Panayiota Antypas
Tasmania, Australia

For most of my life, I believed that suicidality was a direct consequence of acute and unmedicated mental illness. I thought that if we admitted the patient, removed the means, and administered treatment, they would be quickly reinvigorated with a will to live.

Then I met patients, colleagues, and friends who wanted to die.

Now I wasn’t so sure.

During my Emergency Department placement, I encountered a woman who was actively suicidal. She was in an abusive relationship, unemployed, and living in poverty. Chronic pain deprived her of freedom, sleep, and function, and she had often presented to the emergency department with a similar disposition. There was no disordered thinking when she looked us in the eyes and said, “I cannot continue like this.”

We did what we knew how to do—put her under an assessment order, admitted her, and kept her alive. But had we changed her world? The circumstances that led her to believe that death was the only conceivable escape hummed in the background, or perhaps in the foreground. Still, we told her she had a reason to live, that she was loved, that she should keep going. But did we believe what we uttered? Or were we just repeating the same hopeful script because it protected us from admitting our futility?

I have watched suicide prevention efforts swing back and forth between frenzied panic and indifference. Maybe that is all we can reasonably ask of an emergency department, which is made for acute crises, after all. But suicidality is not always an acute catastrophe; sometimes it is the culminating point of chronic, unalleviated suffering. 

After this experience, I began to ask myself some difficult questions: Why do people want to die? Do they all have a mental illness? Do we have a right to intervene? Are we complicit in driving suicidality?

And perhaps most troubling of them all: Is the crisis that people want to die, or that we have created a world wherein people cannot bear to be alive?

Diagnosing society

Historically, suicide has been denounced both religiously and morally: Christian doctrine condemns it as a sin,¹ and Kant² declared it a violation of the “duty of a human being to himself.” However, as secularism was popularized and evidence emerged associating suicide with psychiatric illness, suicide was progressively medicalized throughout the twentieth century.³ While this was arguably revolutionary, it also overshadowed the important role of social determinants such as discrimination, poverty, and family violence in contributing to suicidality.^4,5

When sorrows come, they come not single spies / But in battalions⁶
—Hamlet (Shakespeare, Act 4, Scene 5)

Durkheim, a nineteenth-century sociologist, was the first to suggest that suicide is a product of societal disorder, rather than solely individual psychopathology.⁷ He argued that suicide risk is inversely associated with the degree to which someone is socially integrated, and proposed other risk factors including familial conflict, economic hardship, and imprisonment.⁷ These ideas were reaffirmed in recent studies, wherein a 2019 systematic review found that only 58% of people who died by suicide in low- and middle-income countries had a diagnosed mental illness.⁸ Additionally, an Australian study determined that approximately 10% of suicides between 2004 and 2016 were directly attributable to under- and un-employment.⁹

Suicide rates are disproportionately higher in marginalized communities.¹⁰ For example, the suicide rate in Australian Indigenous communities is more than twice that of the non-Indigenous population. Colonization, intergenerational trauma, and racism have an ongoing negative impact on well-being.¹¹ Furthermore, a staggering 43% of transgender Australians have attempted suicide.¹² This may again be understood within a societal context, wherein transgender individuals face obstacles to accessing appropriate care and experience institutional discrimination.¹²

Suicide is not solely a psychiatric emergency but also a product of an unjust world. Indeed, we must offer counseling, admission, and medication when required, but we must also look beyond the realm of clinical medicine. In completely medicalizing suicide, we may also stigmatize individuals as well as absolve society of a responsibility to reform injustice.

To be or not to be

“There is but one truly serious philosophical problem and that is suicide.”¹³
—Albert Camus, “The Myth of Sisyphus”

In most Australian states, patients with terminal illnesses can legally end their lives under voluntary assisted dying legislation.¹⁴ Conversely, suicidal individuals who do not fit into this “terminal” category are not only deprived of this autonomy, but pathologized.¹⁵ How do we decide who can and cannot end their life?

Autonomy is often removed from suicidal people under the pretense that they lack decision-making capacity. This is a reasonable contention, given many are acutely mentally unwell and may lack the insight needed to weigh the implications of living versus dying.¹⁵ However, as stated previously, not all suicidal people are mentally ill, and many may retain decision-making capacity.¹⁵

There is also a premise that the act of suicide is inherently irrational, wherein rationality is the characteristic of deciding based on good reason.¹⁶ However, this notion is ethically ambiguous. How can we expect someone to compare life (which no one can predict) with death (which no one really understands)?¹⁷ We cannot—and therefore deciding whether suicide is rational or irrational is challenging.

So, if someone has capacity, should we let them kill themselves? I don’t believe we should, because capacity alone is not a reliable ethical compass. Atul Gawande writes that autonomy is not solely the right to make decisions for oneself; rather, it is the act of someone being informed and supported to choose an option that is aligned with one’s intrinsic values.¹⁸ Indeed, it has been postulated that many suicidal people do not actually want to die; they want to escape unbearable suffering by whatever means possible.¹⁹

Mirroring this existential dilemma, in Hamlet’s famous soliloquy⁶—“To be or not to be”—I do not believe he is questioning whether to die, but rather deliberating whether he can continue to live amidst suffering.

Therefore, honoring a suicidal person’s wish to die may well be a dangerous misinterpretation of what they are asking for: a more bearable life.¹⁹ We are not upholding autonomy when we facilitate their death, but when we understand who they are and why they want to die, and help them find a way to live around their suffering. Indeed, we must attempt to understand what Gawande also asks: “What were her biggest fears and concerns? What goals were most important to her? What trade-offs was she willing to make, and what ones was she not?”¹⁸

Still to be

Suicidality does not exist in a vacuum—so neither should our interventions.

The Lancet corroborates this notion, stating that “public health measures that target the whole population” are likely to be more effective than individual-level interventions in preventing suicide.²⁰ Furthermore, it is unlikely that we could ever train or employ enough healthcare workers to deliver personalized care to all suicidal individuals.²⁰

This means that our responsibility as clinicians extends beyond the clinical realm of risk assessments and crisis management. We must also advocate for public health interventions, including but not limited to: improved community safety (reducing family violence, child abuse); economic security (affordable housing, secure employment); social inclusion (reducing racism, workplace bullying); support during life transitions (retirement, bereavement, release from prison); and better access and quality of mental health services.¹⁰

Finally, on a grassroots level, I think that we as developing healthcare professionals must ensure that we do not let bias or prejudice impact our practice. We are human, yes. We carry subconscious biases, yes. But we must also remember that we wield enormous power. So, when we disregard an Aboriginal person’s culture, demean a transgender person, or dismiss someone’s chronic pain, we are not just harming that individual but directly contributing to a culture that drives suicidality.^11,12

Through reading literature and sitting with the suffering of others as well as my own, I now understand that suicidality is not a symptom that can be ameliorated with psychiatric intervention alone. It is a cry for the world to become kinder, safer, and fairer. We are doctors, but we are also human beings. It is nothing less than our duty to build that world.

“The time is out of joint: O cursed spite. That ever I was born to set it right.”⁶
—Hamlet (Shakespeare, Act 1, Scene 5)

References

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