COMMENTARY

Suicide and Communal Values: Ethical Implications for Psychiatrists

Ronald W. Pies, MD

Disclosures

January 27, 2014

In This Article

The "Reality Test"

As physicians, we have ethical and legal responsibilities to protect our suicidal patients from self-harm. Furthermore, it is our charge, as psychiatrists, to understand the genesis of suicide and to treat its underlying psychiatric precipitants -- most commonly, severe major depressive episodes. This is not to say that all suicides are a consequence of psychopathology. But even if we accept the notion of a perfectly "rational" suicide -- a dubious and rarely applicable concept, in my view -- the communitarian argument made by Hecht is compelling.

Most suicides leave a deep and painful wound in the emotional life of families and communities. It may take years for such a wound to heal, if it heals at all. I can attest to suicide's emotional damage in the microcommunity of my own family, following my uncle's death. To this day, my uncle's widow and her daughters bear the deep emotional scars of his action. And I, too, still second-guess my own involvement, often wondering if more persistence on my part might have prevented my uncle's death.

To be clear: Nothing I have said means that we, as physicians, should affix a scarlet letter to those who contemplate or attempt suicide. Nor do suicidal patients need high-minded lectures on "communal responsibility." Neither should we endorse the benighted view that suicidal people are "selfish" or indifferent to the feelings of others. On the contrary, the suicidal person is already burdened by the darkest of thoughts, and often by corrosive self-loathing. The last thing we should do is add our censure to the person's suffering. Rather, it is our task to comfort, care for, and heal those so afflicted.

Nevertheless, as psychiatrists, we may have good reason to discuss the issue of family and communal values with suicidal patients, without condemning their feelings or impulses. Many suicidal patients expound, at great length, on how important their friends and families are to them -- yet many are irrationally and tragically convinced that their loved ones would be better off without them. In my experience, this view is virtually never shared by the patient's friends and family, who believe that their lives would be immeasurably diminished by the patient's death. Psychiatrists can and, in my view, should "reality test" such distorted perceptions -- not as a way of guilt-tripping the suicidal patient, but as a means of exploring the patient's own values.

In principle, there may be rare circumstances in which ending one's life is both understandable, and by some lights even justifiable. Perhaps many readers would reach this conclusion in the case of Mr. Jones. Indeed, Dr. Judith Schwartz[2] questions whether VSED should even be considered in the same moral sphere as suicide:

It is generally thought that those who commit suicide inflict shock and tragedy on their surviving loved ones, and that "typical" suicidal acts are expressions of despair and futility -- acts that are secretive, impulsive, and often violent in nature. Such a description seems at odds with a thoughtful and considered decision to stop further intake of food and fluids as a means to slowly but surely hasten an inevitable death as a means to escape further intolerable suffering.

Perhaps Schwartz is right in suggesting that VSED in the context of painful, terminal illness represents a special case of self-chosen dying, clinically and ethically distinct from suicide. But such "thoughtful and considered" actions before inevitable death are rarely the case in most instances of suicide. As an ethicist, I largely agree with Jennifer Hecht, that suicide's communal damage is a compelling reason to urge our suicidal loved ones to stay, and respectfully to suggest that life isn't too hard to bear -- only, as Hecht poignantly puts it, "almost too hard to bear."[1]

Acknowledgments: I greatly appreciate the suggestions and comments of my colleagues, particularly Cynthia M.A. Geppert, MD, PhD; Steven Moffic, MD; Boris Vatel, MD; and James L. Knoll IV, MD, on earlier versions of this essay. The views stated here, however, are my own. This piece is expanded and considerably revised from my blog on the Psychiatric Times Website.

Suggested Reading

Gebbia R. Understanding suicide: mental illness, not irony. New York Times. December 10, 2013.

Moffic HS. Suicide among the elderly. Over 65 Blog. November 11, 2013.

Pies R. Is suicide immoral? Psychiatric Times. December 11, 2013.

Szasz T. Fatal Freedom: The Ethics and Politics of Suicide. Syracuse: Syracuse University Press; 1999.

Web Resource

American Foundation for Suicide Prevention

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