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What is suicide? Conventionally, it is intentionally caused self-destruction. However, that clear definition is fraught with problems; for example, what is meant by intentional?
If a soldier chooses to lay down his or her life to save others, is that suicide or heroism? If a civil rights campaigner decides to go where they know there will be an assassination attempt, is that suicide or martyrdom? If a health professional volunteers to treat people with a lethal disease, is that suicide or medical heroism?
Suppose a person who is suffering from a cancer which kills 50% of people, chooses to refuse the treatment that may save their life but leaves everyone who survives the ‘treatment’ disabled and mutilated for life. Is that suicide or rational decision-making?
If a drug or alcohol-addicted person chooses to continue their lethal consumption in full knowledge of the endpoint, is that suicide or self-medication? In many of the possible difficult circumstances facing us, choice and courage seem to play central roles:
- ‘A man [person] with outward courage dares to die; a man [person] with inner courage dares to live,’ says Lao Tzu
What are the suicide figures? According to the WHO (World Health Organization), there are around 700,000–800,000 deaths by suicide each year (one every 0.75 seconds). However, that range is probably a huge under-estimate; it excludes people whose accidental death involved such behaviour that was certain or near certain to cause death.
It excludes those who choose to end their lives but do not want their friends and relatives to face the aftermath of a suicide and, as such, end their lives in ways that look accidental.
Among young people (15–19 years), suicide is the fourth most common cause of death. Around 77% of suicides occur in low to middle-income countries. In the higher income countries, suicides are more commonly linked to alcohol and depression and occur most among vulnerable groups of people such as migrants and refugees, indigenous peoples (in countries where the majority are immigrants ), and vulnerable minorities such as in the LGBTQAI+ community, prisoners, people with mental illness, and the elderly.
Among the UN-recognised 196 countries in the world, only 38 have a suicide prevention strategy. The ratio is even lower among the 50 or so countries that have declared themselves independent but are yet to be universally recognised.
Globally, between 1.7% and 5% of annual deaths are by suicide. More than twice as many men end their lives by suicide than women. There is huge cultural variation in verifiable suicides: the highest is in South Korea at 4.5% of deaths, and the lowest are Indonesia (0.5%) and Greece (0.4%). The fact that there is more than a 10 times difference between the highest and lowest indicates that suicide has a large cultural component.
Indeed, even a rapid journey through the cultural history of suicide reveals widely varying attitudes. Early Greek and Roman cultures had a laissez-faire attitude to suicide. Later thinking took a different approach: Pythagoras thought suicide would change the number of souls and thus upset some mathematical balance. At the same time, Aristotle focussed on the loss to the economy if someone were to choose to end their life.
Roman law later believed that suicide by three categories of people was economically harmful: those accused of a capital crime, enslaved people and soldiers. Each would have their assets confiscated if they chose to kill themselves. Other suicides were regarded as noble: patriotic suicide.
In several religions, during the middle ages and even today, suicide was and is regarded as a sin, punishable by the removal or funeral rights and promised eternal damnation. However, during the Renaissance, some humanists, such as Moore, believed that suicide was a reasonable course of action if afflicted by the torture of suffering, but for any other reason was a damnation-inducing crime.
Suicide has been used as a protest against injustice, for instance, the slave suicides in the US before the abolition of slavery. Suicide has also been preferable to falling into enemy hands after countless lost battles throughout history.
The weaponisation of suicide has existed across time and cultures. For example, Japanese Kamakaze pilots during WWII, and today we have suicide bombers, and all too frequently, in the US, mass shooters know their murderous actions will lead to suicide by cop.
What triggers suicidal ideation? From our brief trip through history, it is clear that the question is misleading. Suicidal ideation implies that some mental illness is behind suicidal intent and that suicide is, somehow, an irrational act.
Some suicides are entirely rational. Faced with a fatal degenerative disease that will cause immeasurable pain and suffering, many people decide to end their lives in a dignified way of their choosing, at a time and place of their choosing.
They go about putting their affairs in order, say all their goodbyes, and make the best of what life they have before their pre-chosen trigger point is reached. They make a rational, measured and balanced decision and carry it out with grace and dignity.
The three strongest known associations with suicide are health conditions, life stressors, and access to lethal means. For those people for whom suicide was a short-term impulse, having reduced access to lethal means minimises the likelihood of acting on that impulse. However, that does not stop or deter people with long-term settled intentions to end their lives.
The psychological factors in suicide are not well understood, and many involved variables can have the same effect but for completely opposite reasons. For example, hope. In some cases, suicidal thoughts enter when hope has departed. For others, suicidal thoughts enter when the hope that the sacrifice will help others arrives.
Suicide can be for altruistic motives. Throughout history, soldiers in battle have knowingly gone on suicide missions to benefit others.
All over the world, as you read, some people are knowingly working themselves to death for the benefit of others, usually family. Police officers in troubled countries work daily, not knowing if they will return to their families.
Are such people suicidal? No, but they are prepared to take risks that are potentially, even probably, suicidal.
Others are actively and altruistically suicidal. There have been many reports of older adults choosing to end their lives to avoid the increasing health care costs that would damage their children’s inheritance.
Having been practising psychology for over 35 years, it is difficult to conclude other than this: suicide is a choice. It is a choice to end or prevent the pain and suffering of the person who dies or to prevent harm to others. Suicide is a choice almost everyone has open to them, but few take it.
Contrary to popular belief, the evidence indicates that most suicides have no mental illness component. That means, at the point of suicide it was, to the person, a rational choice based on the evidence in their mind at that time, as indicated by a large number of suicide notes studied.
How many of us make the perfect decision every time? None. We tend to emphasise some pieces of evidence too much and not enough on others.
How many of us have not worked ourselves into an emotional state that clouds our judgement that impedes our ability to weigh the evidence objectively? Very few, or none. We can make impulsive choices that have permanent consequences.
We don’t know how many suicides each year are for impulse reasons, but most people agree that trying to prevent those suicides is the right thing to do.
Society has a very confused view of suicide. The soldier who knowingly lays down his or her life to save colleagues is a hero. However, the person who ends their life to prevent their family from being financially ruined by health care costs, or being psychologically damaged by watching a loved one suffer a slow, agonising death, is viewed very differently. Both parties made a rational choice to benefit others, and only one is viewed favourably.
It is widely known that in medicine, physicians will be sometimes put in a position to ease the pain of a dying person; the dose of painkillers given is knowingly going to be a person-killer, too.
When a person in the last stages of life asks for a painkiller, is the physician knowingly assisting a suicide? Technically, it seems so, but legally a blind eye is turned. Why? Because it is the humane and reasonable thing to do at that time.
If so, we are no longer arguing about whether a person should be given painkillers that will kill them; we are merely discussing when the pain is so severe that a fatal dose of painkillers is appropriate. The only person who knows how much pain they are in is the person suffering the pain. In this context, we are knowingly giving the choice of when to end life to the dying person.
Here are three uncomfortable questions. First, do we want to prevent all suicides? Second, do we want to stop the soldier who would lay down their lives to save others? Third, do we want to stop altruistic suicides, all suicides, or just mental illness and impulse suicides?
The harsh reality is that individuals can end their lives if they choose to whatever the law, ethics or morals, whatever society decides it wants. The only people who cannot exercise choice over their existence are those whose illness or disability has removed that choice.
In trying to understand suicide, perhaps we can remind ourselves that whatever the motive of the person who ends their own life, being in a position where suicide was their choice at that time, and in those circumstances, is tragic.
Most suicides are preventable with the right support. Here are some thoughts to share that might save someone’s life.
- ‘The longer we dwell on our misfortunes, the greater is their power to harm us,’ says Voltaire
- ‘Suicide does not end the chances of life getting worse. Suicide eliminates the possibility of it ever getting better,’ says Kat Calhoun
- ‘The great thing about suicide is that it’s not one of those things you have to do now or you lose your chance. I mean, you can always do it later,’ says Harvey Fierstein
- ‘To anyone out there who’s hurting–it’s not a sign of weakness to ask for help. It’s a sign of strength,’ Barack Obama
If you are affected by the contents of this article, please reach out for help.
Professor Nigel MacLennan runs the performance coaching practice PsyPerform.