pay anything. The psychiatrist may, of course, charge what he or she likes, but Medicare will only reimburse the set fee-the patient pays the “gap” amount. Medicare set fees are arrived at in consultation with the requisite medical health provider associations: the Australian Medical Association (AMA) or the Royal Australian and New Zealand College of Psychiatrists (RANZCP). A safety net is available but needs to be applied for that covers most of any gap fees the patient is unable to meet, thus preventing the patient from going into long-term debt.

Private health insurance in Australia is encouraged (but can be expensive). A tax rebate may be applied for to reduce the overall cost to the private patient. A privately insured patient may attend any hospital (public or private) and will be charged accordingly.

Moreover, as I understand it, there is no requirement for a psychiatrist, or any health care provider, to report suicidal ideation to any government authority. Suicide-or attempted suicide-while actively discouraged, is not a crime in Australia. The Australian government has many programs in place to help prevent suicide, particularly aimed at young people and the the First People-the Indigenous population-who have extremely high suicide rates.

In answer to my question “Can an Australian psychiatrist be sued if one of his patients, under care, commits suicide?” A lawyer told me that in his opinion, “Potentially the answer is yes. However, before the psychiatrist would be found liable, he or she would have to show that either contact with the patient was the direct cause of what eventually happened or that the therapist knew or should have known that the person was in crisis. This is always the difficult part in these types of cases. It is not so much getting sued as being held liable. The problem here would be proving that the therapist knew or should have known that this person was going to harm himself and that is very difficult to establish.”

Andrew Campbell-Watt
April 25, 2019

Read More on This Topic

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Will the AMA Heed Its Own Ethics Council Regarding Assisted Suicide?

What Depression Does to Our Minds When It Attacks

Disclosures:

Mr Campbell-Watt reports no conflicts of interest concerning the subject matter of this article.