SUICIDE

Among industrialized countries that provide statistics on suicide, nearly all report that suicide rates rise progressively with age, with the highest rates occurring for men age seventy-five and older. In the United States in 1997, older white males age eighty-five and older had a rate of 65.4 per 100,000. This latter rate is almost six times the rate of all ages combined. Reviewed here is the available research evidence on correlates and risk factors in later life suicidal behavior, and suggested opportunities for prevention.

Demographic correlates and methods of later life suicide

U.S. data on completed suicides by sex, age, race, marital status, and method are based on vital statistics information gathered by the Centers for Disease Control and Prevention’s National Center for Health Statistics, with each state reporting from death certificates. From this data source we know that increased age among persons sixty-five and older is associated with higher rates of suicide. Also, older adults as a group are more likely to use a firearm as a suicide method compared to the total U.S. rate; 70 versus 60 percent. In terms of demographic correlates of suicide deaths, male sex, white race, older age, and unmarried status are associated with higher rates of suicide.

Older suicide victims are more likely to have lived alone than younger suicides. However, older adults are also likely to be those members of the population who live alone, so the potency of living arrangement as a risk factor for suicide is not clear. A correlate associated with living arrangement is marital status. The suicide rate for unmarried older adults is higher than the suicide rate for married older adults. For older men, the suicide rate for those who are divorced or widowed is much higher when compared with older females or with their married counterparts (Buda and Tsuang).

Psychological status and life events associated with later life suicide

In the absence of adequate prospective studies, the psychological autopsy (PA) method has been used to reconstruct a detailed picture of the victim’s psychological state prior to death, including psychiatric symptomatology, behavior, and life circumstances during the weeks or months before death. This includes interviewing knowledgeable informants, reviewing available clinical records, and comprehensive case formulation by one or more mental health professionals with expertise in postmortem studies. The PA method has been used to provide an inclusive, well-defined sample of all persons who die by suicide within a defined catchment area, region, or population. One of the most striking and consistent findings of the PA method is that psychiatric disorder and/or substance use is present in about 90 percent of all suicides, with affective disorder as the most common psychopathology, followed by substance use and schizophrenia (Conwell and Brent).

When compared to younger suicide victims, older victims are more likely to have had a physical illness, and to have suffered from depression that is not comorbid with a substance disorder (Conwell and Brent). The type of depression found in the majority of later life suicides is usually a first episode of depression, uncomplicated by psychoses or other comorbid psychiatric disorders, and, ironically, is the most treatable type of late-life depression. Such age-related patterns have appeared in reports from a number of countries including the United States, Finland, and the United Kingdom.

Although substance use is less frequent among elderly suicides, there is some evidence that among the ‘‘young old,’’ alcohol may be a correlate. For men with early onset alcoholism who have survived to their fifties and sixties, the combination of continued alcohol abuse and burn out among their social support network may be lethal. Murphy and his associates described that for older male alcoholics, loss of the last social support can be a pivotal event in suicide risk (Murphy, Wetzel, Robins, and McEvoy). How current, as well as past alcohol abuse, lowers the threshold for suicidal behavior in later life requires further systematic examination. Although it is often assumed that medication misuse (e.g., benzodiazepine dependence, psychotropic medication with alcohol abuse) is a risk for late life suicide, there is little published information on this topic.

Despite high rates of dementia and delirium in later life, few studies have found these diagnoses to be risk factors for suicide (Conwell and Brent). Controlled PA studies are needed to determine what other factors in combination with mental and physical disorders are related to risk for later life suicide.

The PA has been used to explore possible personality traits that may increase risk for later life suicide (Duberstein). Duberstein used an informant-based personality inventory measure to examine possible personality traits among older and younger suicides, relative to age- and sex-matched controls. The inventory measured five general personality traits: neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness. Suicides were found to have higher neuroticism scores than normal controls, and older suicide victims had lower openness to experience scores than both younger suicides and normal controls.

Hopelessness, a set of beliefs related to lack of anticipated positive outcomes about the future, has also been examined in the context of later life suicide. A prospective investigation of a retirement community found a single item asking about hopelessness was related to later completed suicides (Ross, Bernstein, Trent, Henderson, and Paganini-Hill).

Suicide intent has also been examined in older adult suicide victims. Using the PA method, older adults were found to be more intent compared to younger suicide victims (Conwell, Duberstein, Cox, Herrmann, Forbes, and Caine). That is, older adults were more likely to have avoided intervention, taken precautions against discovery, and were less likely to communicate their intent to others. Moreover, older men, in particular, were less likely to have had a history of previous attempts.

The PA method has also been used to examine patterns of health services use among suicide victims. Health services for older adults who later suicided was typically available, and used. A number of reports indicate that approximately 70 percent of older suicide victims had seen a primary health care provider within a month (Conwell). In contrast, few older adult suicide victims have had a history of mental health care.

Neurobiological correlates of late life suicide

Postmortem brain tissue studies of suicide victims have found that the sertonergic systems (presynaptic and nontransporter nerve terminal binding sites) had reduced activity (Mann). Although there is optimism about new refinements and applications of neurobiological, brain imaging, and candidate gene markers to identify high risk individuals, there are currently no specific biological markers for suicidal behavior. With regard to older adults, it is conceivable that a ‘‘neurobiological vulnerability’’ to suicide might be modulated by age-related changes in neurobiological systems (Schneider). The consistency of increased suicide risk with age and male sex across nations also suggests a possible neurobiological process. Decreased brain concentrations of serotonin, dopamine, norepinephrine and their metabolites (HVA, 5-HIAA); increased brain MAO-B activity; increased hypothalamic-pituitary-adrenal (HPA) activity; and increased sympathetic nervous system activity are associated with both depression and normal aging (Schneider). Although several reviews have examined the evidence for neurobiologic abnormalities among older suicide victims relative to controls, there are too few studies that included sufficient ‘‘older’’ subjects (older than sixty years) to draw any conclusions (Conwell and Brent). This is particularly true of the subgroup of the older adults most at risk: those eighty-five and older.

Suicide attempts in later life

There are currently no national surveillance data of suicide attempts in the United States. Using data from the National Institute of Mental Health Epidemiologic Catchment Area study of five communities, Moscicki and her associates found a much lower prevalence of lifetime suicide attempts for older adults than younger populations. For persons age sixty-five and older, the lifetime prevalence for suicide attempts was 1.1 percent. By comparison, the rate was 4 percent for persons age twenty-five to forty-four. Other community-based studies have estimated lower attempt to completion ratios for older, compared to younger, adults (e.g., Nordentoft et al.). These findings support Conwell and colleagues’s 1998 report that older adults are more intent in their efforts to commit suicide.

Other information about attempted suicide in late life comes from studying the characteristics of older persons recently admitted to a hospital due to the attempt. Draper reviewed twelve studies of later life suicide attempts published between 1985 and 1994. Despite variation in sampling contexts and approaches to measurement, and lack of adequate control groups, he reported several consistent factors associated with attempted suicide in late life: depression, social isolation, and being unmarried. The degree to which physical health was a risk factor was unclear. In some studies it appeared to play a major role, while in another only about one-third of the patients identified health as a salient factor.

The relationship between hopelessness and suicide attempts in later life was examined by studying the course of hopelessness in depressed patients (Rifai et al., 1994). Patients who had attempted suicide in the past had significantly higher hopelessness scores than nonattempters during both the acute and continuation phases of psychiatric treatment. Moreover, a high degree of hopelessness persisting after the remission of depression in older patients appeared to be associated with a history of suicidal behavior. This study by Rifai and her associates also suggested that a high degree of hopelessness may increase the likelihood of premature discontinuation of treatment and lead to future attempts or suicide. One prospective study of older depressed inpatients followed over a year found that 8.7 percent attempted suicide (Zweig and Hinrichsen). Patients who attempted suicide were more likely to have an incomplete remission of depression, history of suicide attempts, and familial interpersonal strain compared to those who did not attempt within the one year follow-up.

Prevention strategies

Prevention strategies should follow the most potent risk factor findings. Since the majority of older adults use firearms as a means of suicide, some have proposed that reduction in access to firearms may be an effective, preventive measure. However, others have argued that substitution in suicide methods may minimize the potency of this prevention approach (1990).

Research findings of increases in intent with age suggest that older persons who are at risk for suicide may be more difficult to identify as being at imminent risk than is the case for younger persons. Thus, clinical intervention strategies that target individuals who are at high risk for suicide, as indicated by a variety of demographic and psychiatric variables, may be more effective for preventing suicide than interventions that solely target individuals with suicide ideation or behavior. The fact that the majority of older adults are seen in primary care settings within the month of their deaths, coupled with the finding that most later life suicide victims have had a late onset, depressive episode, suggests that detecting and treating depression in primary care may be an efficient way to prevent later life suicides.

Although the identification and adequate treatment of depression is proposed as the most promising research avenue when considering preventive interventions in late life suicide, there are a number of factors that work against these prevention efforts. Ageism works against out-reach efforts. Many health providers, family members, and older adults themselves believe that depression and suicidal ideation are part of the normal aging process. Prevention efforts will need to consider these issues in public education and provider training to advance efforts in increased detection and treatment of depression.

Jane L. Pearson

See also Depression; Euthanasia and Senicide; Suicide and Assisted Suicide, Ethical Aspects.

BIBLIOGRAPHY

Buda, M., and Tsuang, M. T. ‘‘The Epidemiology of Suicide: Implications for Clinical Practice.’’ In Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. Edited by S. J. Blumenthal and D. J. Kupfer. Washington, D.C.: American Psychiatric Press, Inc., 1990. Pages 17–37.

Conwell, Y. (1994). ‘‘Suicide in Elderly Patients.’’ In Diagnosis and Treatment of Depression in Late-Life. Edited by L. S. Schneider, C. F. Reynolds, B. D. Lebowitz, and A. J. Friedhoff. Washington, D.C.: American Psychiatric Association, 1994. Pages 397–418.

Conwell, Y., and Brent, D. ‘‘Suicide and Aging I: Patterns of Psychiatric Diagnosis.’’ International Psychogeriatrics 7 (1995): 149–181.

Conwell, Y.; Duberstein, P. R.; Cox, C.; Herrmann, J. H.; Forbes, N. T.; and Caine, E. D. ‘‘Age Differences in Behaviors Leading to Completed Suicide.’’ American Journal of Geriatric Psychiatry 6 (1998): 122–126.

Draper, B. ‘‘Attempted Suicide in Old Age.’’ International Journal of Geriatric Psychiatry 11 (1996): 577–587.

Duberstein, P. R. ‘‘Openness to Experience and Completed Suicide across the Second Half of Life.’’ International Psychogeriatrics 7 (1995): 183–198.

Mann, J. J. ‘‘The Neurobiology of Suicide.’’ Nature Medicine 4 (1998): 25–30.

Moscicki, E. K.; O’Carroll, P.; Rae, D. S.; Locke, B. Z.; Roy, A.; and Regier, D. A. ‘‘Suicide Attempts in the Epidemiologic Catchment Area Study.’’ Yale Journal of Biology and Medicine 61 (1988) 259–268.

Murphy, G. E.; Wetzel, R. D.; Robins, E.; and McEvoy, L. ‘‘Multiple Risk Factors Predict Suicide in Alcoholism.’’ Archives of General Psychiatry 49 (1992): 459–463.

Nordentoft, M.; Breum, L.; Munck, L.; Nordestgaard, A. G.; Hunding, A.; and BjÆldager, P. A. L. ‘‘High Mortality by Natural and Unnatural Causes: A 10 Year Follow Up Study of Patients Admitted to a Poisoning Treatment Centre after Suicide Attempts.’’ British Medical Journal 306 (1993): 1637-1641.

Rifai, A. H.; George, C. J.; Stack, J. A.; Mann, J. J.; and Reynolds, C. F. ‘‘Hopelessness in Suicide Attempters After Acute Treatment of Major Depression in Late-Life.’’ American Journal of Psychiatry 151 (1994): 1687–1690.

Ross, R. K.; Bernstein, L.; Trent, L.; Henderson, B. E.; and Paganini-Hill, A. ‘‘A Prospective Study of Risk Factors for Traumatic Death in the Retirement Community.’’ Preventive Medicine 19 (1990): 323–334.

Schneider, L. S. ‘‘Biological Commonalities among Aging, Depression, and Suicidal Behavior.’’ In Suicide and Depression in Late-Life: Critical Issues in Treatment, Research and Public Policy. Edited by G. J. Kennedy. New York: John Wiley & Sons, Inc., 1996. Pages 39–50.

Szanto, K.; Reynolds, C. F., 3d; Conwell, Y.; Begley, A. E.; and Houck, P. ‘‘High Levels of Hopelessness Persist in Geriatric Patients with Remitted Depression and a History of Attempted Suicide.’’ Journal of the American Geriatrics Society 46 (1998): 1401–1406.

Zweig, R. A., and Hinrichsen, G. A. ‘‘Factors Associated with Suicide Attempts by Depressed Older Adults: A Prospective Study.’’ American Journal of Psychiatry 150 (1993): 1687–1692.

Suicide

I. Social AspectsJack D. Douglas

BIBLIOGRAPHY

II. Psychological Aspects (1)Edwin S. Shneidman

BIBLIOGRAPHY

III. Psychological Aspects (2)Norman L. Farberow

BIBLIOGRAPHY

I. SOCIAL ASPECTS

Suicide has been an object of fundamental concern to Western men of all cultural periods, though the importance given to suicide itself, as well as the degree to which it has entered into other concerns, has varied greatly from one period to another. “Suicide,” said Goethe, “is an incident in human life which, however much disputed and discussed, demands the sympathy of every man, and in every age must be dealt with anew” ([1811-1833] 1908, vol. 2, p. 125).

This is not to say that suicide has failed to interest people in other cultures but, rather, that the reasons have usually been different. In feudal Japan, for instance, suicide was an ultimate act of honor, redemption, or union. In the Western world, however, suicide has always been regarded as fundamentally problematic. Possibly because suicide in the West has nearly always been interpreted as voluntary self-destruction, with no element of social constraint or obligation, philosophers from Plato to Camus have used it as a starting point for reflection on the eternal problems of human existence. Indeed, ambivalence toward the fact of his own existence is one of Western man’s most persistent characteristics; life and death, the relation of man to man, and the relation of man to himself have been subject to continual questioning, and suicide has been seen as relevant to all of these. In such a climate of thought, it is not surprising that neither settled opinion nor emotional consensus has ever been reached concerning the nature of suicide.

Early writings . Early Western writers on suicide were primarily concerned either with its desirability (including its honorability) or with its morality. But all of them, whether Greek, Roman, Jew, or Christian, were concerned to some degree with the particular facts of actual cases of suicide. Most importantly, from our point of view, they implicitly assumed that before one could properly judge the actor in the case, one had also to know his intentions, the situation in which he found himself, and the nature and outcome of his actions.

After the normative arguments against suicide by Augustine, the Council of Aries, and the Council of Bourges, there is little evidence that the normative evaluation of suicide was considered to be very problematic until the seventeenth century. But there remained the cognitive problem of deciding which set of facts concerning intentions, situations, and actions should be imputed to the category of suicide. Most important to Christian thinkers was the problem of categorizing “martyrs”: were they suicides or not? This cognitive problem was to be just as difficult for sociologists in the twentieth century as for theologians in the fifth century (see Halbwachs 1930).

The nineteenth century . The fundamental forms of thought about suicide, including the implicit assumptions that suicide must be studied as a form of normative action and that suicide is connected with the problem of man’s relation to God and man’s relation to man, were all part of the literary and common-sense background of sociological thought about suicide in the nineteenth century. But there were many other, more specific influences on these nineteenth-century works.

Almost all of the many works on suicide in the eighteenth and nineteenth centuries included extensive and detailed considerations of the historical cases, the literary examples, and the philosophical treatments of suicide. The works of Appiano Buona-fède, Louis F. Bourquelot, Carl F. Stäudlin, Albert des Étangs, Pierre J. C. Debreyne, Alexandre Brière de Boismont, and Alfred Legoyt, to mention but a few, were greatly concerned with such sources. Among the literary, philosophical, and historical influences on the developing sociology of suicide, three can be singled out as most important.

(1) Knowledge of the high frequency of suicide among the upper classes in ancient Rome, and of the honorableness of suicide among the Romans, led to the idea that suicide is fundamentally a matter of social custom. According to Voltaire and other thinkers of the Enlightenment, suicide in a society where suicide is neither the custom nor positively valued or expected was due to a failing, weakness, or disease. This background assumption helped to produce both the psychological theory that suicide is caused by insanity (or character weakness, or disequilibrium), a theory of great influence even today (Dahlgren 1945; Achille-Delmas 1932; Deshaies 1947), and the sociological theory that suicide is caused by a failure of the normative control of individuals by society (Brière de Boismont 1856; Morselli 1879; Durkheim 1897; Cavan 1928).

(2) In the eighteenth century, suicide became a focal point in the ethical argument between the philosophes and the church supporters. Largely as an outgrowth of this struggle, the relation of religion to suicide became a leading concern of the nineteenth-century sociologists. Specifically, this tradition of thought was largely responsible for the explanations of the great statistical increase in suicide in nineteenth-century Europe in terms of meaninglessness of life, lack of discipline, self-centeredness, moral disorganization, and materialism. These developments are dealt with more fully below.

(3) Death, especially death by suicide, was a favorite theme in the literature of the romantic movement. Indeed, the most important contribution of this literary tradition to the developing sociology of nineteenth-century Europe was probably that it helped to focus attention on suicide. Largely because of its treatment in literature, suicide was seen by the educated public as a fundamental social problem. Nineteenth-century Europeans, especially the French, were as frightened of la manie du suicide (as Tissot [1840] called it) as twentieth-century Americans are of juvenile delinquency and the Mafia. But the literary concern with suicide also provided the core of certain very important, specific “theoretical” explanations. Of fundamental importance was the prime romantic symbol of an isolated, lonely hero of a poetic (or intellectual) bent who wanders far from human society in search of the impossible and, failing of the impossible, becomes increasingly melancholy and enamored of eternity. The idea that self-imposed isolation produces “melancholy,” and thence suicide, was hardly novel; indeed, Robert Burton’s seventeenth-century treatise, The Anatomy of Melancholy, had carefully documented its classical sources. But this prime symbol of romanticism contained the most unclassical ideas of both egoism and anomie. Indeed, the romantic image of suicide seems to have been so much the mythical model which the sociologists of suicide had in mind that both Morselli ([1879] 1882, p. 297) and Durkheim (1897) had a strong tendency to treat egoism and anomie as almost identical. It is even possible to specify the work of Chateaubriand, especially as treated by Briére de Boismont (1856, pp. 39-40), as the major source of Durkheim’s idea of anomie suicide (Douglas 1965, pp. 20-26).

Some of the fundamental ideas about suicide which the sociologists inherited from history, philosophy, literature, and common sense became the cores of the various sociological theories of suicide. There were other influences on these theories which will be described later. But the sociologists of the period were dependent upon these nonscientific and, most importantly, nonempirical sources for their ideas about suicide as a specific phenomenon. Though this is somewhat less true today, the sociological study of suicide is in substantially the same condition.

The definition of suicide

A great number of different definitions of suicide have been proposed by the students of suicide during the first two hundred years of the term’s general use. Almost all of these definitions have included, to varying degrees and in various combinations, one or more of the following conceptual dimensions: (a) the initiation of an act that leads to the death of the initiator; (b) the willing of an act that leads to the death of the wilier; (c) the willing of self-destruction; (d) the loss of will; (e) the motivation to be dead (or to die, or to be killed) which leads to the initiation of an act that leads in turn to the death of the initiator; (f) the knowledge of an actor concerning the relations between his acts and the objective state of death; (g) the degree of central integration of the decisions of an actor who decides to initiate an action that leads to the death of the actor; (h) the degree of firmness or persistence of the decision to initiate an act that leads to the death of the initiator; (i) the degree of effectiveness of the act in producing death. (For a detailed presentation of the various definitions, see Schneider 1954, pp. 9-59; for an analysis of the definitions of suicide, see Douglas 1965.)

The great profusion and confusion of definitions of suicide have been very largely the result of combining an abstract, a priori approach to defining the concept with an assumption of “verbal realism” —i.e., the assumption that if the same name is in fact used to refer to a set of phenomena, then that set of phenomena must in fact have some shared property that is designated by the shared word. Durkheim and almost all other sociologists and psychologists who have attempted to carefully define suicide, have assumed that one should arbitrarily define the concept to fit his scientific methods and his theoretical purposes but that the definition should not differ too much from common usage (Durkheim [1897] 1951, pp. 41-42). Durkheim further assumed that the most common definition of suicide was that of death caused by an action initiated by the actor with the intention of causing his own death. Since, however, teleology is anathema to positivists, Durkheim decided that intentions are too “intimate” to yield valid information and that, consequently, “knowledge” by the actor of the deadly consequences of his actions should be the fundamental factor in deciding that a death is a suicide, even if the consequences are relatively uncertain (ibid., pp. 43-46).

Unfortunately, Durkheim’s definition of suicide was quite irrelevant to his work on suicide. As Maurice Halbwachs most astutely argued, Durkheim was almost totally dependent on the official suicide statistics for his data, so the only definition that really mattered was that (rather, those) which the officials had in mind when they categorized the causes of deaths. Since Halbwachs believed that one could not know what definitions these officials used, he concluded that sociologists must be satisfied with no definition at all (Halbwachs 1930). Actually, the coroners and doctors who do the categorizing seem generally to be firm believers in the common-sense theory of teleology. Moreover, the laws governing the certification of cause of death very generally specify “intention” as necessary for a classification of suicide. Benoit-Smullyan (1948) has also pointed out that since Europeans do not generally consider self-sacrifices to be suicides, Durkheim’s “altruistic suicides” would not be included in the official statistics on suicide. Consequently, it seems clear that Durkheim’s definition of suicide was not so much irrelevant to his data as it was a complete distortion of the meaning of the data.

With the exception of Halbwachs’ work, the published sociological works on suicide since Durkheim’s Suicide have generally assumed that Durkheim’s definition is best; they have even failed to note Halbwachs’ valid criticism of it. They have, however, also either implicitly assumed “intention” to be a necessary factor, or else they have totally avoided the problem. The result has been both confusion and a failure to recognize the problems involved in defining suicide. The sociology of suicide is in obvious need of a system of categories which will describe the observed phenomena that are significant in terms of a theory of suicide. Such descriptive categories must be worked out in partial independence of the theories in order to aid their development, but they must also be worked out in partial dependence on developing theories. However, the first critically important thing for sociologists to do is to make direct observations of the empirical phenomena which are called suicide in any society, so that definitions will be relevant and so that the meanings of the data will be known to the theorists.

Official statistics on suicide

Largely because of the rapid acceleration in statistics-keeping in eighteenth-century Europe, the systematic recording and tabulating of suicides had become standard practice in many of the governmental regions of Europe by the first quarter of the nineteenth century. The basic ideas of “moral statistics,” especially the fundamental idea that a given incidence of a phenomenon such as suicide is regularly associated with a given population, had been clearly formulated in the eighteenth century, certainly by 1741, when Johann Peter Süssmilch published his famous treatise on the “divine order” underlying demographic phenomena. The traditions of “political arithmetic,” of studying racial and national character, and of comparative studies of suicide rates were synthesized by Adolphe Quetelet (1835) in order to produce his “average man” theory of suicide rates. Quetelet’s fundamental idea was that each stable “social system” produces a stable, average personality type about which the individual personalities tend to cluster. The average man, therefore, has a given, stable probability of committing suicide in a given period of time.

Quetelet’s probabilistic theory was specifically intended to explain the observed regularity (or order) in the official suicide statistics. This regularity, which was first observed for the different nations of Europe, seemed to the moral statisticians to be a remarkable demonstration of the deterministic, lawlike nature of the actions of individuals. Since the seventeenth century, Europeans had believed suicide to be more frequent in some nations than in others. The French considered suicide to be as English as gambling (they seem to have believed that more Englishmen preferred death to life because the fog made living so unworthwhile), though Voltaire thought this impression was due to more newspaper coverage of suicide in England. But before the nineteenth century, the explanations of these (assumed) regular differences in suicide frequencies always involved the assumption that the individual will was the ultimate cause of the action. In the early nineteenth century both the psychiatric theory that all suicides are insane (and, therefore, do not cause their own actions) and the direct comparison of national suicide rates (without any real consideration of the individuals who committed the actions) combined to eliminate the individuals (or wills, or personalities) from consideration as possible causes of suicide. Quetelet’s early work on the comparisons of social rates of suicide (work that gained much support from the researches of Gustave F. Étoc-Demazy and Andre M. Guerry) was quickly given a metaphysical basis by the English positivists, especially by Henry Thomas Buckle. This largely eliminated Quetelet’s variable of average personality; the direct comparison of other external, objective data (such as geographical-ecological distributions and marriage rates) with suicide rates was now an established method with a metaphysical justification, that of positivistic determinism.

Largely because of the vast influence of Brière de Boismont’s great work on suicide (1856), based primarily on case studies of 4,595 suicides, including 1,328 suicide notes (a source of data first used by Guerry as early as 1833), and 265 attempted or planned suicides, the more important works on suicide by Wagner (1864) and Morselli (1879) did not deny causal significance to various individual factors, such as motives. They did, however, consider the comparative analysis of officially computed suicide rates to be necessary for establishing causes of suicide “. . . such as the most positive mode of psychological study would fail to discover in the individual” (Morselli [1879] 1882, p. 10). Durkheim’s sociologistic theory of suicide proposed that suicide rates are a sine qua non of the sociological study of suicide, and the great influence of his Suicide (the first edition of which appeared in 1897, although it was not translated into English until 1951) quickly made the statistical approach almost identical with the sociological approach, especially in the United States. Indeed, Kruijt (1960) and others have recently assumed the two to be totally identical.

Validity of official data . Since sociologists have relied almost exclusively on the official statistics and coroners’ reports on suicide for the data from which to develop and test theories of suicide, the question of the validity of the official data is absolutely critical in any evaluation of these sociological works. Throughout the nineteenth century most students of suicide were highly critical of the official statistics on suicide. Esquirol (1838), Brière de Boismont (1856), Legoyt (1881), Strahan (1893), and many others believed the official statistics grossly underestimated the actual number of suicides. Even Morselli (1879) most emphatically warned against the dangerous misuse of suicide statistics. But the sociologists, especially Durkheim (who included very little consideration of the value of his data in Suicide), consistently assumed that the evidence was good enough for the kinds of positivistic (i.e., objective, by definition) analyses they wanted to make. In general, they argued that (a) the stability of the statistics shows that there are no significant errors in them and (b) there are no good reasons to conclude that there are consistent biases in the data, i.e., the errors cancel each other out.

The first argument is based on the mistaken assumption that errors cannot be patterned or stable. Buckle (1857-1861, p. 18) even noted that the frequency of incorrectly addressed letters is extremely stable from year to year without noting the obvious implication for stable suicide statistics. Though contemporary sociologists (especially Americans) who have used the official records on suicide rarely have explicitly considered their value as evidence, they seem generally to have assumed that the second argument given above is correct. The most fundamental reasons for denying the validity of the argument, and therefore the adequate validity of the statistics, are as follows.

(1) It seems quite likely that the official categorizers of suicide in different nations, states, and cities have used different abstract and operational definitions of suicide. We have noted above that the formal definitions of suicide by the students of suicide have varied greatly and in a most complex fashion. But there have been some consistent differences in definitions between groups, such as those between the psychiatrists, the psychologists, and the sociologists. Why would one not expect to find similar consistent differences in the abstract and operational definitions of suicide used by different groups of official categorizers of causes of death? A coroner of a large city who will categorize a cause of death as suicide only if a suicide note is found clearly will produce results consistently different from those of a coroner in another city who uses a different rule-of-thumb definition, such as that there must be an eyewitness report, a clearly perceptible motive, etc. Only “verbal realism” can lead one to assure a priori that the coroner in Lapahaw, Georgia, applies the word “suicide” in a fashion substantially similar to the way the word is applied by the coroner in Los Angeles, California.

(2) It also seems most plausible to assume that there are consistent differences in the abstract and operational definitions of the terms of the different definitions, such as “cause,” “responsible,” “sane,” “death,” and “intention.” For example, some official agencies will not categorize the cause of death as suicide if death occurs three days after the injurious act; and it is worth observing here that all bureaucracies create ad hoc rules of thumb in order to effectively apply general policy to their own particular problems.

(3 ) A great deal of evidence has been presented by Herman Krose, Georg von Mayr, Halbwachs (1930, pp. 19-39), and Achille-Delmas (1932) which has shown both that (a) there are consistent differences in the administrative practices of dealing with suicide (and related categories) and that (b) changes (hence, differences) in administrative practices regarding suicide produce immediate and highly significant changes in suicide rates. Two brief examples are instructive. Halbwachs (1930, pp. 33-34) found that, though a ruling in 1866 made certification of cause of death by a doctor or public health official obligatory throughout France, in fact almost all rural deaths escaped certification; certification of cause of deaths in public places was made by police officials, and certification by family doctor was universally acceptable. He also found that a reform in the Prussian Bureau of Statistics in 1883 produced a 20 per cent stable increase in the suicide rate, beginning in 1884 (Douglas 1965, pp. 259-377).

These and other facts strongly suggest that the relationship between statistical organizations and the suicide rates they produce is subject to the following principle: other things being equal, suicide rates vary directly with the degree of professional medical training of the categorizers, the average rate of man-hours devoted to “cause of death” categorization, and the independence of the categorizers from “interested parties” (for which see below). This general principle leads us to expect, among other things, that (a) urbanization and suicide rates will vary directly; (b) both industrialization and the wealth of populations will vary directly with suicide rates (a possible explanation of the great increase in suicide rates of Europe in the nineteenth century and of developing nations today); and (c) periods of general disorganization or reorganization, such as wars, will produce decreases in suicide rates (because the officials are fewer and have more important things to do). And, in general, these predictions are strongly supported.

(4) The most important set of “other things” that are not equal, and which we must expect to cause great biases in official statistics on suicide, are the various social meanings of suicide, especially as they relate to approval or disapproval. Because of his positivist philosophy, his peculiar theory of “social pathology,” and his theory of “juridical norms,” Durkheim assumed that all groups in Europe were equally against suicide. With the partial exception of the works of Halbwachs (1930) and Cavan (1928), almost all sociological theories of suicide since Durkheim have implicitly assumed the normative definitions of suicide to be both invariant and highly negative. This is a totally fallacious and most unfortunate assumption. In his brilliant study of French attitudes toward suicide, Albert Bayet (1922) conclusively demonstrated that over a long period of time there was a consistently far more negative (even horrified) attitude toward suicide on the part of the “simple,” uneducated population (largely rural) than on the part of the more educated, upper-class population. Such patterned differences in the normative meanings of suicidal actions might produce different frequencies in actual (or real) suicidal actions, but they would seem far more likely to produce differences in the frequency and strength of attempts to conceal suicide both by the suicidal individual and by his significant others. Moreover, one would expect that the more a primary group has to lose from having one of its members socially categorized as a suicide, the greater will be the frequency and strength of attempts to conceal suicide. These two factors make up what can be called a group coefficient of attempted concealment of suicidal actions. We must also expect, however, that different groups will have different coefficients of success in such attempts, the major determinants of which would seem to be degree of social influence and degree of social integration of the group (or individual) making the attempt at concealment. Obviously, these two coefficients could produce many biasing effects on official statistics, the most likely of which seems to be that, given a certain degree of negative normative definition of suicidal action, the degree of social integration of the suicide’s primary group into the general community will vary directly with the coefficient of attempted concealment and with the coefficient of success in attempted concealment. This means, of course, that official statistics on suicide will tend to be biased in such a direction that they will support an integration theory of suicide, such as Durkheim’s.

(5) Over half a century before the publication of Durkheim’s Suicide, Jean-Étienne Esquirol (1838) had established that some methods of committing suicide make valid categorization of the cause of death more difficult. Since, moreover, there seem to be patterned variations between social categories in suicide methods, we must expect biases in official statistics from this source. For example, women use barbiturates and gas far more frequently than do men. Suicides by barbiturates and gas are very difficult to distinguish from accidents. Since such doubtful cases are almost always categorized as “accidental” or “accidental suicide,” we must expect bias in the direction of lower official suicide rates for women.

Two conclusions regarding the official statistics on suicide seem justified: (a) we have little specific, systematic knowledge about the means employed by different statistical bureaus to arrive at these figures; (b) what knowledge we do have about these figures and the means of arriving at them strongly supports our arguments that they are highly biased in certain directions. In general, at the present time there seems to be no adequate justification for using official statistics on suicide to build or test a scientific theory of suicide. There seems to be every reason for not using them (Douglas 1965, pp. 259-377).

Sociology and the official data . Almost every published theory of suicide that has been called sociological has depended on the official statistics on suicide for its testing. This means, of course, that the testing of these theories is subject to all of the biases of the official statistics and therefore cannot generally be accepted.

But this does not necessarily mean that the theories of suicide are themselves wrong. All the so-called sociological theories have been general abstract theories which the authors believed to be applicable to a great variety of social behavior—for instance, to all deviant behavior. These theorists have never derived their general theories from the official statistics, still less from any actual observations of cases of suicide. On the other hand, they have always known from the beginning most of the patterns of suicide shown by the official statistics, so that they have been able to select (no doubt unconsciously) just those patterns for consideration in the testing stage which their theories can “predict.” In spite of rhetorical disclaimers that any such bias exists, the fact remains that all published sociological theories of suicide have been supported at a high level of statistical significance by “tests” using the official statistics on suicide. Moreover, since all of these works after Durkheim’s Suicide have included only the most perfunctory consideration of alternative theories for explaining the same data, there is at present no justification for considering any one theory better than any other, unless one were to consider sophistication of argument an acceptable criterion, in which case Durkheim would hold the field unopposed (Douglas 1965, pp. 112-259).

Major theories of suicide

Durkheim’s sociologistic theory. In Suicide Durkheim was, of course, primarily concerned with proving by demonstration that sociology is a scientific discipline sui generis. The work was a polemic in a great ideological war; and as Halbwachs has said (1930, p. 3), its argumentative power has made it convincing (though, I would add, only to those already convinced of its general position). To achieve his goal of demonstration, Durkheim made use of the mass of published material on suicide statistics, the many statistical relations already established between suicide rates and social relations by the flourishing school of “moral statisticians,” and the methods of analysis developed by Bertillon and many others. Earlier sociologists, especially Morselli (1879), had considered “society,” and in particular the morals of a society, to be the most important cause of a given suicide rate. It was from these previous works that Durkheim took his specific ideas, such as “egoism” and “lack of moral restraint,” about what caused suicide rates to vary. But previous theorists, with the major exception of Quetelet, had proposed multifactored explanations; Durkheim proposed a general synthesis. In general, he took his notion of statistical relations and methods from the moral statisticians and, like many of the moral statisticians before him, turned to the romantics, and the psychologists whom they had influenced, for his fundamental causal variables. Durkheim’s own contribution was to translate “egoism,” “need for an external, moral authority,” and similar psychological variables into “social” (or cultural) variables which he finally reduced to the two opposing moral dimensions of egoism-altruism and anomie-fatalism.

Unfortunately for Durkheim’s ambitious program, Suicide (1897) is an extremely uneven work. The theory presented in Books 1 and 2 is for the most part extremely positivistic, relating external (or “objective”) variables to other external variables. In Book 3, however, the theory is radically different: internal variables are related both to each other and to external variables. The positivistic version is the one usually given primacy by American sociologists (see, for example, Gibbs & Martin 1964); but the later version is the more considered, developed, and tenable theory. The core of the latter is very simple, though its presentation is confused by Durkheim’s penchant for multiple terms (e.g., “disintegration,” “disorder,” “disequilibrium,” “lack of unity or cohesion”), petitio principii, and lack of conceptual clarity. He assumes that for all societies there is some optimal equilibrium or integration of egoism-altruism, on the one hand, and anomie-fatalism, on the other. Any change in the relative strengths of these ideas (or forces) will produce an increase in “social disintegration,” which will lead in turn to an increase in the suicide rate and in the particular type of social relation associated with the “force” that is on the increase. Hence, there is a statistical relation between suicide rates and the incidence of different types of social relations.

The critical flaw in the work is the lack of any means of measuring these forces of egoism, anomie, etc., either independently of each other or independently of a change in suicide rates. Yet Durkheim assumed that these were the fundamentally important variables: any change in suicide rates or social relations meant to him that one or more of the forces was increasing relative to the others. But how did he determine which force was increasing? We must conclude that he inferred it from the associated changes in social relations, and that, for the most part, he assumed he knew from common sense what these changes meant. Unfortunately, the concrete examples Durkheim gives us will not support the notion that his common sense was superior, as a scientific instrument, to anyone else’s (Douglas 1965, pp. 7-112).

The major contribution of Durkheim’s Suicide was its grand conception of the general nature of sociological theory. Durkheim’s intentions in this work went much too far beyond the possibilities of the theory and data of his day—and of ours.

Halbwachs’ theory of suicide. The work of Maurice Halbwachs (1930) began as a supplement to Durkheim’s Suicide but became a radical re-orientation of sociological theory. Halbwachs concluded that Durkheim, in spite of his extensive use of replicative analyses, had overlooked the high degree of overlap of the variables he found to be related to suicide rates. The only fundamentally significant independent relation, Halbwachs argued, is between suicide rates and the degree of complexity of a society: thus, the rural style of life (or sociocultural system) is simpler than the urban and therefore has a lower suicide rate. But Halbwachs also rejected Durkheim’s sociologism. He maintained that there is a complementary relation between the motives imputed to suicides and social situations of isolation. To support his theory, Halbwachs presented the most extensive and thorough analysis of official statistics in all of the sociological literature. As we have already said, however, it seems clear that there is a fundamental bias in the official statistics in the direction of underestimating rural rates (Douglas 1965, pp. 195-209).

Social disorganization theories . Unlike almost all other recent sociological works on suicide, the various “ecological” works on suicide have been done quite outside the tradition initiated by Durk-heim. Ruth Cavan’s Suicide (1928), the first of these works, was predominantly influenced by Morselli. Most ecological studies of suicide have relied heavily on some form of social disorganization theory. Various population variables, such as high mobility and complexity, are hypothesized as the causes of a relative lack of effect of social values on behavior (this being the meaning that “social disorganization” usually has for these writers), which in turn is hypothesized as the cause of suicide and similar deviant acts.

The social disorganization approach to suicide involved certain extreme assumptions which have more recently been shown to be clearly unacceptable. For one thing, it assumed cultural homogeneity of values and behavior patterns, that is, it was taken for granted that all of the many ethnic groups of cities like Chicago shared the same values and behavior practices with regard to any form of “deviance,” such as suicide was thought to be. An extensive literature has attacked this assumption when applied to delinquency, and Bayet (1922) has amassed enough evidence to prove that attitudes toward suicide may vary considerably even in a nation with a supposedly homogeneous culture. The social disorganization approach also assumed that cultural values are the only social meanings that determine rates of suicidal actions. But there is no evidence whatsoever in favor of this assumption—and, indeed, it was contradicted by Cavan’s own arguments concerning the importance of spite and other purely personal motives in causing suicide (Cavan 1928).

Cavan’s work, the earliest of the significant ecological works on suicide in America, did not involve the so-called ecological fallacy (for which see Robinson 1950). In fact, Cavan clearly recognized the fundamental principle involved in this fallacy, even to the extent of criticizing the statistical arguments of Morselli and Durkheim in terms of it (1928, p. 289). Realizing what was needed in order to avoid this fallacy, she did attempt to provide evidence regarding individual cases of suicide. In general, she argued that social disorganization causes individual disorganization, and that the latter manifests itself in patterns of increasing inability to cope with crisis situations. In an attempt to demonstrate the validity of this theory, she presented lengthy selections from the personal documents of two individuals who committed suicide. Though it seems clear now that the attempted demonstration involves an imposition of the general category of “individual disorganization” upon the statements of the individuals, it is also clear that Cavan’s work, which was followed in most important details by that of Schmid (1928), involved more consideration of real cases of suicide than any other sociological work to appear before the later 1960s. Moreover, her material on the case of Marion is still among the best available on real cases of suicide (see the discussion in Douglas 1965, pp. 140-167, 471-483).

Recent sociological theories . Most of the recent sociological theories of suicide have been formulated ostensibly within a Durkheimian content, yet most of them are psychosocial theories that are actually quite different from Durkheim’s.

The one theory that actually seems to be socio-logistic in the Durkheimian manner is that proposed by Gibbs and Martin (1964). This theory, although derived from far too simple an interpretation of Durkheim’s Suicide, is true to its positiv-istic aspect in rejecting any consideration of real cases of suicide and in attempting to relate official statistics on official categories (such as marriage) to official statistics on suicide. The basic idea of the theory is that the more socially integrated (or less “conflictful”) a set of statuses (such as age, race, marital status), the more frequently that set of statuses will be occupied by members of the society and the less frequently it will be associated with suicide. This whole approach suffers from all of the weaknesses already detected in Durkheim’s and from some important additional ones. Thus there is almost no consideration of the real-world (as opposed to official) social meanings of statuses, whereas Durkheim did at least make use of well-informed common sense to provide him with social meanings for the status categories he was interested in analyzing. In addition, the “testing” of the theory involved the analysis of only four of the truly immense number of statuses in our society, and all four of these are the standard categories used in analyses of official data on suicide, so that any sociologist making an analysis of the relations between these categories and suicide rates knows what the relations are before he begins (Douglas 1965, pp. 121-135).

Most of the other recent theories of suicide that purport to be sociological—the most significant is that of Henry and Short (1954)—include psychological variables. They almost all agree that socio-economic status change (or “reverse of fortune,” as Brière de Boismont called it) is the basic sociological cause of suicide, but each proposes a different personality theory (frustration-aggression theory, self theory, loss-of-meaning theory, etc.) to explain why some few individuals commit suicide when confronted with a given status change and almost all others do not. The basic problem is that status change is “significantly” related to an immense number of things. These statistical works never involve any demonstration that other factors are not causing both the supposed cause and the suicide. They rarely include consideration of the many alternative, conflicting theories that purport to explain the same official statistics. They generally involve careful arrangement and choice of data so that statistically “significant” results can be obtained. For example, in the work by Henry and Short (1954), social classes in America are dichotomized into high and low, an arrangement which completely obscures the U-functional relationship almost always found to exist between socioeconomic status and official suicide rates in the Western world. Moreover, theoretical argument in these works is frequently quite divorced from statistical analysis; in some cases, the two can be related only through the addition of many ad hoc assumptions (see, for instance, the analysis of Henry & Short 1954 in Douglas 1965, pp. 209-229). In some of these works, changes in the population bases for the official suicide statistics were actually not taken into consideration. For example, some of the most important analyses made by Henry and Short were for periods during which new states were being added almost each year to the U.S. Death Registration Area. This fact had led Dublin and Bunzel (1933) to use only the original Death Registration Area, but Henry and Short completely overlooked the whole problem.

However, a few of these psychosocial works, as this mingling of psychological and sociological approaches can be called, have introduced valuable new orientations into the study of suicide. Thus Breed’s interviews of the surviving families of individuals who committed suicide (1963) have finally introduced into sociology a research method long established in psychiatry. This method has moved sociologists one step further toward direct observation of real-world cases of suicidal events. Indeed, it has shown them that henceforth they must consider the effects of a suicide on others as part of the suicide phenomenon. The case studies reported by psychologists (Deshaies 1947; Schneider 1954) and the sociocultural studies of suicide made by a few anthropologists and psychiatrists (Devereux 1931; Hendin 1964) make clear what should have been obvious to sociologists long ago: suicidal actions are socially meaningful actions, and individuals commit them in order to communicate something to themselves and others about themselves and about others. Even an individual whose primary goal is a state of nonbeing will not commit suicide unless he can do so in such a way as to communicate, to himself and possibly to others as well, just the right meanings. The empirical study of suicidal actions as socially meaningful— cognitively, affectively, and normatively—opens new directions of highly fruitful research and theory (Douglas 1965, especially pp. 377-543).

Only the most comprehensive observation and description of the everyday actions and statements relevant to suicide are likely to result in scientifically useful empirical and theoretical generalizations concerning suicidal actions as socially meaningful actions. Systematic analyses of existing case studies have, however, already resulted in some very important generalizations concerning the social meanings of suicidal actions in the Western world. The best attempt to generalize about suicide in this way for a non-Western society is by Devereux (1931); there are some important contributions to such an approach in other works (see, for instance, Bohannan 1960).

Perhaps the most important high-level generalization about suicide that can be made at this time is that the situated meanings of suicidal acts are often very different from their abstract meanings. In other words, the meaning of a suicidal act for those who are directly involved with it will very rarely be the same as the meaning it has for those who are not so involved, and will certainly not be the same as for the individual who, by committing suicide, is trying to communicate something (Douglas 1965, pp. 406-440). This finding has two fundamental implications for all investigation of the social meanings of suicide and, perhaps, for all of sociology. First, it is not possible to predict or explain specific types of social events, such as suicide, in terms of abstract social meanings, such as values favoring suicide. Second, it is not possible to study the situated social meanings of suicide, which are most important in its causation, without reference to actual instances of suicidal acts with which the individuals to be questioned have been directly involved. This generalization leads one to question the value of any method for investigating any realm of social action if it attempts to abstract members of society from the involvements of their everyday lives.

This does not imply that there are no patterns of meanings common to all the events that members of a society call “suicide” or “suicidal.” When one looks at the meanings imputed to particular suicidal actions, one does find that certain general features tend to recur. Most importantly, any suicidal action is usually believed to mean something fundamental about the self of the individual committing it, or about the situation (especially the persons involved) in which he committed it, or about both of these. Whether the specific meanings realized will be directed to the actor’s self or to his situation will depend on the imputations of causality made by the various persons in the situation: will they see the individual as the cause of his own actions—that is, as “responsible” for them —or will they see him as having been caused (”driven”) to do them by circumstances (loss of job, family trouble, etc.)? The individual committing the suicidal action often attempts to place one of these two general constructions upon the action by pointing out in some way the external cause that is to be “blamed” for his suicide.

There is no one meaning or set of meanings that can be imputed to all (or even most) suicidal actions. Just what meanings are imputed in each case will depend on (1) the intentions of the various actors; (2) the socially perceived ways in which the actions are committed; (3) the specific patterns of suicidal meanings that are realized; (4) the argument processes before, during, and after the suicidal actions. It should be clearly noted that whether or not actions are socially categorized as “suicidal” depends on precisely the same sort of process. The obvious example is that of individuals who with various ends in mind (avoiding embarrassment to their families, loss of insurance money, or disgrace to themselves), arrange suicides that are designed to be taken for accidents.

It is probably not possible for individuals to construct any meanings they please for their actions, though individual creativity does extend the limits immensely, and all cases include imponderable idiosyncrasies. However, the limits remain. There are, first of all, various criteria of plausibility of motives, or rationality, though it is very likely that in some instances individuals intend their actions to be considered implausible or irrational. Second, a relatively few patterns of situated meaning play important parts in most interpretations of particular suicidal actions, and it therefore seems likely that individuals take these patterns into consideration when attempting to construct the meanings of their actions for others. The most common patterns of this sort in the Western world are those involving such motives as the search for help (Sacks 1966), sympathy, escape, repentance, expiation of guilt, self-punishment, and “seriousness” (Douglas 1965, pp. 440-511).

Much careful description and analysis in this area remain to be done (ibid, pp. 511-540). However, the basic problems and the most appropriate methods for solving them now seem clear, and there is great promise of rapid development in both the empirical and the theoretical study of suicide.

Jack D. Douglas

[See also Deviant behavior; Integration, article onsocial integration; Sociology, article onthe early history of social research; and the biographies ofDurkheim; Halbwachs; Quetelet.]

BIBLIOGRAPHY

Achille-Delmas, FranÇois 1932 Psychologie pathologique du suicide. Paris: Alean.

Bayet, Albert 1922 Le suicide et la morale. Paris: Alean.

BenoÎt-Smullyan, Émile 1948 The Sociologism of Émile Durkheim and His School. Pages 499-537 in Harry Elmer Barnes (editor), Introduction to the History of Sociology. Univ. of Chicago Press.

Bohannan, Paul (editor) 1960 African Homicide and Suicide. Princeton Univ. Press.

Breed, Warren 1963 Occupational Mobility and Suicide Among White Males. American Sociological Review 28:179-188.

BriÈre de Boismont, Alexandre 1856 Du suicide et de la folie suicide. Paris: Baillière.

Buckle, Henry Thomas (1857-1861) 1913 The History of Civilization in England. 2d ed. 2 vols. New York: Hearst.

Cavan, Ruth S. 1928 Suicide. Univ. of Chicago Press.

Dahlgren, Karl G. 1945 On Suicide and Attempted Suicide. Lund (Sweden): Universitets Bokhandel.

Deshaies, Gabriel 1947 La psychologie du suicide. Paris: Presses Universitaires de France.

Devereux, George 1931 Mohave Ethnopsychiatry and Suicide. Washington: Government Printing Office.

Douglas, Jack D. 1965 The Sociological Study of Suicide: Suicidal Actions as Socially Meaningful Actions. Ph.D dissertation, Princeton Univ.

Douglas, Jack D. 1966 The Sociological Analysis of Social Meanings of Suicide. Archives européennes de sociologie 7:249-275.

Douglas, Jack D. 1967 The Social Meanings of Suicide. Princeton Univ. Press.

Dublin, Leonard I.; and Bunzel, Bessie 1933 To Be or Not to Be: A Study of Suicide. New York: Smith & Haas.

Durkheim Émile (1897) 1951 Suicide: A Study in Sociology. Glencoe, 111.: Free Press. → First published in French.

Esquirol, Jean-ÉTIENNE D. (1838) 1845 Mental Maladies. Philadelphia: Lea & Blanchard. → First published as Des maladies mentales considérées sous les rapports médical-hygiéniques et médico-legal.

Gibbs, Jack P.; and Martin, Walter T. 1964 Status Integration and Suicide. Eugene: Univ. of Oregon.

Goethe, Johann Wolfgang Von (1811-1833) 1908 Poetry and Truth From My Life. 2 vols. London: Bell. → First published in German.

Guerry, AndrÉ M. 1833 Essai sur la statistique morale de la France. Paris: Crochard.

Halbwachs, Maurice 1930 Les causes du suicide. Paris: Alean.

Hendin, Herbert M. 1964 Suicide and Scandinavia: A Psychoanalytic Study of Culture and Character. New York: Grune.

Henry, Andrew F.; and Short, James F. JR. 1954 Suicide and Homicide: Some Economic, Sociological and Psychological Aspects of Aggression. Glencoe, 111.: Free Press.

Kruijt, Cornelius S. 1960 Zelfmoord: Statistich-sociologische verkenningen. Suicide: Sociological and Statistical Investigations. Assen (Netherlands): Van Gorcum. → Contains a summary in English.

Legoyt, Alfred 1881 Le suicide ancien et moderne. Paris: Droiun.

Morselli, Enrico (1879) 1882 Suicide. New York: Appleton. → First published in Italian.

Quetelet, Adolphe (1835) 1842 A Treatise on Man and the Development of His Faculties. 2 vols. Edinburgh: Chambers. → First published in French.

Robinson, W. S. 1950 Ecological Correlations and the Behavior of Individuals. American Sociological Review 15:351-357.

Sacks, Harvey 1966 The Search for Help: No One to Turn to. Unpublished manuscript.

Schmid, Calvin F. 1928 Suicides in Seattle, 1914 to 1925: An Ecological and Behavioristic Study. University of Washington, Publications in the Social Sciences, Vol. 5, no. 1. Seattle: Univ. of Washington Press.

Schneider, Pierre-B. 1954 La tentative de suicide. Neuchâtel (Switzerland): Delachaux & Niestlé.

Sthahan, Samuel 1893 Suicide and Insanity. London: Sonnenschein.

SÜssmilch, Johann P. (1741) 1788 Die göttliche Ordnung in den Veränderungen des menschlichen Geschlechts, aus der Geburt, dem Tode und der Fort-pflanzung. 3 vols. Berlin: Verlag der Buchhandlung der Realschule.

Tissot, Joseph 1840 De la manie du suicide et de l’esprit de révolte: De leur causes et de leur remèdes. Paris: Lagrange.

Wagner, Adolf H. G. 1864 Die Gesetzmässigkeit in den scheinbar willkuhrlichen menschlichen Handlungen vom Standpunkte der Statistik. Part 2. Statistik willkuhrlichen Handlungen. Hamburg (Germany): Boyes & Geisler.

II. PSYCHOLOGICAL ASPECTS (1)

The clear definition and meaningful classification of various suicidal phenomena are fundamental to advancements in the treatment, prevention, and investigation of self-destruction in man. The purpose of this article is to present some new conceptions of suicidal phenomena, first by identifying current confusions and then by proposing a taxonomic scheme that attempts to embrace many of the diverse aspects of self-destructive behavior.

Definition

As a beginning, a straightforward definition of suicide might read: “Suicide is the human act of self-inflicted, self-intentioned cessation.” At least five points are to be noted in this brief definition: (1) it states that suicide is a human act; (2) it combines both the decedent’s conscious wish to be dead and his actions to carry out that wish; (3) it implies that the motivations of the deceased may have to be inferred and his behaviors interpreted by others, using such evidence as a suicide note, spoken testimony, or retrospective reconstruction of the victim’s intention; (4) it states that the goal of the action relates to death, rather than to self-injury, self-mutilation, or inimical or self-reducing behaviors; and (5) it focuses on the concept of the cessation of the individual’s conscious introspective life. (An explication of the concept of “cessation” may be found in Shneidman 1964.)

Difficulties of definition. Assuming the validity of the definition of suicide cited above—that a human being, with the intention of stopping his life, inflicts upon himself the equivalent of a mortal wound—the meaning would seem clear enough if it were stated that a certain individual had “committed suicide.” On the other hand, confusions of meaning arise immediately if a specific individual is labeled as “suicidal.” Although suicide seems to be not too difficult to define, suicidal phenomena are, in fact, very complicated. Some of the current confusions relating to the term “suicidal” may be listed as follows.

(1) The word “suicidal” is used indiscriminately to cover different categories of behavior. For example, one cannot be sure whether it is being used to convey the idea that an individual has (a) committed suicide, (b) attempted suicide, (c) threatened suicide, (d) exhibited depressive behavior with or without suicidal ideation, or (e) manifested generally self-destructive or inimical patterns. Of recent writers, Stengel and Cook (1958) especially have emphasized the importance of differentiating specifically between data on attempted suicide and data regarding individuals who have committed suicide. But the fact remains that the classification of suicidal behavior currently most common in everyday clinical and research use is a rather homely, supposedly common-sense division: in its barest form it implies that all humanity can be divided into two groupings, suicidal and nonsuicidal; and then, with seeming meaningfulness, it divides the suicidal category into subgroups of committed, attempted, and threatened. Although this elaboration is more sophisticated than the suicidal-versus-nonsuicidal view of life, it remains neither theoretically nor practically adequate for understanding or treatment.

(2) There is constant confusion in respect to the temporal dimension of suicidal acts. One sees the word “suicidal” used to convey the information that an individual was self-destructive (or manifested behavior in any of the other categories listed immediately above), is currently self-destructive, or will be so. This obviously contains confusions among statements that are postdictive (relating to the past), “paridictive” (relating to the more-or-less present), and predictive (relating to the future). Most diagnoses of individual “suicidality” are post hoc definitions in that they refer to those cases in which an individual is labeled as “suicidal” only after he has committed suicide. Statistics on suicide are, of course, based primarily on post hoc definitions of suicide. The primary difficulty in all such cases lies in determining whether or not the individual actually intended to kill himself. The case of the individual who writes a suicide note and then shoots himself is fairly clear, but many cases of death are unclear or equivocal as to mode of death. For example, in the case of an individual who “jumps or falls” from a high place or who is found dead of barbiturate poisoning, the question is often raised whether the case was suicidal or accidental. The coroner’s traditional concern has been with assessing whether God (natural and accidental deaths) or man (suicidal or homicidal deaths) is responsible. The term “suicide” as used by coroners in the certification of death is a medicolegal term and includes, as a sine qua non, the concept that the person played a major role in bringing about his own demise, that is, that it was his intention to die. It should be obvious that statistics on suicide can be greatly influenced (in any city or country) by the manner in which these equivocal deaths are labeled.

(3) There are confusions relating to the characteristics of suicidal behaviors. In many past and current investigations of self-destructive behaviors, several different dimensions of behavior have unfortunately been thrown together. (If one were, for example, studying homicidal phenomena, it is unlikely that he would fail to differentiate among homicides committed on the highway, in the bedroom, during armed robberies, on the field of battle, etc.—and yet a comparable lack of discrimination has been characteristic of many studies of suicidal phenomena.) These issues also relate to the phenomenologic and semantic confusions in the use of the word “suicidal.” Some individuals who “die by their own hand” do not necessarily “commit suicide.” That is to say, they do not, in their own minds, kill themselves or seek death. Instead of fleeing into a vaguely conceptualized “death,” they behave so as to escape from aspects of life. For some the concept of death, or final cessation of being, does not enter into their thinking. They rather indulge in either a planned or a momentary impulsive act—and termination of life is the result. Then we say that they have “committed suicide,” whereas such an individual might conceivably have left a note which states that “. . . all I did was to swallow those pills ... I just wanted some relief at that moment. . . . The tension was so great I had to do something. ... I did not know what I was doing or what would happen. ... It was a gamble. ... I was desperate.. . .” Operationally, it would seem that the key characteristics of suicidal behaviors do not lie in the differences in method (shooting, sedation, cutting, hanging) but rather in the differences in the individual’s life phase, in the lethality of his acts, and in his intention vis-à-vis death, as indicated below in (4), (5), and (6), respectively. That is, it may very well be that the confusions listed above in (1), (2), and (3) might, in large measure, be avoided by making the very distinctions suggested in the subsequent paragraphs.

(4) Many confusions arise because each individual’s attitudes toward his own death are biphasic: that is, any adolescent or adult, at any given moment, has (a) more or less long-range, pervasive, relatively habitual orientations toward his own death. These characterological orientations are an integral part of his total psychological make-up and reflect his philosophy of life, need systems, aspirations, identifications, conscious beliefs, etc. And he is also capable of having (b) relatively short-lived, acute, fairly sudden shifts of his orientations toward his own death. Indeed, this is what is usually meant when one says that an individual has “become suicidal.” It is therefore crucial in any complete assessment of an individual’s orientations toward his own death to know both his habitual and his current (today’s) orientations. Failure to make this distinction is one reason why many current efforts to relate “suicidal state” to psychological test data or to case-history data have been barren and confusing. For individuals in their “normal” (usual for them) state, their habitual and their current orientations toward their own demise will be the same; for individuals who are acutely disturbed, their current orientations toward their demise will often reflect this perturbation. “Being suicidal” involves being disturbed, although not necessarily psychotic.

(5) Popular accounts of “suicidal” behaviors often focus on the method used (for example, wrist cutting) or on the precipitating cause (ill health, losing money) without regard for one of the key dimensions in the assessment of suicidal behavior, namely lethality. The primary clinical goal of any suicide prevention agency is to keep people out of the coroner’s department. Thus, an individual’s unhappiness, perturbation, loneliness, alcoholism, schizophrenia, homosexuality, depression, etc., are relevant in suicide prevention primarily as they bear on the assessment of his lethality potential. To say that an individual has “threatened” suicide or has “attempted” suicide is relatively uninformative without some indications of the potentialities of a lethal outcome with which the threat or attempt was made. Recently, at the Suicide Prevention Center in Los Angeles specific procedures have been evolved for the rapid assessment of the lethality of an individual’s suicidal potential (see Litman & Farberow 1961; Tabach-nick & Farberow 1961).

(6) The most obfuscating confusions relating to suicidal phenomena may occur if the individual’s intentions in relation to his own cessation are not considered. “Suicide” also has an administrative definition. In the United States (and most of the countries reporting to the World Health Organization), “suicide” defined from the point of view of the coroner or vital statistician is simply one of the four modes of death, the others being natural, accidental, and homicide (N-A-S-H). This traditional fourfold classification of all deaths leaves much to be desired. Its major deficiency is that it emphasizes relatively adventitious details in the death (that is, whether the individual was invaded by a lethal virus or a lethal bullet, which may make little difference to the deceased) and, more important, it erroneously treats the human being as a Cartesian biological machine rather than appropriately treating him as a psychosocial organism, thus obscuring the individual’s intentions in relation to his own cessation. Further, the traditional N-A-S-H classification of deaths completely neglects the concepts of contemporary psychology regarding intention and purpose, the multiple determination of behavior, unconscious motivation, etc.

Much of the problem arises because of a confusion between methods and purpose. Although it is true that the act of putting a shotgun in one’s mouth and pulling the trigger with one’s toe is almost always related to lethal self-intention, this particular isomorphic relationship between method and intent does not hold for most other means, such as ingesting barbiturates or cutting oneself with a razor. Individuals can attempt to attempt suicide, attempt to commit suicide, or attempt to be nonsuicidal. Cessation intentions may range all the way from deadly ones, through the wide variety of ambivalences, rescue fantasies, cries for help, and psychic indecisions, all the way to clearly formulated nonlethal intention in which a semantic usurpation of a “suicidal” mode has been consciously employed.

Deaths classified by intention. As a way out of this impasse it is suggested that all deaths—in addition to their being labeled as natural, accidental, suicide, or homicide—also be designated as intentioned, subintentioned, or unintentioned (Shneidman 1963).

Intentioned deaths. An intentioned cessation is one in which the deceased played a direct, conscious role in his own demise. The death was due primarily to the decedent’s conscious wish to stop his conscious life and to his actions in carrying out that wish. In this category would be individuals who seek their own demise, initiate or participate in their own demise, or take calculated risks where the odds are critically unfavorable to their survival, as in Russian roulette, where the individual bets his life on the objective probability of as few as five out of six chances that he will survive.

Subintentioned deaths. Subintentioned deaths are those in which the deceased played an important indirect, covert, partial, or unconscious role in his own demise. The death is suspected to be due in some part to the actions of the decedent which seemed to reflect his unconscious wishes to hasten his death, as evidenced by his own carelessness, foolhardiness, neglect of self, imprudence, resignation to death, mismanagement of alcohol or drugs, disregard of life-saving medical regimen, brink-of-death patterns, etc. This concept of subintentioned death is similar in some ways to Karl Menninger’s concepts (1938) of chronic suicide, focal suicide, and organic suicide, except that these relate to self-defeating ways of continuing to live, whereas the notion of subintentioned death relates to ways of stopping the process of living.

In terms of the traditional N-A-S-H classification of modes of death, it is important to note that some instances of all four types can be found in the category of subintentioned deaths, depending upon the particular details of each case. There is a growing literature on the role of the individual in his own natural, accidental, suicidal, or homicidal death. Subintentioned deaths involve what might be called the psychosomatics of death, that is, cases in which essentially psychological processes—like fear (including fear of voodoo), anxiety, derring-do, hostility, withdrawal, etc.—seem to play some role in exacerbating the catabolic or physiological processes which bring on termination, as well as those cases in which the individual seems to play an indirect, largely unconscious role in inviting or hastening his own demise [see Psychosomatic Illness; see also Gengerelli & Kirkner 1954; Macdonald 1961; Weisman & Hackett 1961; Weiss 1957; Wolfgang 1959].

It can be noted that the subintentioned death implies more than ambivalence toward wanting to be dead and wishing to be rescued (the to-be-or-not-to-be inner dialogue ) found in practically every suicide. It rather reflects the active indirect (largely unconscious) participation of the individual in hastening his own demise.

Unintentioned deaths. Unintentioned deaths are those in which the deceased played no significant psychological role in his own cessation. The death was due entirely to failures within the body or to assault from without (by a bullet, a blow, a steering wheel, etc.) in a decedent who, rather unambivalently, wished to continue to live. Such a person at the time of his death is, as it were, going about his business (even though he may be lying in the hospital) with no conscious intention or strong drive in the direction of effecting or hastening his demise. What happens is that something from the outside—outside of his mind— happens to him. This lethal “something” may be a cerebral vascular accident, a myocardial infarction, some malfunction, some catastrophic catabolism, some invasion—whether by bullet or by virus—which he did not, in any part, himself generate. “It” happens to “him.”

Practical applications. A practical application of the above schematization of death in terms of the individual’s intention has been made since 1960 in Los Angeles. This procedure, labeled the “psychological autopsy” (Curphey 1961; Litman et al. 1963), has been used in those cases that are equivocal as to mode of death. The procedure consists of the use of especially adapted interview techniques to generate psychological information about the deceased. Survivors, friends, and professional acquaintances of the deceased are interviewed. Clues are sought, especially in relation to the prodromal aspects of suicide. A judgment is made along traditional lines (for example, probable suicide, probable accident, probable natural cause, suicide-accident undetermined, suicide-natural undetermined, etc.). An additional judgment is also made in terms of the intentioned, subintentioned, and unintentioned categories. Although one would, a priori, expect all suicidal deaths to be intentioned and all natural, accidental, and homicidal deaths to be unintentioned, the findings in the Los Angeles procedures indicate that the relationship between traditional modes of death and types of intention is a complicated one, with the crucial role occupied by subintentioned deaths.

It might be protested, inasmuch as the assessments of these intentioned states involve the appraisal of unconscious factors, that some workers (especially lay coroners) cannot legitimately be expected to make the psychological judgments required for this type of classification. To this, one answer would be that medical examiners and lay coroners make judgments of this nature every day of the week. The fact is that in the situation of evaluating a possible suicide, the coroner often acts (sometimes without realizing it) as psychiatrist and psychologist and as both judge and jury in a quasi-judicial way. This is because certification of death as suicide does, in itself, imply some judgments of reconstruction of the victim’s motivation or intention. Making these judgments is an inexorable part of a coroner’s function. It might be much better for these psychological dimensions to be made explicit and for an attempt, albeit crude, to be made to use them, rather than for these psychological dimensions to operate on an unverbalized level.

Theoretical and taxonomic positions

We now turn from our consideration of the definitional problems of suicide to a brief historical resume of the major theoretical and taxonomic positions in relation to suicidal phenomena.

Durkheim and other sociological positions . In this century (or at least since 1897, the date of the publication of Durkheim’s Le suicide) there have been two major approaches to the definition and understanding of suicide: the sociological and the psychological. The former historically is identified primarily with Émile Durkheim, French sociologist (1897). Durkheim was interested not so much in suicidal phenomena per se as he was in the explication of his own sociological method. He used the analysis of suicidal phenomena as the occasion to work out four types of factors in suicide—altruistic, egoistic, anomic, and fatalistic—but discussed only the first three.

There are studies generally classified as “sociological” (in the sense that they present statistical or ecological data, but not in the sense that they follow Durkheim’s interest in explaining the variety of man’s moral commitments to his society) which are worthy of note, among them Sainsbury (1955) and Stengel and Cook (1958) in England, and Dublin (1963) in the United States. Dublin’s book, especially, furnishes the student with an encyclopedia of statistical information about suicide phenomena.

Freudian and other psychological positions . The psychological approach is identified primarily with Freud, who is generally acknowledged to have first stated comprehensive psychological insights into suicide. Freud’s conceptualization of suicide (1917a; 1917b) was that of a primarily intra-psychic phenomenon, stemming from within the mind, primarily the unconscious mind, of the individual. In one of his formulations Freud envisaged suicide as being the result of a process wherein feelings of love and affection which had originally been directed toward an internalized love object had become, as a result of rejection and frustration, angry, hostile feelings; however, because the object had become internalized and part of the self, the hostile feelings were then directed toward the self. Thus suicide, from a psychoanalytic point of view, might be described as murder in the 180th degree.

The classical Freudian approach not only tended rather systematically to ignore social factors but also tended to focus on a single complex or psychodynamic constellation. But we now know that individuals kill themselves for a number and variety of psychologically felt motives: not only hate and revenge, but also dependency, shame, guilt, fear, hopelessness, loyalty, fealty to self-image, pain, and even ennui. Just as no single formula or pattern can be found to explain all human homosexuality or prostitution, so no single psychological pattern is sufficient to contain all human self-destruction. (For a comprehensive review of this topic, see Litman 1967.)

Synthesis—the concept of self. The synthesis of the psychological position, with its clinical emphasis on the individual internal drama within the single mind, and the sociological position, discussed in the previous article, remains to be accomplished. A recent study bearing on this point (Shneidman & Farberow 1960) emphasized the interplay between both the social and psychological factors as mutually enhancing roles in each individual’s suicide. This finding is consistent with that of Halbwachs (1930), whose position—unlike that of his mentor, Durkheim—was that the “social” and “psychopathological” explanations of suicide are complementary rather than antithetical. A synthesis of these two lies in the area of the “self,” especially in the ways in which social forces are incorporated within the totality of the individual. In understanding suicide, one needs to know the thoughts and feelings and ego functionings and unconscious conflicts of an individual, as well as how he integrates with his fellow man and participates morally as a member of the groups within which he lives.

Taxonomic positions . Not many classifications of suicidal phenomena have been proposed. Durk-heim’s classification distinguished between anomic, egoistic, and altruistic suicide (1897). To this can be added Menninger’s classification of the sources of suicidal impulses, namely the wish to kill, the wish to be killed, and the wish to die (1938). Menninger also classified subsuicidal phenomena into chronic suicide (asceticism, martyrdom, addiction, invalidism, psychosis); focal suicide (self-mutilation, malingering, multiple accidents, impotence and frigidity); and organic suicide (involving the psychological factors in organic disease). A composite listing of other rubrics would include the following: suicide as communication; suicide as revenge; suicide as fantasy crime; suicide as unconscious flight; suicide as magical revival or reunion; suicide as rebirth and restitution. A classification of suicidal types in terms of cognitive or logical styles has been proposed (Shneidman 1961). This classification, which stemmed from the logical analysis of suicide notes, divides the thinking styles of suicides into three types: logical, catalogical, and paleological.

Thus, in general, we see that the term “suicidal” is a broad one, starting from a base line of the individual who consciously and advertently takes his own life, through those individuals who by virtue of their unconscious mechanisms hasten their demise, through those individuals who indulge in partial or focal or chronic suicide, and perhaps even to those many individuals who by their own daily inimical acts truncate and diminish the full scope of their potential self-actualizations.

A concluding note concerning the current professional status of suicide prevention: Since 1955 there has been a marked spurt in interest in suicide prevention activities. In the United States, in 1958, there were 3 suicide prevention centers; in 1960, there were 5; in 1964, 9; in 1965, 15; and in 1967, 40. A Center for Studies of Suicide Prevention was established within the National Institute of Mental Health (NIMH) in 1966. A new multidisciplinary profession, suicidology—the scientific and humane study of human self-destruction—has come into being; special training courses in suicidology are offered at Johns Hopkins University.

Edwin S. Shneidman

[See alsoDeath. Other relevant material may be found in Psychoanalysis; Self concept; Medical care; and in the biography of Durkheim.]

BIBLIOGRAPHY

The bibliography for this article is combined with the bibliography of the article that follows.

III. PSYCHOLOGICAL ASPECTS (2)

The continuum of suicidal activity comprises total self-destruction (death); self-injury (but non-lethal), including crippling, maiming, painful and nonpainful activities; threats and other verbalized indications of intention toward self-destruction or self-injury; feelings of despair, depression, and unhappiness (which may not include thoughts of self-injury, but frequently do); and thoughts of separation, departure, absence, and relief and release. Somewhere within this continuum the thought or impulse becomes translated into action. The clinical impression is that once the psychological defenses against suicidal activity have been breached and the action has occurred, the possibility for further future acting out when emotional tension and strain recur is facilitated. It seems likely also that increasingly serious behavior results, possibly because of feelings of guilt or of feelings that such behavior is necessary in order to communicate with equivalent impact. The factor that determines the behavior remains puzzling. Perhaps the controls developed through coping mechanisms and defense patterns, brought to bear at different levels of dysfunctioning (Menninger 1963), play a crucial role, and the intensive study of these might provide the understanding necessary for suicide prevention for different individuals in various suicidal situations.

Characteristics of the suicidal person . The identification of the suicidal person is not especially difficult once the process has begun. Most persons considering self-destruction will identify themselves by communicating this tendency either behaviorally or verbally long before any specific act occurs. The typical suicidal person will generally reveal all or most of the following characteristics: (1) ambivalence—the desire, either conscious or unconscious or both, to live and to die, present at the same time; (2) feelings of hopelessness and helplessness, futility, and inadequacy to handle problems; (3) feelings of either physical or psychological exhaustion, or both; (4) marked feelings of unrelieved anxiety or tension, depression, anger, and/or guilt; (5) feelings of chaos and disorganization with inability to restore order; (6) mood swings, for example, from agitation to apathy or withdrawal; (7) cognitive constriction, inability to see alternatives, limitation of potentialities; (8) loss of interest in usual activities, such as sex, hobbies, and work; (9) physical distress, such as insomnia, anorexia, psychasthenia, and psychosomatic symptoms.

Prediction of lethal behavior . The more difficult problem is the evaluation of the suicidal person in terms of the relatively immediate potentiality of lethal acting out. The suicidal crisis presents the professional person with the need for quick appraisal. A schedule, evolved from experiences in the Suicide Prevention Center in Los Angeles, lists the following criteria used in evaluation of the emergency situation (see Litman & Farberow 1961). (1) Age and sex: older white males generally have the highest suicidal potentiality; a young female, on the other hand, is usually less lethally suicidal. (2) Suicidal plans: specificity about time, place, and method, plus the means for carrying out a plan, indicate high suicidal danger; vague, diffuse talk by a nonpsychotic about dying indicates that the situation is less serious. (3) Resources: external sources of support and interest, such as family, relatives, friends, physician, or hospital, are helpful; when the patient’s resources are exhausted the suicidal potentiality rises. (4) Prior suicidal behavior: a past history of suicidal behavior indicates greater present danger, and the seriousness of the prior suicide attempt adds an additional important consideration. (5) Onset of suicidal behavior: the acute suicidal crisis may be more immediately serious but also more amenable to intervention. The chronically suicidal person, especially the alcoholic or borderline schizophrenic, who presents repeated feelings of depression, is the more serious long-term therapeutic problem. (6) The medical situation: many patients visit physicians with minor physical complaints which are in reality indications of severe depression. Studies (Motto & Greene 1958; Robins et al. 1959; Dorpat & Ripley I960; and Shneidman & Farberow 1961) have indicated that more than 50 per cent of the patients who had committed suicide had seen their physicians within three months prior to their deaths. (7) Loss of a loved one: where death, separation, quarrel, or divorce from someone close has recently occurred, the suicidal potentiality is increased. (8) Communication: if communication still exists between the patient and others the suicidal risk is lowered; when the communication breaks and the person withdraws the danger increases. (9) Reaction of the referring person: if interest and concern about the patient continue, this is helpful. If, however, the referring person is angry, rejecting, and attempting to rid himself of responsibility, the potentiality is increased.

Psychological theories

The psychological theories have been summarized by Jackson (1957), who divided them roughly into nonpsychoanalytic and psychoanalytic.

Nonpsychoanalytic formulations . The nonpsychoanalytic formulations refer to “exhaustion” causing restriction of the field of consciousness so that an “organic depression” occurs; failure of adaptation; a disturbance of balance of will to live from a dynamic fixation of infantile attachment; infantile protest and hostility against harsh, restraining figures; narcissism in a rigid personality; compensations for homicidal impulses against members of the immediate family; and spite in children.

Psychoanalytic formulations . Most of the psychoanalytic theories stern from two of Freud’s theoretical contributions: his elaboration of the dynamics of depression in Mourning and Melancholia (1917b) and his postulations of the death instinct in Beyond the Pleasure Principle (1920). Depression, and consequently suicide, occurs as a result of strong, aggressive urges directed against an introjected object formerly loved but now hated. Menninger (1938) adopts the concept of a death instinct and elaborates it by postulating three elements in suicide: a wish to kill, a wish to be killed, and a wish to die. Zilboorg (1936; 1937) considers suicide a way of thwarting outside forces and one method of gaining immortality. O’Connor (1948) adds the feeling that the person achieves omnipotence by a return to early power narcissism. Palmer (1941) suggests that arrested psychosexual development as a result of the unavailability of important figures at crucial stages is the basic mechanism. Garma (1943) stresses the loss of an important love object, suicide being used to recover it. Bergler (1946) describes the introjec-tion suicide, aggression against guilt feelings; hysteric suicide, unconscious dramatization of how one does not want to be treated; and the miscellaneous type, such as paranoid schizophrenics reacting to voices. Farberow (1961), in the collection The Cry for Help, summarizes his contributors’ several theoretical approaches to suicide. To the formulations already presented above, some of his contributors add frustrated dependency; longing for spiritual rebirth and seeking to re-establish contact with the self by destruction of the ego; strong inferiority feelings and veiled aggression in dependent individuals with “pampered life style”; a depressive, hateful type of personality structure developed from interpersonal experiences; alienation and feelings of disparity between idealized self and real self; and the person’s attempts to validate his self according to his own “constructions.”

Contributing factors

From the variety of theories and multitude of factors in suicide, it is apparent that suicidal phenomena are both widespread and complex. They reflect common sociological roots and influences and, at the same time, express singular personal experiences and impulses. A psychology of suicide must take as many such factors as possible into account if understanding is to be attained. A single schema encompassing the major factors which enter into the understanding of any suicidal event can, as yet, be only a desirable goal. The following factors are necessary considerations in any comprehensive overview of suicidal behavior.

Sociological background . It is obvious that any event needs to be viewed in the setting within which it occurs, but suicide especially has varying significance when it takes place in such widely different countries as, for example, Denmark, Italy, Japan, or the southern part of the United States. National differences are further compounded by racial, religious, and economic factors. Similarities and specific differences will be found. Studies of suicide in some of the tribes of east Africa (Bohannan 1960) and in aboriginal tribes of central India (Elwin 1943) have shown motives remarkably similar to those of Western cultures, for example, domestic strife or loss of social status, as well as features specific to these tribes, such as intervention by the gods or bewitchment by ghosts.

Fluctuations of economic status or the changing political scene influence suicide. For example, suicide has varied with economic depressions, as when the rate soared in the United States during the depression of the mid-1930s and dropped markedly during the war years of the 1940s. An investigation by Arkun (1963) of the suicide rates in Turkey during the periods from 1927 to 1946 (after sweeping social reforms) and 1950 to 1960 (after World War n) showed startling changes in rates which, during the earlier period, could be attributed to the upheavals in the culture of Turkey and especially to the change in the role of women because of the reforms of Ataturk. Japan’s suicide rate has always been high; but whereas in ancient times the traditions of hara-kiri and seppuku were prominent, today much of the suicide rate is contributed to by a younger age group, such as students in universities who are faced with failure or fear of it (Iga 1961).

Cultural background . Cultures often surround death with taboos and rituals which illustrate feelings about death and dying and which include attitudes toward suicide. Myths and folklore illustrate some of the attitudes, as in the history of the Vikings and the tales of Valhalla, and contribute to the condemnation or condoning of suicide.

The culture may also determine interpersonal relationships that influence the occurrence of suicide. Hendin (1964) examines the “Scandinavian suicide phenomenon” and arrives at an explanation for the high suicide rates in Denmark and Sweden in contrast to those in Norway by a determination of the “psychosocial characteristics.” Using psychoanalytic methods, he finds differences in the psychodynamic constellations of the three countries, such as in dependency aspects, attitudes toward performance and accomplishment, handling of aggression and guilt feelings, relationships between the sexes, methods of discipline, and other dynamic features.

Individual demographic characteristics . Epidemiological aspects of suicide, such as age, sex, nationality, race, religion, marital status, education, financial status, have all been studied exhaustively for various countries (Dublin 1963). Where the individual falls in respect to each of these provides immediately invaluable information about the suicidal person. Important to include here also is the physical and mental status of the individual. A chronic, debilitating, or possibly fatal illness such as emphysema, cardiac disease, or cancer, or a recurrent mental illness which hospitalizes the individual for several months every two or three years will obviously influence the individual suicide (Farberow et al. 1963; Shneidman et al. 1962).

Psychological factors . It is within the psychological factors that the core of the problem of understanding suicide is met. These factors include not only the current personality status and psycho-dynamic constellations of the individual in question but also the motivations for his suicidal behavior, the reasons why his actions, thoughts, or feelings lead him to suicide. The categorization of motivations into interpersonal and intrapersonal factors seems to offer a meaningful classification of many of the various phenomena. The distinction is arbitrary, of course, for it is practically impossible for a suicide to occur without both types of relationships being involved. Nevertheless, one or the other aspect will often predominate.

Interpersonal motivations in suicide occur when the suicidal person attempts by his behavior either to bring about an action on the part of another person or persons or to effect a change in attitude or feeling within another person or persons, or both. The suicidal behavior can thus be seen as a means to influence, persuade, force, manipulate, stimulate, change, dominate, reinstate, etc., feelings or behavior in someone else. The other person is most often someone who has been in a close relationship, such as spouse, fiancee, or member of the family. Infrequently, the object of the behavior is more generalized, and it may be society itself.

Interpersonal motivations can be found, of course, in all ages but are usually predominant in the younger and middle-aged groups. A typical example is that of the girl between the ages of 20 and 25 who is reacting with strong feelings of rejection to a quarrel with a loved one or to divorce or separation. Her emotional state is one of agitation, dependency, immaturity, poor judgment, and impulsivity. Her suicidal behavior is used to express anger or feelings of rejection and to force a change in the rebuffing person or to arouse guilt feelings in him. Much of the behavior is still verbal, some is impulsive acting out, and most of it contains an “appeal” element (Stengel & Cook 1958).

Less often the aim is the expiation of or the need to express the guilt the person feels for having done something either imaginary or real in the relationship with another person. Ambivalence about dying is relatively low, inasmuch as the person, despite the fact that he is engaging in suicidal behavior, does not usually wish to die.

Intrapersonal motivations appear most often in older persons and thus in situations in which ties with others have dissipated. The individual’s action seems aimed primarily at expressing the pressures and stresses from within and at fulfilling important needs in himself. The typical person is a male aged 60 or over who has recently suffered the death of a loved one, whose physical condition has deteriorated so that there is illness or pain, or whose children are married and so live their own separate lives. There are intense feelings of loneliness, feelings of not being needed any longer, of no longer being able to work effectively, perhaps because of physical condition, or of feeling that life has been lived and holds no more. The mood is often depressed, withdrawn, and physically and emotionally exhausted. There may be strong need for expiation and for atonement stemming from excessive feelings of guilt. An important dynamic is the need to maintain “psychological integrity” (Appelbaum 1963) or self-esteem or self-concept, even by the paradoxical act of self-destruction. Ambivalence is again low inasmuch as the person, if he embarks on a suicidal course, usually does so with full intent to die. [See Aging, article onpsychological aspects.]

Some cases of suicide occur in which it is difficult to distinguish whether interpersonal or intra-personal motivations are predominant. Rather it seems that each is equally present, although perhaps not always in the same strength at the same time. A typical example is a middle-aged person, the precipitating suicidal stimulus is the death of a loved one, separation, divorce, loss of job, loss of status, or sometimes a crippling, debilitating illness. Such a person is generally depressed, anxious, frustrated, and sometimes agitated, showing poor judgment and disorganization which will sometimes extend to psychotic or near-psychotic proportions. Marked symptoms of frustrated dependency, hostility, and aggression, perhaps because of rejection or masochism, and the two elements “appeal” and “ordeal” are readily seen (Stengel 1956). The ordeal element is especially apparent in the greater ambivalence about dying and the marked tendency to leave survival up to fate, destiny, or chance. Suicidal attempts are usually more lethal, but there are also more provisions for rescue, both conscious and unconscious.

Importance of work. Work takes on special significance for this group. Often with premature dissolution of relationships in the middle-aged group, work becomes the principal source of self-significance and self-esteem. The nonpersonal aspects of the work itself, rather than the people involved with whom interaction on the job occurs, become important. So long as the person is able to function in his job and to lose himself in its details, there is sufficient defense against suicidal impulses. For the very severely and chronically depressed person, work may provide a cover for the feeling of emptiness and void from which he is continually trying to escape. The routine of work keeps him busy and prevents him from thinking about himself. Not to work provides him with time during which he is free to think about himself and to feel useless and empty. Once the work is lost, perhaps through some personal difficulty, physical crisis, or enforced retirement, a crucial defense seems to be breached and suicidal impulses will burst through.

Can any suicide be entirely intrapersonal? One suggestion has been that this may occur only in the psychotic. However, the problem may well be only one of understanding on the part of the observer. The psychotic may be reacting entirely on an interpersonal basis but in a bizarre or devious process which simply is not comprehended by others.

Feelings about death and the afterlife. Most often the individual simply reflects the prevailing attitudes of his culture about suicide, death, or life after death. However, the individual may arrive at his own conceptualizations, which may vary markedly. Convictions of eternal peace after death, of the possibility of reunion with a deceased loved one, visions of hell-fire and brimstone, or of pain and unmitigated suffering, belief in the supernatural, or faith in magic may be key factors in an individual’s suicidal behavior.

Communication . Seen as a communication process, suicidal behavior often achieves clearer perspective. In most instances, the suicidal activity occurs at the end of a long train of events that have finally led the person to the decision that life is no longer worth living. Accompanied by many communications along this course, the suicidal act itself then becomes a communication which may have many meanings and much significance. The communication in suicidal behavior can be grouped under five headings. (1) Form: the communication may be verbal, including written, or nonverbal and behavioral. (2) Directness or indirectness: the communication may be straightforward and clear, or disguised and indirect. Withdrawal, giving away prized possessions, remarks about not needing articles, fantasies of death, burial, or rescue from dangerous situations may occur. (3) Substance or content: the communication may contain expressions of affect, either fixing or expiating guilt or blame, explanations of the suicidal act, or instructions and directions to survivors, as in wills and suicide notes (Shneidman & Farberow 1957a; Tuckman et al. 1959). (4) Object of the communication: in most interpersonal situations, the communication is directed to a specific person or persons; in intrapersonal motivations it is more often directed to society in general. (5) Purpose: the communication may be overt or indirect in aim. Sometimes it is a cry for help, a plea to be stopped or to be rescued, a means for expression of hostility and hate, a final fixing of blame, a way to cause shame or arouse guilt, or a way to assume blame, absolve others, and expiate one’s own guilt.

Countersuicidal controls

The factors that mitigate against suicide are as important as those that influence toward it. In many instances, the fact that self-destruction is not chosen as the way out of seemingly unbearable situations—as in the concentration camps of Germany, or when the individual is subject to continuous pain and discomfort in the terminal stages of cancer—impresses the observer. The controls may be external or internal.

External controls . External controls refer to all the controls that society may bring to bear on an individual to keep him conforming and alive, such as taboos, religion, myths, mores, group and subgroup identifications, marriage, family, children. Also significant are the actions of others toward the individual. Indications of support, understanding, interest, and concern, especially on the part of the “significant other” but also by hospital and professional personnel, may be the essential preventive factor.

Internal controls . Internal controls may stem from the ideals, standards, morality, conscience, or feelings of responsibility of the individual. In addition, the ego structure of the individual may provide him with flexibility, adaptability, independence, and feelings of self-esteem which will permit him to endure severe emotional stress. Or he may be more vulnerable because of rigidity, overdependence, and poor self-concept.

Psychology of the survivors

The suicide has great impact on the survivors, regardless of whether it had predominantly interpersonal or intrapersonal motives. These reactions generally vary directly in intensity with distance of relationship with the suicidal person. Among the group in a close relationship, the spouse, children, family, relatives, close friends, or therapist, a variety of feelings and reactions may be aroused. These may include (1) strong feelings of loss, accompanied by sorrow and mourning; (2) strong feelings of anger for (a) being made to feel responsible, or (b) being rejected in that what was offered was refused; (3) guilt, shame, or embarrassment with feelings of responsibility for the death; (4) feelings of failure or inadequacy that what was needed could not be supplied; (5) feelings of relief that the nagging, insistent demands have ceased; (6) feelings of having been deserted, especially true for children; (7) ambivalence, with a mixture of all the above; (8) reactions of doubt and self-questioning whether enough was attempted; (9) denial that a suicide has occurred, with a possible conspiracy of silence among all concerned; and (10) arousal of one’s own impulses toward suicide.

Among those in a more distant relationship, such as neighbors, employer or fellow employees, the hospital, or society, the reactions may also be those of (1) anger because of (a) a feeling that the suicidal person has rejected his social and moral responsibilities, or (b) being made to feel responsible, or (c) an implied accusation of not enough concern, interest, or caring about its members and fellow man; (2) guilt that not enough was offered to make the person want to live; (3) rejection, resulting from the suicidal person’s obvious choice to do without them; and (4) uneasiness, manifested by a vague need for self-examination to determine what was wrong or to rationalize the discomfort away.

Norman L. Farberow

[See alsoDeath. Other relevant material may be found in Depressive disorders; Medical care; and in the biography of Durkheim.]

BIBLIOGRAPHY

Appelbaum, Stephen A. 1963 The Problem-solving Aspect of Suicide. Journal of Protective Techniques and Personality Assessment 27:259-268.

Arkun, Nezahat 1963 Intiharin psikodinamikleri. Istanbul (Turkey): Baha Matbaasi.

Bergler, Edmund 1946 Problems of Suicide. Psychiatric Quarterly (Supplement) 20:261-275.

Bohannan, Paul (editor) 1960 African Homicide and Suicide. Princeton Univ. Press.

Curphey, Theodore J. 1961 The Role of the Social Scientist in the Medicolegal Certification of Death from Suicide. Pages 110-117 in Norman L. Farberow and Edwin S. Shneidman (editors), The Cry for Help. New York: McGraw-Hill.

Dorpat, Theodobe L.; and Ripley, Hebbert S. 1960 A Study of Suicide in the Seattle Area. Comprehensive Psychiatry 1:349-359.

Dublin, Louis I. 1963 Suicide: A Sociological and Statistical Study. New York: Ronald.

Durkheim, ÉMILE (1897) 1951 Suicide: A Study in Sociology. Glencoe, 111.: Free Press. → First published in French.

Elwin, Verrier 1943 Maria Murder and Suicide. Oxford Univ. Press.

Farberow, Norman L. 1961 Summary. Pages 290-321 in Norman L. Farberow and Edwin S. Shneidman (editors), The Cry for Help. New York: McGraw-Hill.

Farberow, Norman L.; and Shneidman, Edwin S. (editors) 1961 The Cry for Help. New York: McGraw-Hill. → Contains a bibliography on suicide, 1897-1957, on pages 325-388.

Farberow, Norman L.; SHNEIDMAN, E. S.; and Leonard, C. V. 1963 Suicide Among General Medical and Surgical Hospital Patients with Malignant Neoplasms. U.S. Veterans Administration, Medical Bulletin No. 9. Washington: Veterans Administration.

Farberow, Norman L. et al. 1966 Suicide Among Patients With Cardiorespiratory Illnesses. Journal of the American Medical Association 195:422-428.

Freud, Sigmund (1917a) 1959 The Psychogenesis of a Case of Homosexuality in a Woman. Volume 2, pages 202-231 in Sigmund Freud, Collected Papers. International Psycho-analytic Library, No. 10. London: Hogarth; New York: Basic Books.

Freud, Sigmund (1917b) 1959 Mourning and Melancholia. Volume 4, pages 152-170 in Sigmund Freud, Collected Papers. International Psycho-analytic Library, No. 10. London: Hogarth; New York: Basic Books. → Authorized translation from the German under the supervision of Joan Riviere. The first English edition was published in 1925.

Freud, Sigmund (1920) 1950 Beyond the Pleasure Principle. Authorized translation from the 2d ed., by C. J. M. Hubback. International Psycho-analytic Library, No. 4. New York: Liveright. → First published as Jenseits des Lustprinzips. A paperback edition, translated by James Strachey, was published in 1959 by Bantam Books.

Gahma, Angel (1943) 1944 Sadism and Masochism in Human Conduct: Part 2. Journal of Clinical Psycho-pathology and Psychotherapy 6:355-390. → First published in Spanish.

Gengerelli, Joseph A.; and Kirkner, Frank J. (editors) 1954 The Psychological Variables in Human Cancer, A symposium presented at the Veterans Administration Hospital, Long Beach, California, October 23, 1953. Berkeley: Univ. of California Press.

Halbwachs, Maurice 1930 Les causes du suicide. Paris: Alean.

Hendin, Herbert M. 1964 Suicide and Scandinavia: A Psychoanalytic Study of Culture and Character. New York: Gruñe.

Iga, Mamoru 1961 Cultural Factors in Suicide of Japanese Youth With Focus on Personality. Sociology and Social Research 46:75-90.

Jackson, Don D. 1957 Theories of Suicide. Pages 17-21 in Edwin S. Shneidman and Norman L. Farberow (editors), Clues to Suicide. New York: McGraw-Hill.

Kubie, Lawrence S. 1964 Multiple Determinants of Suicidal Efforts. Journal of Nervous and Mental Disease 138:3-8.

Litman, Robert E. 1967 Sigmund Freud on Suicide. Unpublished manuscript.

Litman, Robert E.; and Farberow, Norman L. 1961 Emergency Evaluation of Self-destructive Potentiality. Pages 48-59 in Norman L. Farberow and Edwin S. Shneidman (editors), The Cry for Help. New York: McGraw-Hill.

Litman, Robert E. et al. 1963 Investigations of Equivocal Suicides. Journal of the American Medical Association 184:924-929.

Macdonald, John M. 1961 The Murderer and His Victim. Springfield, 111.: Thomas.

Menninger, Karl A. 1938 Man Against Himself. New York: Harcourt.

Menninger, Karl A. 1963 The Vital Balance: The Life Process in Mental Health and Illness. New York: Viking.

Motto, Jerome A.; and Greene, Clara 1958 Suicide and the Medical Community. Archives of Neurology and Psychiatry 80:776-781.

National Institute OF Mental HealthBulletin of Suicidology. → Published since 1967.

O’Connor, William A. 1948 Some Notes on Suicide. British Journal of Medical Psychology 21:222-228.

Palmer, D. M. 1941 Factors in Suicide Attempts: Review of 25 Consecutive Cases. Journal of Nervous and Mental Disease 93:421-442.

Ridout, Aileen B. 1962 Suicide as a Factor in Public Health. Journal of the Royal Institute of Public Health and Hygiene 25:115-128.

Robins, Eli et al. 1959 The Communication of Suicidal Intent: A Study of 134 Consecutive Cases of Successful (Completed) Suicide. American Journal of Psychiatry 115:724-773.

Sainsbury, Peter 1955 Suicide in London: An Ecological Study. London: Chapman. → A paperback edition was published in 1956 by Basic Books.

Shneidman, Edwin S. 1961 Psycho-logic: A Personality Approach to Patterns of Thinking. Pages 153-190 in Conference on Contemporary Issues in Thematic Apperceptive Methods, Fels Research Institute, 1959, Contemporary Issues in Thematic Apperceptive Methods. Edited by Jerome Kagan and Gerald S. Lesser. Springfield, 111.: Thomas.

Shneidman, Edwin S. 1963 Orientations Toward Death: A Vital Aspect of the Study of Lives. Pages 200-227 in Robert W. White (editor), The Study of Lives: Essays on Personality in Honor of Henry A. Murray. New York: Atherton.

Shneidman, Edwin S. 1964 Suicide, Sleep, and Death: Some Possible Interrelations Among Cessation, Interruption, and Continuation Phenomena. Journal of Consulting Psychology 28:95-106.

Shneidman, Edwin S. (editor) 1967 Essays in Self Destruction. New York: International Science Press.

Shneidman, Edwin S.; and Farberow, Norman L. (editors) 1957a Clues to Suicide. New York: McGraw-Hill.

Shneidman, Edwin S.; and Farberow, Norman L. 1957b Some Comparisons Between Genuine and Simulated Suicide Notes in Terms of Mowrer’s Concepts of Discomfort and Relief. Journal of General Psychology 56:251-256.

Shneidman, Edwin S.; and Farberow, Norman L. 1960 A Socio-psychological Investigation of Suicide. Pages 270-293 in Henry P. David and J. C. Brengelmann (editors), Perspectives in Personality Research. New York: Springer.

Shneidman, Edwin S.; and Farberow, Norman L. 1961 Statistical Comparisons Between Attempted and Committed Suicides. Pages 19-47 in Norman L. Farberow and Edwin S. Shneidman (editors), The Cry for Help. New York: McGraw-Hill.

Shneidman, Edwin S.; Farberow, Norman L.; and Leonard, C. V. 1962 Suicide: Evaluation and Treatment of Suicidal Risk Among Schizophrenic Patients in Psychiatric Hospitals. U.S. Veterans Administration, Medical Bulletin No. 8. Washington: Veterans Administration.

Stengel, Erwin 1956 The Social Effects of Attempted Suicide. Journal of the Canadian Medical Association 74:116-120.

Stengel, Erwin; and Cook, Nancy G. 1958 Attempted Suicide: Its Social Significance and Effects. London: Chapman.

Tabachnick, Norman D.; and Farberow, Norman L. 1961 The Assessment of Self-destructive Potentiality. Pages 60-77 in Norman L. Farberow and Edwin S. Shneidman (editors), The Cry for Help. New York: McGraw-Hill.

Tuckman, Jacob; Kleiner, R. J.; and Lavell, M. 1959 Emotional Content of Suicide Notes. American Journal of Psychiatry 116:59-63.

Weisman, Avery D.; and Hackett, Thomas P. 1961 Predilection to Death: Death and Dying as a Psychiatric Problem. Psychosomatic Medicine 23:232-256.

Weiss, James M. A. 1957 The Gamble With Death in Attempted Suicide. Psychiatry 20:17-25.

Westermabck, Edward A. (1906-1908) 1924-1926 The Origin and Development of the Moral Ideas. 2d ed. 2 vols. London: Macmillan.

Wolfgang, Marvin E. 1959 Suicide by Means of Victim-precipitated Homicide. Journal of Clinical and Experimental Psychopathology and Quarterly Review of Psychiatry and Neurology 20:335-349.

Zilboorg, Gregory 1936 Suicide Among Civilized and Primitive Races. American Journal of Psychiatry 92: 1347-1369.

Zilboorg, Gregory 1937 Considerations in Suicide, With Particular Reference to That of the Young. American Journal of Orthopsychiatry 7:15-31.

SUICIDE

SUICIDE . The topic of religiously motivated suicide is a complex one. Several of the major religious traditions reject suicide as a religiously justifiable act but commend martyrdom; among them are Judaism, Christianity, and Islam. These religions distinguish between actively willing to end one's life in suicide and passively accepting one's death as the divine will by means of martyrdom at the hands of another. Nonetheless, the actions of some of the early Christian martyrs and the deaths of the Jews at Masada in 74 ce blur this distinction.

In contrast to religiously motivated suicide one may speak of heroic and altruistic suicide, the act of a person who decides that he or she has an ethical responsibility to die for the sake of community or honor. One must also differentiate between religiously motivated suicide and suicide that may be virtually forced upon an individual by the norms of society and may constitute either a duty or a punishment. One thinks of satī, widow burning in India, and of seppuku, self-disembowelment, when it occurred as a punishment in Japan. In these cases too, however, no simple distinction holds true. Satī became an accepted practice within medieval Hinduism, upheld by the brahmans, and accounts indicate that even into modern times it was often a voluntary practice. By her self-sacrifice the widow both achieved an honored status for herself and atoned for the sins and misdeeds of herself and her husband. Seppuku was often the voluntary last act of a defeated warrior who chose to demonstrate both his fealty to his lord and his mastery over himself.

Like the major Western traditions, both Buddhism and Confucianism condemn suicide, but there are examples of self-immolation by Buddhist monks and of the seeking of honorable death by Confucian gentlemen. In contrast to these traditions, Jainism regards favorably the practice of sallekhana, by which a Jain monk or layperson at the end of his lifetime or at the onset of serious illness attains death by gradual starvation.

These few examples demonstrate the complexity of the topic of religiously motivated suicide and the difficulty in distinguishing it from martyrdom or sacrifice, on the one hand, and from heroic or altruistic suicide, on the other. In addition, the occurrence in 1978 of the mass suicides at Jonestown, Guyana, raises the question of the relation between religious motivations for suicide and general fear of persecution, combined with mass paranoia. This question applies equally well to the mass suicide of Jews faced with persecution in York, England, in 1190 and to the mass suicides of Old Believers in Russia in the late seventeenth century.

On the whole, what may be termed religiously motivated suicides constitute but a small proportion of the total number of suicides. In his classic work Le suicide, Émile Durkheim discussed the social causes for egoistic, altruistic, and anomic suicides. His work and that of many other scholars demonstrate that suicide has most often occurred for reasons other than religious ones. These include the desire to avoid shame, to effect revenge, to demonstrate one's disappointment in love, and to escape senility and the infirmities of old age. Suicide as a means of avoiding shame and upholding one's honor was considered a creditable act in societies as different as those on the Melanesian island of Tikopia, among the Plains and Kwakiutl Indians of North America, and in ancient Rome.

Scholars have argued that the incidence of and attitude toward suicide are largely dependent on the individual's and society's view of the afterlife. Where death is perceived as a happy existence, scholars such as Jacques Choron believe, there is an inducement to suicide. In the first known document that apparently reflects on suicide, the Egyptian text entitled The Dialogue of a Misanthrope with His Own Soul, death is seen as attractive because it will lead to another and better existence. The tendency toward suicide is strengthened when suicide is regarded either as a neutral act or as one worthy of reward. Suicide rates also increase when this life is regarded as no longer acceptable or worthwhile. For example, Jim Jones, the founder of the Peoples' Temple, urged his followers in Guyana to commit suicide in order to enter directly into a new and better world, where they would be free of persecution and would enjoy the rewards of the elect. In the Jonestown community, suicide on a mass scale was appreciated as a religiously justifiable act that would be rewarded in the afterlife.

Ancient Greek and Roman Civilization

While the ancient Greek writers and philosophers did not consider suicide an action that would lead to a better existence, they did see it as an appropriate response to certain circumstances. The fact that Jocasta, the mother of Oedipus, chose to commit suicide upon learning of her incestuous relationship with her son was understood and appreciated by the ancients as an appropriate response to a disastrous situation. Heroic suicide in the face of a superior enemy and the choice of death to avoid dishonor or the agony of a lengthy terminal illness were accepted as justifiable actions. Through the voice of Socrates, Plato in his Phaedo did much to form the classical attitude toward suicide. Socrates himself chose to drink the hemlock, but he also affirmed the Orphic notions that humans are placed in a prison from which they may not release themselves and that they are a possession of the gods. The decision to commit suicide is thus an act against the gods, depriving them of their prerogative to end or to sustain human life. The key word for both Plato and Socrates is necessity. A person may appropriately end his life only when the gods send the necessity to do so upon him, as in fact they did to Socrates. Plato's disciple, Aristotle, argued even more strongly against suicide. He regarded it as an offense against the state, since by such an act a person fails to perform his obligations as a citizen. Thus it became a social outrage—a view that has continued to dominate thought in the West until the most recent times.

Whereas the Pythagoreans and Epicureans opposed suicide, the Stoics regarded it favorably under certain circumstances. The Stoic was obliged to make a decision that properly addressed the demands of the situation; at times the decision might be to commit suicide. Both Zeno and his successor, Cleanthes, are reported to have done so.

Heroic suicide and suicide to avoid dishonor or suffering became frequent within the society of the Roman empire. Seneca, in particular, moved beyond the insistence on a divine call or necessity for suicide to the assertion that suicide at the appropriate time is a basic individual right. For Seneca, the central issue was freedom, and he affirmed that the divine had offered humankind a number of exits from life; he himself chose to exercise the right to suicide. His successor, Epictetus, placed more limits on suicide, stressing again the belief that one must wait for the divine command before acting: The suffering that is a normal part of daily life for much of humanity does not of itself constitute a sufficient reason for suicide—although exceptional pain and suffering offer justifiable cause. For Epictetus, Socrates was the best model and guide in deciding when one might legitimately choose to end one's life.

Judaism

Whereas suicide was at the very least tolerated, and often applauded, among the ancient Greeks and Romans, the Hebrew people disapproved of it. Judaism draws a clear distinction between suicide, which it defines as self-murder, and martyrdom, which it defines as death on behalf of one's faith and religious convictions. Nonetheless, the Hebrew scriptures, which contain few references to dying by one's own hand, do describe several instances of heroic suicide. The king Abimelech, gravely wounded by a woman, called upon his armor-bearer to kill him (Jgs. 9:52–54). Although he did not literally kill himself, his command to his aide may be regarded as effecting what he could not perform himself, so that he might not die in dishonor. The death of Samson (Jgs. 16:28–31) may certainly be judged a heroic suicide, since by his act he brought about the demise of a large number of the enemy Philistines. The gravely injured Saul fell upon his own sword in order to avoid a disgraceful death at the hands of his enemies (1 Sm. 31:4), and his armor-bearer, who had failed his master's request to kill him, then fell upon his own sword. The death of Ahithophel, the counselor to David and then to David's son Absalom, would appear to be a suicide motivated by disgrace. When Absalom refused to follow the advice Ahithophel gave him regarding his battle with David, Ahithophel returned home, set his affairs in order, and hanged himself (2 Sm. 17:23). The last suicide recorded in the Hebrew scriptures, the death of the king Zimri, occurred because of the loss of a decisive battle (1 Kgs. 16:18).

Although Hebrew scriptures do not explicitly forbid suicide, the Judaic tradition came to prohibit it, partly in the belief that God alone gives life and takes it away, and partly on the basis of the sixth commandment, which forbids unjustified homicide. However, rabbinic law regards persons committing suicide as most frequently being of unsound mind and thus not responsible for their actions. Under these circumstances, they may still receive normal Jewish burial rites. Furthermore, suicides committed under duress, as for example to avoid murder, idolatry, or adultery, were considered blameless and indeed even praiseworthy. The mass suicide at Masada in 74 ce and other mass suicides in Europe during the Middle Ages were considered in this light.

Concerning Masada, the historian Josephus Flavius recounts, on the basis of the report of a few survivors, that on the eve of the Roman assault on that hill the leader of the vastly outnumbered Jewish resistance, Elʿazar ben Yaʾir, called the community together and reminded them of their vow not to become the slaves of the Romans. That night many of the soldiers killed their families and committed suicide. Others drew lots to decide who would kill his fellows and then die by his own hand. It is impossible to say how many of the more than nine hundred defenders allowed themselves to be killed and how many ended their lives by suicide. In spite of the Jewish prohibition against suicide, Masada came to be regarded as a heroic sacrifice, and it remains a living symbol of a people's response to oppression.

Although accounts of individual suicide within Judaism are rare, there are examples of mass suicides during times of persecution. During the First Crusade, in 1096, Jews who had obtained sanctuary in the bishop's castle at Worms chose mass suicide over baptism; similar instances of suicide to avoid baptism occurred in various Rhineland towns, such as Mayence, and in York, England, where in 1190 some 150 Jews set fire to the building in which they had sought safety and then consigned themselves to the flames. Yet other instances of mass suicide occurred during the Black Death, when popular superstition blamed the outbreak of the plague on the Jews. Although abuse and persecution were certainly major motivating factors during the periods of the Crusades and the Black Death, these mass or multiple suicides appear to have arisen from a deep religious desire to remain true to the faith. They point again to the difficulty in distinguishing between, on the one hand, suicides motivated by fear of persecution and, on the other, suicides motivated by religious convictions and ideals, deaths that in the latter case the tradition judges to be acts of martyrdom. Certainly the deaths at Masada must be regarded as both faithful obedience to religious affiliation and identity and the culmination of a desire to give the Jews' enemies a hollow victory.

Christianity

Christianity repudiates suicide on much the same biblical grounds as does Judaism. The only suicide recorded in the New Testament is that of Jesus' betrayer, Judas Iscariot; it is described in such a way as to indicate that it was a sign of repentance for his deed (Mt. 27:3–5). The church father Tertullian referred even to Jesus' death as voluntary—a description approximating that of suicide, since clearly a divine being controls his own life. In his book Conversion (1962), Arthur Darby Nock points to the "theatricality" present in some of the actions of the early martyrs, as in "the frequent tendency of Christians in times of persecution to force themselves on the notice of the magistrates by tearing down images or by other demonstrations" (p. 197). Bishop Ignatius of Antioch, writing to his fellow Christians in Rome, pleaded that they do nothing to hinder his martyrdom but allow him to be consumed entirely by the beasts. But whereas Tertullian asserted that only martyrs would reach paradise before the Parousia, Clement of Alexandria sought to stem the tide of those rushing to martyrdom by differentiating between self-motivated suicide and genuine martyrdom for the faith.

In his City of God, which appeared in 428 ce, the church father Augustine wrote against suicide in a way that became determinative for the tradition. He discussed various situations in which a Christian might find himself or herself, and concluded that suicide is not a legitimate act even in such desperate circumstances as those of a virgin seeking to protect her virtue. Augustine argued that suicide is a form of homicide, and thus prohibited by the sixth commandment; that a suicide committed in order to avoid sin is in reality the commission of a greater sin to avoid a lesser; and that one who commits suicide forfeits the possibility of repentance. Subsequent church councils, as well as such eminent theologians as Thomas Aquinas in the thirteenth century, sided with Augustine. Suicide, in contrast to martyrdom, came to be regarded as both a sin and a crime. Dante placed suicides in the seventh circle of the inferno in his Divine Comedy, and popular opinion throughout Christian Europe regarded suicides in the same light as witches and warlocks. Indeed, their corpses were treated in a similar manner: Suicides were frequently buried at crossroads with stakes driven through their hearts to prevent their ghosts from causing harm. The last recorded instance of such a burial in England occurred in 1823, and the law mandating confiscation of the property of a convicted suicide remained on the books until 1870.

In spite of ecclesiastical censure, religious impulse did lead to suicides, sometimes on a mass scale. Some thirteenth-century Cathari or Albigensians may have chosen suicide by starvation. Even more dramatic are the accounts of the Old Believers (raskolʾniki) in late-seventeenth-century Russia who chose death by fire over obedience to liturgical changes introduced by the archbishop Nikon, with the subsequent backing of the tsars. According to tradition, on several occasions one to two thousand people who had been besieged by government troops, as at Paleostrovskii monastery in 1688, locked themselves within chapels or monasteries and burned them to the ground, consigning their own bodies to the flames.

Although martyrdom as a testimony to one's faith continues to be honored within Christianity, suicide as an individual act undertaken for nonreligious motives is regarded as a sin, and until recently it was regarded as a crime unless done in ignorance of its implications or in a state of lunacy. Few Christian theologians and philosophers challenged this view. John Donne, who served as dean of Saint Paul's in London, was a notable exception. In his book Biathanatos, written in 1608 but not published until 1644, Donne challenged the Augustinian belief that suicides cannot repent; he argued that a totally negative attitude toward suicide places limitations on the mercy and charity of God. New attitudes toward suicide were subsequently expounded by a variety of philosophers such as David Hume, who argued that suicide is not a crime. However, although the Christian attitude toward suicide may now be characterized as more compassionate than during earlier periods, the act of suicide, in contrast to martyrdom, continues to be regarded as a serious sin.

Islam

Islam joined Judaism and Christianity in prohibiting suicide (intiḥār ) while glorifying those who die the death of a martyr (shahīd) or witness to the faith. While scholars debate whether or not the Qurʾān itself specifically forbids suicide, they agree that the ḥadīth, the traditions that preserve the words of the Prophet on a wide variety of issues, prohibit suicide. According to these sources, Muḥammad proclaimed that a person who commits suicide will be denied Paradise and will spend his time in Hell repeating the deed by which he had ended his life. By the tradition's own standards, religiously motivated suicide is an impossibility, since the taking of one's own life is both a sin and a crime. Nonetheless, as with Judaism and Christianity, the line between suicide and martyrdom is not clear. Since it is believed that the Muslim martyr who dies in defense of the faith is rewarded with immediate entrance into Paradise, where he or she will enjoy great pleasures and rewards, it would not be surprising if some Muslims readily participated in battles even when badly outnumbered, in the hope that they might die while fighting.

Within Islam the Shīʿī sect emphasizes the self-sacrifice and suffering of its imams, the successors to Muḥammad. The death of Ḥusayn, the grandson of the Prophet, and the third imam, was regarded by his followers as an act of voluntary self-sacrifice that could be termed a religiously motivated death. Although he died on the battlefield, his death was subsequently interpreted as a goal he both desired and actively sought; the passion play enacted as the climax of ʿᾹshūrāʾ (tenth of Muḥarram) depicts his death as actively willed. In a translation of this play (Muhammedan Festivals, edited by G. E. von Grunebaum, New York, 1951) Husayn says: "Dear Grandfather [Muḥammad], I abhor life; I would rather go visit my dear ones in the next world" (p. 92). Within Shiism, and the Ismāʿīlī sect, Ḥasan-i Sabbāḥ in the twelfth century formed the order of the Assassins, which was devoted to establishing its own religious and governmental autonomy, in part by killing both Crusaders and Sunnī Muslims. The death of a member of this order was regarded not as a suicide, even when his mission had been one almost certain to result in his death, but rather as a glorious martyrdom that would earn him both the veneration of society and the delights of Paradise. The tradition cites many accounts of a mother who rejoiced on hearing of the death of her son, only to put on mourning clothes when she learned subsequently that he had not died and thus had not attained the glorious state of martyrdom.

Hinduism and Jainism

In discussing Judaism, Christianity, and Islam, this article has pointed to the close relationship between suicide and martyrdom and the difficulty frequently encountered in distinguishing between them. Regarding the religions of the East, the difficult issue is the relation between suicide and sacrifice. In Hinduism, the Brāhmaṇas laid the foundation for religiously motivated suicide by declaring that the fullest and most genuine sacrifice is that of the individual's self. The Śatapatha Brāhmaṇa outlines the procedure by which one renounces the world, forsaking one's belongings and departing into the forest. Certainly Hinduism affirms that suicide must be a thoughtful decision—as in the resolve of a person to end the sufferings of old age—or that it must be a religiously motivated act. One Upaniṣad condemns those who attempt suicide without having attained the necessary degree of enlightenment. The Dharmasūtras firmly prohibit any suicide other than one religiously motivated. In ancient and medieval Hinduism a number of methods of committing suicide were regarded favorably, such as drowning oneself in the Ganges, jumping from a cliff, burning oneself, burying oneself in snow, or starving oneself to death. Various places of pilgrimage, such as Prayāga (present-day Allahabad) or Banaras, were seen as particularly auspicious places for ending one's life.

Two types of suicide in Hinduism, very different in form and intention, are worthy of special examination. The first is the death by suicide of the enlightened person, the world renouncer. Such a person, in his or her quest for release from saṃsāra, has been devoted to increasingly difficult acts of penance and to a thorough study of the Upaniṣads. Once this person has attained the goal of freedom from all desires, he or she may begin the great journey in the direction of the northeast, consuming nothing other than air and water. According to the lawgiver Manu, a brahman might also follow this procedure when beginning to be overcome by a serious illness.

The second form of suicide in Hinduism that deserves special attention is satī, widow burning. It appears to have been a form of suicide motivated by both social and religious considerations. Although the custom is not unique to India, it nonetheless was practiced there most frequently and over the longest period of time. The practice may go back as far as the fourth century bce, but it began to grow in popularity only after about 400 ce. According to Upendra Thakur in his study The History of Suicide in India, "satī in its latest forms was a mediaeval growth though it had its germs in ancient customs and rituals" (1963, p. 141). The practice of satī might take one of two forms. In one, sahamaraṇa, the woman ascended the funeral pyre and was burned alongside the corpse of her husband. In the second, anumaraṇa, when the wife learned that her husband had died and his body had already been cremated, she would ascend the pyre and die alongside his ashes, or with some belonging of his. Certainly, at least in some cases, satī was motivated by genuine feelings of grief and affection on the part of the widow. Although the practice remained voluntary, in some areas social pressure may have made satī more the rule than the exception. No doubt the practice also gained popularity because the life of a widow was both lonely and degrading. On the other hand, the blessing or curse of a woman on her way to perform satī was believed to be very powerful, and her act of sacrifice was believed to purify both herself and her husband. Thus, although the act of satī may not always have been religiously motivated, it did have its religious reward. The British, during their rule of India, made a determined effort to abolish the practice, finally outlawing it as homicide in 1829.

Perhaps the tradition that most explicitly condones religiously motivated suicide is Jainism. Following the teaching of their saint Mahavira, who lived in the sixth century bce, the Jain monk and the Jain layperson lead, in differing degrees, a rigorously ascetic life in order to attain liberation and to free the soul from karma. Members of the laity as well as monks are encouraged to practice sallekhanā (austere penance), in order to attain a holy death through meditation. Jains believe it is their duty to prevent disease or the infirmities of old age from undermining the spiritual progress they have attained through asceticism and meditation. Jainism prescribes strict rules for when sallekhanā is appropriate. As Padmanabh S. Jaini indicated in his book The Jaina Path of Purification, Jainism distinguishes between impure suicide, by which the passions are increased, and pure suicide, the holy death attained with "inner peace or dispassionate mindfulness" (Jaini, 1979, p. 229). Sallekhanā involves gradual fasting, often under the supervision of a monastic teacher, until the stage is reached whereat the individual no longer consumes any food or drink and thus gradually attains death by starvation. Jains perceive sallekhanā to be the climax of a lifetime of spiritual struggle, ascetic practice, and meditation. It allows the individual to control his own destiny so that he will attain full liberation or at the very least reduce the number of future reincarnations that he will undergo.

Buddhism and Confucianism

Turning to Buddhism and Confucianism, one finds that suicide is legislated against in both traditions, but that there are notable exceptions involving religiously motivated suicide. Gautama Buddha, in his personal search for salvation, deliberately chose against the practice of fasting unto death. Nonetheless, under certain extraordinary circumstances, Buddhists see religiously motivated suicide as an act of sacrifice and worship. Indications of this positive attitude toward suicide, or self-sacrifice, are found in some of the accounts of the Buddha's previous lives contained in the Jatakas (Birth Tales). The stories of the Buddha's previous lives as a hare (Śaśa Jātaka) and as a monkey (Mahākapi Jātaka) both describe suicide as an act of self-sacrifice to benefit another, and only in the story of the monkey does this act lead to death. Another famous account is that from the Suvarṇaprabhāsa, a Mahāyāna sūtra, which describes the suicide or sacrifice of the Buddha, during his life as the prince Mahāsattva, in order to feed a hungry tigress unable to care for herself. Following this model, Buddhism in its various forms affirms that, while suicide as self-sacrifice may be appropriate for the person who is an arhat, one who has attained enlightenment, it is still very much the exception to the rule.

Confucianism based its attitude toward suicide on another consideration, that of filial piety and obligation. The person who commits suicide robs his ancestors of the veneration and service due them and demonstrates his ingratitude to his parents for the gift of life. The duty of a gentleman is to guide his life according to li, the code or rules of propriety. In rare cases, suicide was required of the gentleman who failed to uphold these rules. In some instances a gentleman might commit suicide to protest improper government, since above all a gentleman was obliged to uphold the virtue of humaneness. Thus, in these unusual instances suicide was the correct way to demonstrate adherence to the precepts of Confucianism.

Although the Japanese tradition of seppuku, or harakiri, should be regarded in its voluntary form as heroic rather than as religiously motivated suicide, it nonetheless does contain certain religious elements. The standard by which all acts of seppuku (disembowelment) were judged was set by the heroic Minamoto Yorimasa during a desperate battle in 1180. While suicide was usually performed as an individual act by a noble warrior or samurai, there are examples in Japanese history of mass suicides, such as that of the forty-seven ronin who accepted the penalty of seppuku in order to avenge the death of their lord in 1703.

While Christian missionaries in Japan, from the time of the arrival of the first Jesuits, sought to prevent seppuku, the Zen Buddhist tradition continued to regard it as a form of honorable death. The selection of the hara, or belly, as the point at which the sword was plunged into the body reflected the belief that the abdomen is the place where one exercises control over one's breathing and is, indeed, the central point of self-discipline. More generally, as Ivan I. Morris states in his book The Nobility of Failure, the abdomen was considered in the Japanese tradition as "the locus of man's inner being, the place where his will, spirit, generosity, indignation, courage, and other cardinal qualities were concentrated" (Morris, 1975, p. 367). Thus, by committing oneself to the performance of seppuku, which became a clearly defined ritual, one demonstrated in this final act the greatest degree of self-control, discipline, and courage.

Conclusion

This article has focused directly on religiously motivated suicide. It has omitted references to suicide among elderly Inuit (Eskimo) and among young Tikopia islanders, to cite only two examples from a vast number of possibilities. In these cases, as in many others, although the suicides may be heroic or altruistic, they do not demonstrate a clear religious motivation. Suicides by reason of financial failure, or loss of honor or of a loved one, occur among the Kwakiutl and Iroquois Indians, as well as among Bantu-speaking peoples of Africa. Occurrences of suicide are not limited by geography or time, but of the many suicides that have taken place throughout the ages, only a small proportion can be judged to be religiously motivated.

The examples of religiously motivated suicide discussed here demonstrate the wide variety of forms and purposes that the act may take. Many of the examples, from both East and West, illustrate the difficulty in distinguishing between suicide that is religiously motivated and suicide that is motivated by heroism, altruism, or fear of persecution and suffering. The deaths at Jonestown in 1978 raise anew the problem of how to differentiate between religiously motivated suicide and suicide induced by paranoia and terror. There is no simple distinction between suicide and martyrdom, on the one hand, or between suicide and sacrifice, on the other. In formulating these distinctions and in evaluating the morality and religious value of certain acts that result in death, each person brings to bear his or her own religious and ethical values and tradition. Such personal judgment must, however, be conjoined with the awareness that what may be perceived by one observer as needless self-sacrifice or even self-murder may be judged by another as the noblest example of religiously motivated suicide in behalf of beliefs, values, or tradition.

See Also

Martyrdom.

Bibliography

There is a vast literature on suicide, but relatively little of it focuses on the act as religiously motivated. Any student of the topic must begin with Émile Durkheim's Le suicide, translated by John A. Spaulding and George Simpson as Suicide: A Study in Sociology (New York, 1951). It is the classic work on the varieties of suicide analyzed from a sociological viewpoint. Jacques Choron's chapters on "Suicide in Retrospect" and "Philosophers on Suicide" in his volume Suicide (New York, 1972) are quite helpful in understanding the place of suicide in the West at different times. A volume edited by Frederick H. Holck, Death and Eastern Thought: Understanding Death in Eastern Religions and Philosophies (Nashville, 1974), contains several chapters that refer to suicide. Alfred Alvarez also discusses the themes of religious motivation for suicide and religious prohibition of the act in his book The Savage God: A Study of Suicide (London, 1971). He includes personal reflections on his own suicide attempt, and describes his friendship with the poet Sylvia Plath, who committed suicide in 1963.

Among the older studies of the topic, still useful are Suicide: A Social and Historical Study by Henry Romilly Fedden (London, 1938) and To Be or Not to Be: A Study of Suicide by Louis I. Dublin and Bessie Bunzel (New York, 1933).

There are relatively few sources that consider religiously motivated suicide in specific traditions. For the Western religious traditions, the reader should refer to the bibliography of the article Martyrdom as well as to the various primary sources mentioned throughout this article. In addition, for Judaism, the reader will find useful Yigael Yadin's Masada: Herod's Fortress and the Zealots' Last Stand (New York, 1966) and Cecil Roth's A History of the Jews in England (Oxford, 1941), which discusses the events at York. On Christianity, particularly informative is Samuel E. Sprott's The English Debate on Suicide from Donne to Hume (La Salle, Ill., 1961). William A. Clebsch has prepared a new edition of John Donne's work, translated as Suicide (Chico, Calif., 1983), with a very helpful introduction. Robert O. Crummey presents a fascinating account of suicides among the Raskolʾniki in his book The Old Believers and the World of Antichrist: The Vyg Community and the Russian State, 1694–1855 (Madison, Wis., 1970). See especially his chapter entitled "Death by Fire." On Islam, the most useful secondary source remains Franz Rosenthal's "On Suicide in Islam," Journal of the American Oriental Society 66 (1946): 239–259. For the Assassins, one should consult the comprehensive historical account by Marshall G. S. Hodgson in The Order of Assassins: The Struggle of the Early Nizârï Ismâʿïlïs against the Islamic World (1955; New York, 1980).

For the Eastern traditions, in addition to the volume edited by Holck and the primary texts mentioned in the article, the following books are useful sources for individual traditions. For Hinduism, see both the older account by Edward Thompson, Suttee: A Historical and Philosophical Enquiry into the Hindu Rite of Widow-Burning (London, 1928), and the more comprehensive study by Upendra Thakur, The History of Suicide in India: An Introduction (Delhi, 1963). For Jainism, Padmanabh S. Jaini offers a detailed account of sallekhanā in his book The Jaina Path of Purification (Berkeley, 1979). The Buddhist account entitled "The Bodhisattva and the Hungry Tigress" may be found in the volume edited by Edward Conze, Buddhist Scriptures (Harmondsworth, 1959). For the Japanese attitude toward suicide and death, see the fascinating work by Ivan I. Morris, The Nobility of Failure: Tragic Heroes in the History of Japan (New York, 1975), and for the study of seppuku among the warrior class, see The Samurai: A Military History by S. R. Turnbull (New York, 1977).

New Sources

Buddhism

Jan, Yün-Hua. "Buddhist Self-Immolation in Medieval China." History of Religions 4 (1965): 243–268. A survey of Chinese Buddhist texts providing justifications of religious suicide.

Lamotte, Etienne. "Le suicide religieux dans le bouddhisme." Bulletin de la Classe des Lettres et des Sciences de l'Académie royale de Belgique 51 (1965). 156–168. A monographic study by the foremost scholar of classic Buddhism.

McCutcheon, Russell. Manufacturing Religion. Oxford, 1997. See the pp. 167–177 for the self-immolations of the Vietnamese Buddhist monks, providing a non-historical political explanation which is unreliable from the religious-historical point of view.

Hinduism

Bosch, Lourens P. van den. "A Burning Question: Sati and Sati Temples as the Focus of Political Interest." Numen 37 (1990): 174–194. The issue is situated in the context of religion's definition.

Weinberger-Thomas, Catherine. Ashes of Immortality: Widow-Burning in India. Chicago, 1999. A radically new interpretation of satī based on fieldwork in northern India as well as extensive textual analysis.

New Cults

Introvigne, Massimo. "The Magic of Death: The Suicides of the Solar Temple." In Millennialism, Persecution, and Violence. Historical Cases edited by Catherine Wessinger. Syracuse, N.Y., 2000, pp. 287–321.

Kabazzi-Kisiniria, S. Deusdedit, R. K. Nkurunziza, and Gerald Banura. The Kanungu Cult-Saga. Suicide, Murder or Salvation? Kampala, Uganda, 2000.

Mayer, Jean-François. Il Tempio Solare. Turin, Italy, 1997.

Nesci, Domenico Arturo. The Lessons of Jonestown. An Ethnopsychoanalytic Study of Suicidal Communities. Rome, 1999. The author is a professional psychoanalyst and psychiatrist but writes as a humanist

Wessinger, Catherine. How the Millenium Comes Violently. From Jonestown to Heaven's Gate. New York and London, 2000.

Islam

Cook, David. "Suicide Attacks or 'Martyrdom Operations' in Contemporary Jihad Literature" Nova Religio: The Journal of Alternative and Emergent Religions. 6, no. 1 (2002): 7–44.

Marilyn J. Harran (1987)

Revised Bibliography

SUICIDE

Philosophical issues concerning suicide arise in a wide range of contemporary end-of-life dilemmas: the withdrawal or withholding of medical treatment; involuntary treatment; high-risk, experimental, and unconventional treatment; euthanasia, assistance, and physician assistance in suicide; requests for maximal treatment; and many others. Although suicide is often popularly understood in a narrower sense of active, pathological self-killing, traditionally abhorred, the underlying issue most broadly conceived concerns the role that individuals may play in bringing about their own deaths.

Two focal issues concerning suicide are evident in these broader dilemmas. First, should suicide be recognized as a right, and if so, under what conditions? On this first question rest the foundations for various applications of the "right to die," as well as a variety of other issues in high-risk and self-sacrificial behavior.

Second, what should the role of other persons be toward those intending suicide? On this second question rest practical, legal, and public-policy issues in suicide prevention and suicide assistance. Both focal issues concerning suicide raise larger questions about the nature of choices to die and the relevance of mental illness, about the role of the state, about conceptual issues in determining what actions are to be counted as suicide, about the role of religious belief concerning suicide, about the possibility of an autonomous choice of suicide, and about the moral status of suicide.

The Incidence of Suicide

The United States exhibits a rate of reported suicide—10.7 per 100,000 year (year 2000 figures)—that falls approximately midway between societies in which reported suicide rates are extremely low, such as the Islamic countries, and those in which reported rates are extremely high, for example, Hungary. In the United States, there are almost 30,000 reported suicides per year and twenty-five times that many reported attempts; it is the eleventh highest cause of death for the U.S. population as a whole, ahead of homicide, the fourteenth highest. This means that, as John L. McIntosh points out, more Americans kill themselves than are killed by others.

Suicide rates are approximately equivalent across socioeconomic groups. Suicide rates are four times higher for males than females, but attempted suicide rates are four times higher for females than males. Attempt rates for whites and blacks are equivalent; rates of death by suicide are twice as high for whites. Suicide is the third leading cause of death for fifteen-to twenty-four-year-olds. For white males, suicide rates increase with age, rising to a peak of 61.7 per 100,000 in the age range eighty-four to eighty-nine; for women, suicide rates peak in midlife and decline thereafter; and elderly black women have the lowest rate of all adult groups, with those eighty-five and above showing the lowest risk (0.04 per 100,000, a rate based on such a low number of deaths that it is considered unreliable). In the United States, suicide rates declined throughout the 1990s and early 2000s—possibly due, among other factors, to the increased availability of antidepressant medications. Nevertheless, the number of deaths remains high. On average, one person commits suicide in the United States every eighteen minutes.

There are no reliable estimates of the number of unreported suicides, particularly those in medical situations involving terminal illness, the very cases that raise the most pressing current ethical issues. Suicide statistics, including those just cited, primarily reflect suicide in the narrower sense of active, pathological self-killing, whereas deaths brought about by refusal of treatment, by self-sacrifice or voluntary martyrdom, by high-risk behavior, or by self-deliverance in terminal illness are rarely described or reported as suicides. Rates of physician-assisted suicide where legal are quite low: In the Netherlands, where both voluntary active euthanasia and physician-assisted suicide are legal, the former comprises approximately 2.4 percent of the total annual mortality and the latter approximately 0.2 percent, figures fairly constant over the sixteen-year period, 1985 to 2001, for which reliable data is available. In Oregon, where physician-assisted suicide has been legal since 1997 under Measure 16, the Oregon Death with Dignity Act, 125 patients used lethal prescriptions provided legally by their physicians during the first five years of the act, representing less than 0.1 percent of the total annual deaths in the state.

Scientific Models of Suicide

Contemporary scientific understandings of the nature of suicide, primarily in the narrower sense, tend to fall into three groups: the "medical" model; the "cry-for-help," "suicidal career," or "strategic" model; and the "sociogenic" model.

THE MEDICAL MODEL. This model, heavily influential throughout most of the twentieth century, has understood suicide in terms of disease: If suicide is not itself a disease, then it is the product of disease, usually mental illness. Suicide is understood as largely involuntary and nondeliberative, the outcome of factors over which the individual has little or no control; it is something that "happens" to the victim. Studies of the incidence of mental illness in suicide often tacitly appeal to this model by attempting to show that mental illness—usually depression, less frequently other mental disorders—is always or almost always present in suicide. This invites the inference that the mental illness or depression "caused" the suicide.

More recent work presupposing the medical model has focused on biological factors associated with suicide, exploring among other findings decreases of serotonin in spinal fluid; drug challenges with fenfluramine; twin studies and other avenues of detecting heritable genetic patterns in families with multiple suicides; and environmental and disease exposures during pregnancy. While work to date remains provisional and in any case establishes correlations rather than causes, it nevertheless points to biological factors that may play a role in suicide.

THE CRY-FOR-HELP MODEL. A second model, developed in the pioneering work of Edwin S. Shneidman and Norman L. Farberow in the 1950s, understands suicide as a communicative strategy: It is a cry for help, an attempt to seek aid in altering one's social environment. Thus it is primarily dyadic, making reference to some second person (or less frequently, an institution or other entity) central in the suicidal person's life. In this view, it is the suicidal gesture that is clinically central; the completed suicide is an attempt that is (often unintentionally) fatal. While the cry for help is manipulative in character, it is also often quite effective in mobilizing family, community, or medical resources to assist in helping change the circumstances of the attempter's life, at least temporarily. Later theorists have developed related models that also interpret suicide attempts as strategic: The concept of suicidal careers interprets an individual's repeated suicide threats and attempts as a method of negotiating the world, though—as for the American poet Sylvia Plath (1932–1963)—an attempt in such a "career" may prove fatal.

THE SOCIOGENIC MODEL. Originally developed by the French sociologist Émile Durkheim (1858–1917) in his landmark work Suicide (1897), the sociogenic model sees suicide as the product of social forces varying with the type of social organization within which the individual lives. "It is not mere metaphor," Durkheim wrote, "to say of each human society that it has a greater or lesser aptitude for suicide, … a collective inclination for the act, quite its own, and the source of all individual inclination, rather than their result" (p. 299). In societies in which individuals are very highly integrated into the society and their behavior is rigorously governed by social codes and customs, suicide tends to occur primarily when it is institutionalized and required by the society (as, for example, in the Hindu practice of sati, or voluntary widow-burning); this is termed altruistic suicide. In societies in which individuals are very loosely integrated into the society, suicide is egoistic, almost entirely self-referential. In still other societies, Durkheim claimed, individuals are neither over-nor underintegrated, but the society itself fails to provide adequate regulation of its members; this situation results in anomic suicide, typical of modern industrial society. In Western societies of this sort, institutionalized suicide has been extremely rare but not unknown, confining itself to highly structured situations: the sea captain who was expected to "go down with his ship" and the Prussian army officer who was expected to kill himself if he was unable to pay his gambling debts.

Like the medical model, the sociogenic model considers suicide to be "caused," but it identifies the causes as social forces rather than individual psychopathology. Like the cryfor-help model, the sociogenic model sees suicide as a responsive strategy, but the responses are not so much matters of individual communication as conformity to social structures and reaction to the social roles a society creates.

Prediction and Prevention

Two principal strategies are employed to recognize the prospective suicide before the attempt: the identification of verbal and behavioral clues and the description of social, psychological, and other variables associated with suicide. Suicide prevention includes alerting families, professionals (especially those likely to have contact with suicidal individuals, such as schoolteachers), and the public generally to the symptoms of an approaching suicide attempt. They are trained to recognize and take seriously both direct warnings(e.g., "I feel like killing myself") and indirect warnings (e.g., "I probably won't be seeing you anymore") and behavior(e.g., giving away one's favorite possessions). They are also encouraged to be especially sensitive to these symptoms in those at highest risk, especially in males, those who are older, live alone, are alcoholic, have negative interactions with important others, are isolated, have poor or rigid coping skills, are less willing to seek professional help, have low religiosity, and have a history of previous suicide attempts—the last of these being a particularly at-risk group. Prevention strategies take a vast range of forms, from the befriending techniques developed by the Samaritans in England and the crisis hot lines widely used in the United States to involuntary commitment to a mental institution. Prevention strategies also include postvention, or post-occurrence intervention, for the survivors—spouse, parents, children, or important others—of a person whose suicide attempt was fatal, because such survivors are themselves at much higher risk of suicide, especially during the first year following the death.

These models of suicide and the associated forms of prediction and prevention are ubiquitous in contemporary medical and psychiatric practice. Yet although suicide has been treated largely as a medical or psychiatric matter, the conceptual, epistemological, and ethical problems it raises have reemerged in two central contexts: that of right-to-die issues in terminal illness and that of political phenomena such as self-sacrifice and suicide terrorism.

Conceptual Issues

The term suicide carries extremely negative connotations. There is little agreement, however, on a formal definition. Some authors count all cases of voluntary, intentional self-killing as suicide; others include only cases in which the individual's primary intention is to end his or her life. Still others recognize that much of what is usually termed suicide neither is wholly voluntary nor involves a genuine intention to die, such as suicides associated with depression or other mental illness. Many writers exclude cases of self-inflicted death that, while voluntary and intentional, appear aimed to benefit others or to serve some purpose or principle—for instance, the Greek philosopher Socrates (c. 470–399 b.c.e.), who drank the hemlock; Captain Lawrence Oates (1880–1912), thean English explorer who, after falling ill during the return trip from an expedition to the South Pole, deliberately walked out into a blizzard to allow his fellow explorers to continue without him; or the Buddhist monk Thich Quang Duc, who immolated himself in the streets of Saigon in June 1963 to protest the Diem regime during the Vietnam war. These cases are usually not called suicide, but self-sacrifice or martyrdom, terms with strongly positive connotations.

However, attempts to differentiate these positive cases from negative ones often seem to reflect moral judgments, not genuine conceptual differences. Conceptual and linguistic framing of a practice plays a substantial role in social policies; for example, supporters of physician-assisted suicide often use the term aid-in-dying as well as earlier euphemisms such as self-deliverance to avoid the negative connotations of suicide, while opponents insist on the more negative term suicide. The term suicide is not used in Oregon's Death with Dignity Act to describe the practice it makes legal, and indeed the statute stipulates: "Actions taken in accordance with this Act shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law" (Section 3.14). In contrast, the U.S. Supreme Court cases Washington v. Glucksberg and Vacco v. Quill (decided jointly in 1997) expressly considered the issue as one involving "suicide." Similarly, Palestinian militants attacking Israeli civilians have been called suicide bombers by their targets and by the Western press, but they are called martyrs by their supporters and those who recruit them for this role.

Cases of death from self-caused accident, self-neglect, chronic self-destructive behavior, victim-precipitated homicide, high-risk adventure, refusal of lifesaving medical treatment, and self-administered euthanasia—all of which share many features with suicide but are not usually termed such—cause still further conceptual difficulty. Consequently, some authors claim that it is not possible to reach a rigorous formal definition of suicide, and prefer a criterial or operational approach to characterizing the term, noting its varied, shifting, and often inconsistent range of uses. Nevertheless, conceptual issues surrounding the definition of suicide are of considerable practical importance in policy formation, affecting, for instance, coroners' practices in identifying causes of death, insurance disclaimers, psychiatric protocols, religious prohibitions, codes of medical ethics, and laws prohibiting or permitting assistance in suicide.

Suicide in the Western Tradition

Much of the extremely diverse discussion of suicide in the history of Western thought has been directed to ethical issues. The Greek philosopher Plato (c. 428–c. 348 b.c.e.) acknowledged Athenian burial restrictions—the suicide was to be buried apart from other citizens, with the hand severed and buried separately—and in the Phaedo, he also reported the Pythagorean view that suicide is categorically wrong. But Plato also accepted suicide under various conditions, including shame, extreme distress, poverty, unavoidable misfortune, and "external compulsions" of the sort that had been imposed on his teacher Socrates by the Athenian court when it condemned him to drink the hemlock. In the Republic and the Laws, respectively, Plato obliquely insisted that the person suffering from chronic, incapacitating illness or uncontrollable criminal impulses ought to allow his life to end or cause it to do so. Plato's pupil, the Greek philosopher Aristotle (384–322 b.c.e.) held more generally that suicide is wrong, claiming that it is "cowardly" and "treats the state unjustly." The Greek and Roman Stoics, in contrast, recommended suicide as the responsible, appropriate act of the wise man, not to be undertaken in emotional distress, but as an expression of principle, duty, or responsible control of the end of one's own life, as exemplified by Cato the Younger (95–46 b.c.e.), Lucretia (sixth century b.c.e.), and Seneca (c. 4 b.c.e.–65 c.e.).

Although Old Testament texts describe individual cases of suicide (Abimilech, Samson, Saul and his armor-bearer, Ahithophel, and Zimri), nowhere do they express general disapproval of suicide. The Greek-influenced Jewish general Josephus (c. 37–c. 100 c.e.), however, rejected it as an option for his defeated army, and clear prohibitions of suicide appear in Judaism by the time of the Talmud during the first several centuries c.e., often appealing to Genesis 9:5, "For your lifeblood I will demand satisfaction." The New Testament does not specifically condemn suicide, and mentions only one case: the self-hanging of Judas Iscariot after the betrayal of Jesus. There is evident disagreement among the early church fathers about the permissibility of suicide, especially in one specific circumstance: Eusebius of Caesarea(c. 260–c. 339), Ambrose (339–397), Jerome (c. 347–c.419), and others all considered whether a virgin may kill herself in order to avoid violation.

While Christian values clearly include patience, endurance, hope, and submission to the sovereignty of God, values that militate against suicide, they also stress willingness to sacrifice one's life, especially in martyrdom, and absence of the fear of death. Some early Christians (e.g., the Circumcellions, a subsect of the rigorist Donatists) apparently practiced suicide as an act of religious zeal. Suicide committed immediately after confession and absolution, they believed, permitted earlier entrance to heaven. Rejecting such reasoning, Augustine (354–430) asserted that suicide violates the commandment "Thou shalt not kill" and is a greater sin than any that could be avoided by suicide. Whether he was simply clarifying earlier elements of Christian faith or articulating a new position remains a matter of contemporary dispute. In any case, it is clear that with this assertion the Christian opposition to suicide became unanimous and absolute.

This view of suicide as morally and religiously wrong intensified during the Christian Middle Ages. Thomas Aquinas (c. 1225–1274) argued that suicide is contrary to the natural law of self-preservation, injures the community, and usurps God's judgment "over the passage from this life to a more blessed one" (Summa theologiae 2a 2ae q64 a5). By the High Middle Ages the suicide of Judas, often viewed earlier as appropriate atonement for the betrayal of Jesus, was seen as a sin worse than the betrayal itself. Enlightenment writers began to question these views. The English statesman Thomas More (1478–1535) incorporated euthanatic suicide in his Utopia (1516). In his Biathanatos (1608, published posthumously in 1647), the English poet John Donne (1572–1631) treated suicide as morally praiseworthy when done for the glory of God—as he claimed was the case for Christ. The Scottish philosopher and historian David Hume (1711–1776) mocked the medieval arguments, justifying suicide on autonomist, consequentialist, and beneficent grounds.

Later thinkers such as the French writer Madame de Staël (Anne-Louise-Germaine, née Necker, the baroness Staël-Holstein, 1766–1817) and the German philosopher Arthur Schopenhauer (1788–1860) construed suicide as a matter of human right—although Mme. De Staë subsequently reversed her position. Throughout this period, other thinkers insisted that suicide was morally, legally, and religiously wrong: Among them, the English evangelist and founder of methodism John Wesley (1703–1791) said that suicide attempters should be hanged, and the English jurist William Blackstone (1723–1780) described suicide as an offense against both God and the King. The German philosopher Immanuel Kant (1724–1804) used the wrongness of suicide as a specimen of the moral conclusions the categorical imperative could demonstrate. In contrast, the Romantics tended to glorify suicide, and the German philosopher Friedrich Nietzsche (1844–1900) insisted that "suicide is man's right and privilege" (Nietzsche, p. 210).

Although religious moralists have continued to assert that divine commandment categorically prohibits suicide, that suicide repudiates God's gift of life, that suicide ruptures covenantal relationships with other persons, and that suicide defeats the believer's obligation to endure suffering in the image of Christ, the volatile discussion of the moral issues in suicide among more secular thinkers ended fairly abruptly at the close of the nineteenth century. This was due in part to Émile Durkheim's insistence (1897) that suicide is a function of social organization, and also to the views of psychological and psychiatric theorists, developing from the French physician Jean Esquirol (1772–1840) to the Austrian neurologist Sigmund Freud (1856–1939), that suicide is a product of mental illness. These new "scientific" views reinterpreted suicide as the product of involuntary conditions for which the individual could not be held morally responsible. The ethical issues, which presuppose choice, reemerged only in the later part of the twentieth century, stimulated primarily by discussions in bioethics of terminal illness and other dilemmas at the end of life.

Suicide and Martyrdom in Religious Traditions

The major monotheisms, Judaism, Christianity, and Islam, all repudiate suicide, though in each martyrdom is recognized and venerated. Judaism rejects suicide but venerates the suicides at Masada, where in May of the year 73 c.e. some 960 Jews trapped in a fortress built on a high rock plateau killed themselves rather than be taken prisoner by the Romans, and accepts kiddush hashem, self-destruction to avoid spiritual defilement. At least since the time of Augustine, Christianity has clearly rejected suicide but accepts and venerates martyrdom to avoid apostasy and to testify to one's faith. Islam also categorically prohibits suicide but at the same time defends and expects martyrdom to defend the faith. Yet whether the distinction between suicide and martyrdom falls in the same place for Judaism, Christianity, and Islam is not clear. Judaism appears to accept self-killing to avoid defilement or apostasy; Christianity teaches passive submission to death when the faith is threatened but also celebrates the voluntary embrace of death in such circumstances; some Islamic fundamentalists support the political use of suicide bombing, viewing it as consistent with Islam and its teachings of jihad, or holy war, though others view this as a corruption of Islamic doctrine. Thus while all three traditions revere those who die for the faith as martyrs and all three traditions formally repudiate suicide, at least by that name, the practices they accept may be quite different: Christians would not accept the mass suicide at Masada; Jews do not use the suicide-bombing techniques of their Islamic neighbors in Palestine; and Muslims do not extol the passive submission to death of the Christian martyrs, appealing on Koranic grounds to a more active self-sacrificial defense of the faith.

Non-Western Religious and Cultural Views of Suicide

Many other world religions hold the view that suicide is prima facie wrong, but that there are certain exceptions. Still others encourage or require suicide in specific circumstances. Known as institutionalized suicide, such practices have included the sati of a Hindu widow, who was expected to immolate herself on her husband's funeral pyre; the seppuku or hara-kiri (suicide by disembowelment) of traditional Japanese nobility out of loyalty to a leader or because of infractions of honor; and, in traditional cultures from South America to Africa to China, the apparently voluntary submission to sacrifice by a king's retainers at the time of his funeral in order to accompany him into the next world. Eskimo, Native American, and some traditional Japanese cultures have practiced voluntary abandonment of the elderly, a practice closely related to suicide, in which the elderly are left to die, with their consent, on ice floes, on mountaintops, or beside trails.

In addition, some religious cultures have held comparatively positive views of suicide, at least in certain circumstances. The Vikings recognized violent death, including suicide, as guaranteeing entrance to Valhalla (the central hall of the afterlife). Some Pacific Islands cultures regarded suicide as favorably as death in battle and preferable to death by other means. The Jains, and perhaps other groups within traditional Hinduism, honored deliberate self-starvation as the ultimate asceticism and also recognized religiously motivated suicide by throwing oneself off a cliff. On Mangareva, members of a traditional Pacific Islands culture also practiced suicide by throwing themselves from a cliff, but in this culture not only was the practice largely restricted to women, but a special location on the cliff was reserved for noble women and a different location assigned to commoners. The Maya held that a special place in heaven was reserved for those who killed themselves by hanging (though other methods of suicide were considered disgraceful), and they recognized a goddess of suicide, Ixtab. Many other pre-Columbian peoples in the western hemisphere engaged in apparently voluntary ritual self-sacrifice, notably the Aztec practice of heart sacrifice, which was generally characterized at least during some historical periods by enhanced status and social approval. The view that suicide is intrinsically and without exception wrong is associated most strongly with post-Augustinian Christianity of the medieval period, surviving into the present; this absolutist view is not by and large characteristic of other cultures.

Contemporary Ethical Issues

Is suicide morally wrong? Both historical and contemporary discussions in the Western tradition exhibit certain central features. Consequentialist arguments tend to focus on the damaging effects a person's suicide can have on family, friends, coworkers, or society as a whole. But, as a few earlier thinkers saw, such consequentialist views would also recommend or require suicide when the interests of the individual or others would be served by suicide. Deontological theorists in the Western tradition have tended to treat suicide as intrinsically wrong, but, except for Kant, are typically unable to produce support for such claims that is independent of religious assumptions. Contemporary ethical argument has focused on such issues as whether hedonic calculus of self-interest—weighing pleasures and pains, or benefits against harms—in which others are not affected, provides an adequate basis for an individual's choice about suicide; whether life has intrinsic value sufficient to preclude choices of suicide; and whether any ethical theory can show that it would be wrong, rather than merely imprudent, for the ordinary, nonsuicidal person, not driven by circumstances or acting on principle, to end her life.

Epistemological Issues

Closely tied to conceptual issues, the central epistemological issues raised by suicide involve the kinds of knowledge available to those who contemplate killing themselves. The issue of what, if anything, can be known to occur after death has, in the West, generally been regarded as a religious issue, answerable only as a matter of faith; few philosophical writers have discussed it directly, despite its clear relation to theory of mind. Some writers have argued that because we cannot have antecedent knowledge of what death involves, we cannot knowingly and voluntarily choose our own deaths; suicide is therefore always irrational. Others, rejecting this argument, instead attempt to establish conditions for the rationality of suicide. Others consider whether death is always an evil for the person involved, and whether death is appropriately conceptualized as the cessation of life. Still other writers examine psychological and situational constraints on decision making concerning suicide. For instance, the depressed, suicidal individual is described as seeing only a narrowed range of possible future outcomes in the current dilemma, the victim of a kind of tunnel vision constricted by depression. The possibility of preemptive suicide in the face of deteriorative mental conditions such as Alzheimer's disease is characterized as a problem of having to use the very mind that may already be deteriorating to decide whether to bear deterioration or die to avoid it.

Public-Policy Issues

It is often, though uncritically, assumed that if a person's suicide is rational, it ought not to be interfered with or prohibited. This assumption, however, raises policy issues about the role of the state and other institutions in the prevention of suicide.

RIGHTS AND THE PREVENTION OF SUICIDE. In the West, both church and state have historically assumed roles in the control of suicide. In most European countries, ecclesiastical and civil law imposed burial restrictions on the suicide as well as additional penalties, including forfeiture of property, on the suicide's family. European attitudes and legal sanctions concerning suicide were translated into colonial societies as well, for example in India, Africa, and various Pacific Islands. In England, suicide remained a felony until 1961, and in Canada until 1971. Suicide has been decriminalized in most of the United States and in England, primarily to facilitate psychiatric treatment of suicide attempters and to mitigate the impact on surviving family members; in most U.S. states, however, assisting another person's suicide is a violation of statutory law, case law, or recognized common law. In Germany assisting a suicide is not illegal, provided the person whose death it will be is competent and acting voluntarily; in the Netherlands, physician-assisted suicide is legal under the same guidelines as voluntary active euthanasia: In Switzerland, assisted suicide is legal if it is done without self-interest on the part of the assister; and in Belgium, physician-performed voluntary active euthanasia is legal but physician-assisted suicide is not. Ongoing ferment characterizes the legal status of physician-assisted suicide in many countries.

Building on Shneidman and Farberow's early work, suicide-prevention strategies have been enhanced by considerable advances in the epidemiological study of suicide, in the identification of risk factors, and in forms of clinical treatment. Suicide-prevention professionals welcome increased funding for education and prevention measures targeted at youth and other populations at high risk of suicide. Nevertheless, philosophers are increasingly alert to the more general theoretical issues these strategies raise, for example, the effect of high false-positive rates on the right to avoid unjustified coercion. Restrictions to prevent suicide—such as involuntary incarceration in a mental hospital or suicide precautions in an institutional setting—typically limit liberty, but because the predictive measures of suicide risk that are available are neither perfectly reliable nor perfectly sensitive, they identify some fraction of persons as potential suicides who would not in fact kill themselves and fail to identify others who actually will. There are two distinct issues here. First, how great an infringement of the liberty of those erroneously identified is to be permitted in the interests of preventing suicide by those correctly identified? Second and more generally, can restrictive measures for preventing suicide be justified at all, even for those who will actually go on to commit suicide? Civil rights theorists are generally disturbed by the first of these problems, libertarians by the second.

Although U.S. law does not prohibit suicide, suicide has not been recognized as a right. There has been considerable pressure from right-to-die groups in favor of recognizing a broad right to self-determination in terminal illness not only by refusal of life-prolonging treatment but also by bringing about one's own death. In the Washington v. Glucksberg and Vacco v. Quill cases, the U.S. Supreme Court ruled unanimously that there was no constitutional right to assisted suicide, though the Court's ruling did not prohibit states from establishing laws that would legalize it. Cases such as these, however, tend to conflate the notion of a negative right to assistance in suicide, which would prohibit interference when a willing physician wished to provide assistance to a patient, with the far more controversial notion of a positive right to assistance in suicide—something that would give patients a claim to be provided with help from physicians when they sought it.

Other rights issues raised by suicide include, for example, freedom of expression. When Hemlock Society president Derek Humphry's Final Exit—a book addressed to the terminally ill that provided explicit instructions on how to commit suicide, including lethal drug dosages—was published in the United States in 1991 and sold over half a million copies, its publication was protected on the grounds of freedom of expression; yet in several other countries, including France and Australia, Final Exit was banned. More recent controversy surrounds web sites that provide explicit how-to information about suicide, including how to do so using readily available materials, and internet chat rooms that encourage or dare visitors to kill themselves.

PHYSICIAN-ASSISTED SUICIDE. Although issues of the permissibility of suicide generally have been the focus of sustained historical discussion, contemporary public-policy debate tends to focus on a narrower, specific issue: that of physician-assisted suicide, usually coupled with the question of voluntary active euthanasia. There are two principal arguments advanced for the legalization of these practices. First, claims about autonomy appeal to a conception of individuals as entitled to control as much as possible the course of their own dying. To restrict the right to die to the mere right to refuse unwanted medical treatment and so be allowed to die, this argument holds, is an indefensible truncation of the more basic right to choose one's death in accordance with one's own values. Thus, advance directives, such as living wills and durable powers of attorney, "do not resuscitate" (DNR) orders, and other mechanisms for withholding or withdrawing treatment, are inadequate to protect fundamental rights. Second, arguments for the legalization of physician-assisted suicide, usually together with arguments for voluntary euthanasia, involve an appeal to what is variously understood as mercy or nonmaleficence. Because not all terminal pain can be controlled and because suffering encompasses an even broader, less controllable range than pain, it is argued, it is defensible for a person who is in irremediable pain or suffering to choose death if there is no other way to avoid it.

Two principal arguments form the basis of the opposition to legalization of these practices. The first is that killing (in both suicide and euthanasia) is simply morally wrong, and hence wrong for doctors to facilitate or perform. The second argument is that legalization would invite a "slippery slope" leading to involuntary killing. The slippery slope argument contends, among other things, that permitting assistance in suicide or the performance of euthanasia would make killing "too easy," so that doctors would turn to it for reasons of bias, greed, impatience, or frustration with a patient who was not doing well; that it would set a dangerous model for disturbed younger persons who were not terminally ill; and that, in a society marked by prejudice against the elderly, the disabled, racial minorities, and many others, and motivated by cost considerations in a system that does not guarantee equitable care, "choices" of death that were not really voluntary would be imposed on vulnerable persons. Suicide in these circumstances would become a matter of social expectation or imperative. The counterargument for legalization replies that more open attitudes toward suicide would reduce psychopathology by allowing more effective counseling, and that by bringing practices that have always gone on in secrecy out into the open—and hence under adequate control—legalization would provide the most substantial protection for genuine patient choice.

Data from the Netherlands, where physician-assisted suicide and voluntary active euthanasia have been legally tolerated since the mid-1980s and are now legal, and from Oregon, where physician-assisted suicide became legal in 1997, do not support claims about a slippery slope, though full legalization is comparatively recent in both. In both only a very small fraction of patients who die actually die with physician assistance. Most are patients with cancer: 75 percent in the Netherlands, 79 percent in Oregon. Even so, of patients with cancer, the vast majority of those who die in either the Netherlands or Oregon do not die with this form of assistance. There is no evidence of disparate impact on groups of patients understood as vulnerable—the elderly, the poor, people with disabilities or with developmental delays, and others, although prior to the development of the protease inhibitors, was high for people with AIDS. Pain has not been the central issue; rather, most patients who have elected physician assistance in dying have done so, according to family members, physicians, and hospice caregivers, to avoid deterioration and loss of control over their circumstances. In Oregon, for example, the most frequently reported concerns by patients who died in 2001 included loss of autonomy (94%), decreasing ability to participate in activities that make life enjoyable (76%), and loss of control of bodily functions (53%); inadequate pain control and the financial implications of treatment were mentioned by just 6 percent each.

Particularly relevant to public-policy discussions is the contention of some contemporary writers that suicide will become "the preferred way of death" because it allows control over the time, place, and circumstances of dying. Others claim that as pain control in terminal illness improves, interest in physician-assisted euthanatic suicide will disappear. These may seem to be mere predictive claims. But in the technologically developed nations, where the epidemiologic transition in causes of death now means that the majority of the population will not die of parasitic and infectious disease, as was the case in all societies until the middle of the nineteenth century and is still the case in many less developed nations, but will die of late-life degenerative diseases with prolonged downhill courses, these claims may seem to harbor quite different normative visions of the roles people may—and should—play in their own deaths. One now faces a death that is comparatively predictable and prolonged, often perceived as burdensome to oneself and to those one loves.

Several particularly contentious issues have been raised in view of these facts. One concerns the question of whether a person can have a "duty to die." Some theorists have argued that as the burdens and costs of terminal care increase, both to the patient and to the family, a person becomes obligated to end his life; other commentators find this claim repugnant, an example of the kind of thinking that would fuel a slide down the slippery slope. Resolution of this issue rests on whether an individual's preferences and personal sense of concern for and obligation to family or others can be disentangled from social expectations about costs and savings.

Another issue of growing philosophical concern is that of suicide in old age, for reasons of old age alone rather than illness that accompanies old age. Despite extensive discussion among the Stoics of this matter—they held it to be a reasonable choice—and despite the prospects of vastly extended life expectancies of people in advanced industrial societies, such matters as preemptive suicide to avoid the deterioration of old age have been very little discussed.

Nor has the issue of altruistic suicide, not only in order to spare healthcare costs or other burdens for family members or others, but also in situations such as political protest and military strategy, received adequate philosophical analysis. In situations in which individuals committing suicide believe themselves to be acting for the common good, even at extreme personal sacrifice, is suicide—though it might be labeled with such euphemisms as martyrdom or heroism—morally acceptable or even praiseworthy? Such issues will form the basis for some of the many ethical challenges concerning suicide to be faced in future years.

margaret pabst battin (1995)

revised by author

SEE ALSO: Aging and the Aged: Old Age; Autonomy; Death; Dementia; Emotions; Human Rights; Life, Quality of; Life Sustaining Treatment and Euthanasia; Medical Codes and Oaths; Medical Ethics, History of Europe; Mental Illness: Conceptions of Mental Illness; Mental Institutions, Commitment to; Natural Law; Pain and Suffering; Pastoral Care and Healthcare Chaplaincy

BIBLIOGRAPHY

Alvarez, Albert. 1971. The Savage God: A Study of Suicide. London: Weidenfeld and Nicolson.

Baechler, Jean. 1979. Suicides, tr. Barry Cooper. Oxford: Basil Blackwell.

Barraclough, Brian M. 1992. "The Bible Suicides." Acta Psychiatrica Scandinavia 86(1): 64–69.

Battin, Margaret Pabst. 1982. Ethical Issues in Suicide. Englewood Cliffs, NJ: Prentice-Hall.

Battin, Margaret Pabst. 1994. The Least Worst Death: Essays in Bioethics on the End of Life. New York: Oxford University Press.

Battin, Margaret Pabst, and Maris, Ronald W., eds. 1983. "Suicide and Ethics." Special issue of Suicide and Life-Threatening Behavior 13(4).

Battin, Margaret Pabst, and Mayo, David J., eds. 1980. Suicide: The Philosophical Issues. New York: St. Martin's Press.

Battin, Margaret P.; Rhodes, Rosamond; and Silvers, Anita, eds. 1998. Physician-Assisted Suicide: Expanding the Debate. New York: Oxford University Press.

Beauchamp, Tom L. 1996. Intending Death: The Ethics of Assisted Suicide and Euthanasia. Upper Saddle River, NJ: PrenticeHall.

Brock, Dan W. 1993. Life and Death: Philosophical Essays in Biomedical Ethics. Cambridge, Eng.: Cambridge University Press.

Brody, Baruch A., ed. 1989. Suicide and Euthanasia: Historical and Contemporary Themes. Dordrecht, Netherlands: Kluwer.

Daube, David. 1972. "The Linguistics of Suicide." Philosophy and Public Affairs 1(4): 387–437.

Donne, John. 1982. Biathanatos, ed. Michael Rudick and Margaret Pabst Battin. New York: Garland.

Droge, Arthur J., and Tabor, James D. 1992. A Noble Death: Suicide and Martyrdom among Christians and Jews in Antiquity. San Francisco: HarperCollins.

Durkheim, Émile. 1951. Suicide: A Study in Sociology, tr. John A. Spaulding, ed. George Simpson. New York: Free Press.

Emanuel, Linda L., ed. 1998. Regulating How We Die: The Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide. Cambridge, MA: Harvard University Press.

Fedden, Henry Romilly. 1938. Suicide: A Social and Historical Study. London: Peter Davies.

Hardwig, John. 1997. "Is There a Duty to Die?" Hastings Center Report 27(2): 34–42.

Hume, David. 1777 (reprint 1963). "Of Suicide." In Essays: Moral, Political, and Literary, ed. T. H. Green and T. H. Grose. London: Oxford University Press.

Humphry, Derek. 1991, 1996, 2002. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Eugene, OR: National Hemlock Society. 2nd edition, New York: Dell. 3rd edition, New York: Delta.

Humphry, Derek, with Wickett, Ann. 1978. Jean's Way. London: Quartet Books.

Kant, Immanuel. 1980. Lectures on Ethics, tr. Louis Infield. Indianapolis, IN: Hackett.

Kant, Immanuel. 1983. Ethical Philosophy: The Complete Texts of the Grounding for the Metaphysics of Morals, and Metaphysical Principles of Virtue, Part II of the Metaphysics of Morals, tr. James W. Ellington. Indianapolis, IN: Hackett.

Kant, Immanuel. 1993. The Critique of Practical Reason, tr. Lewis White Beck. 3rd edition. New York: Macmillan.

Landsberg, Paul-Louis. 1953. The Experience of Death; The Moral Problem of Suicide, tr. Cynthia Rowland. New York: Philosophical Library.

Maris, Ronald W.; Berman, Alan L.; and Silverman, Morton M. 2000. Comprehensive Textbook of Suicidology. New York: Guilford Press.

Minois, George. 1999. History of Suicide: Voluntary Death in Western Culture, tr. Lydia G. Cochrane. Baltimore: Johns Hopkins University Press.

Murray, Alexander. 1998. Suicide in the Middle Ages, vol. 1: The Violent against Themselves. Oxford: Oxford University Press.

Nietzsche, Friedrich. 1953 (1881). The Dawn of Day (Morgenrote), p. 210. Stuttgart: Kroner Verlag.

Perlin, Seymour, ed. 1975. A Handbook for the Study of Suicide. Oxford: Oxford University Press.

Prado, Carlos G. 1990. The Last Choice: Preemptive Suicide in Advanced Age. Westport, CT: Greenwood.

Putnam, Constance E. 2002. Hospice or Hemlock? Searching for Heroic Compassion. Westport, CT: Praeger.

Quill, Timothy E. 1996. A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life. Balti-more, MD: Johns Hopkins University Press.

Seneca, Lucius Annaeus. 1920. "Letter on Suicide" and "On the Proper Time to Slip the Cable." In Ad Lucilium Epistulae Morales, tr. Richard M. Gummere. London: W. Heinemann.

Shneidman, Edwin S., ed. 1976. Suicidology: Contemporary Developments. New York: Grune and Stratton.

Shneidman, Edwin S., and Farberow, Norman L., eds. 1957. Clues to Suicide. New York: McGraw-Hill.

Sprott, Samuel E. 1961. The English Debate on Suicide: From Donne to Hume. La Salle, IL: Open Court.

Thomasma, David C.; Kimbrough-Kushner, Thomasine; Kimsma, Gerrit K.; et al., eds. 1998. Asking to Die: Inside the Dutch Debate about Euthanasia. Dordrecht, Netherlands: Kluwer.

van der Maas, Paul J.; van der Wal, Gerrit; Haverkate, Ilinka; et al. 1996. "Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990–1995." New England Journal of Medicine 335(22): 1699–1705.

INTERNET RESOURCES

McIntosh, John L. 2003. "Recent Suicide Statistics." Available from <http://www.iusb.edu/˜jmcintos/>.

Onwuteaka-Philipsen, Bregje D.; van der Heide, Agnes; Koper, Dirk; et al. 2003. "Euthanasia and Other End-of-Life Decisions in the Netherlands in 1990, 1995, and 2001," The Lancet 361. Available from <http:/image.thelancet.com/extras/03art3297webpdf>.

Oregon Department of Health Services. "Death with Dignity Act." Available from <http://www.dhs.state.or.us/publichealth/programs.cfm>.

van der Heide, Agnes; Deliens, Luc; Faisst, Karin; et al., on behalf of the EURELD consortium. 2003. "End-of-life Decision-Making in Six European Countries: Descriptive Study." The Lancet Available from <http://image.thelancet.com/extras/03art3298web.pdf>.

SUICIDE

What role may a person play in the end of his or her own life? Is suicide wrong, always wrong, profoundly morally wrong? Or is it almost always wrong, but excusable in a few cases? Or is it sometimes morally permissible? Is it not intrinsically wrong at all though perhaps often imprudent? Is it sick? Is it a matter of mental illness? Is it a private or a social act? Is it something the family, community, or society could ever expect of a person? Or is it solely a personal matter, perhaps a matter of right, based in individual liberties, or even a fundamental human right?

What role a person may play in the end of his or her own life is the central ethical issue in suicide around which a set of related issues also form: What should the role of other persons be towards those intending suicide? What should the role of medical and psychiatric clinicians be toward a patient who intends suicide since it is they who are said to be charged with protecting human life? What intervention may the state make to interfere with a person's intention to end his or her own life? What responsibility do others—both immediate others such as family and friends or more distant or generalized others such as employers or institutions or society as a whole—bear when a person commits suicide?

This spectrum of views about the ethics of suicide—from the view that suicide is profoundly morally wrong to the view that it is a matter of basic human right, and from the view that it is primarily a private matter to the view that it is largely a social one—lies at the root of contemporary practical controversies over suicide. These practical controversies include at least three specific matters of high contemporary saliency:

• Physician-assisted suicide in terminal illness, the focus of intense debate in parts of the world with people who have long life expectancies and with high-tech medical systems, particularly the Netherlands, the United States, the United Kingdom, Canada, Switzerland, Belgium, Germany, and Australia;
• Hunger strikes and suicides of social protest, as in Turkey, Northern Ireland, and wartime Vietnam;
• Suicide bombings and related forms of self-destruction employed as military, guerilla, or terrorist tactics in ongoing political friction, including kamikaze attacks by wartime Japan; suicide missions by groups from Tamil separatists to al-Qaeda, and suicide bombings in the conflicts in Israel, Palestine, Iraq, and elsewhere.

Ethical issues have occupied the center of attention in the philosophical discussion of suicide, but conceptual and epistemological ones also play a role, as do a broad range of further issues raised within world historical, religious, and cultural traditions.

Conceptual and Linguistic Issues

The term suicide carries extremely negative connotations. However, there is little agreement on a formal definition. Some authors count all cases of voluntary, intentional self-killing as suicide; others include only cases in which the individual's primary intention is to end his or her life. Still others recognize that much of what is usually termed suicide neither is wholly voluntary nor involves a genuine intention to die, such as suicides associated with depression or other mental illness. Many writers exclude cases of self-inflicted death that, while voluntary and intentional, appear aimed to benefit others or to serve some purpose or principle—for instance, Socrates drinking the hemlock, Captain Lawrence Oates's (1890–1912) walking out into the Antarctic blizzard to allow his fellow explorers to continue without him, or the self-immolation of war protesters. These cases are usually not called suicide but self-sacrifice or martyrdom, terms with strongly positive connotations.

Attempts to differentiate these positive cases from negative ones often seem to reflect moral judgments, not genuine conceptual differences, and the linguistic framing of a practice plays a substantial role in social policies about suicide. For example, supporters of physician-assisted suicide often use the term aid-in-dying as well as earlier euphemisms such as self-deliverance to avoid the negative connotations of suicide while opponents insist on the more negative term suicide. Islamic militants attacking civilians are called martyrs by their supporters and those who recruit them but suicide bombers by their targets and by the Western press.

Differences among languages also play a role in the conceptualization of suicide. While for example English, French, Spanish, and many other languages have just a single, primary word for suicide, German has four: Selbstmord (self-murder), Selbsttötung (self-killing), Suizid (the Latinate term), and Freitod (free death). This latter German term has comparatively positive, even somewhat heroic, connotations, making it possible for German-speakers to think about the deliberate termination of their lives in a linguistic way not easily available to speakers of English or other languages that rely on a single, principal term with strongly negative connotations.

Linguistic issues also arise in attempts to refer to the performance of the act of suicide. The expression to "commit" suicide has been common, echoing the phrase to commit a crime ; contemporary suicidologists typically use a variety of less-stigmatizing alternatives, including suicided, completed suicide, and died by suicide.

Some authors claim that it is not possible to reach a rigorous formal definition of suicide and prefer a criterial or operational approach to characterizing the term, noting its varied, shifting, and often inconsistent range of uses. Translation from one language to another may also prove difficult since there is sometimes little way to preserve comparatively positive connotations of some terms. Cases of death from self-caused accident, self-neglect, chronic self-destructive behavior, victim-precipitated homicide, high-risk adventure, refusal of life-saving medical treatment, and self-administered euthanasia—all of which share many features with suicide but are not usually termed such—cause still further conceptual difficulty.

Nevertheless, conceptual and linguistic issues concerning suicide are of considerable practical importance in policy formation, affecting, for instance, coroners' practices in identifying causes of death, insurance disclaimers, psychiatric protocols, religious prohibitions, codes of medical ethics, laws prohibiting or permitting assistance in suicide, social stigma and respect, and public response to international and political issues such as suicide bombing and protest suicide.

Epistemological Issues

Closely tied to conceptual issues, the central epistemological issues raised by suicide involve the kinds of knowledge available to those who contemplate killing themselves. The issue of what, if anything, can be known to occur after death has generally been regarded as a religious issue answerable only as a matter of faith; few philosophical writers have discussed it directly, despite its clear relation to theory of mind. Some writers have argued that since we cannot have antecedent knowledge of what death involves, we cannot knowingly and voluntarily choose our own deaths; suicide is therefore always irrational. Others, rejecting this argument, instead attempt to establish conditions for the rationality of suicide. Others consider whether death is always an evil for the person involved and whether death is appropriately conceptualized as the cessation of life. Still other writers examine psychological and situational constraints on decision making concerning suicide. For instance, the depressed, suicidal individual is described as seeing only a narrowed range of possible future outcomes in the current dilemma, the victim of a kind of tunnel vision constricted by depression. The possibility of preemptive suicide in the face of deteriorative mental conditions such as Alzheimer disease is characterized as a problem of having to use that very mind which may already be deteriorating to decide whether to bear deterioration or die to avoid it. Still others suggest that suicide would be the most straightforward expression of normative skepticism, expressing the view that life has no meaning and nothing is of value.

Suicide in World Historical Traditions: The West

Much of the extremely diverse discussion of suicide in the history of Western thought has been directed to ethical issues. Plato acknowledges Athenian burial restrictions—the suicide was to be buried apart from other citizens with the hand severed and buried separately—and in the Phaedo, he also reports the Pythagorean view that suicide is categorically wrong. But Plato also accepts suicide under various conditions, including shame, extreme distress, poverty, unavoidable misfortune, and external compulsions of the sort imposed on Socrates by the Athenian court: Socrates was condemned to drink the hemlock. In the Republic and the Laws, respectively, Plato obliquely insists that the person suffering from chronic, incapacitating illness or uncontrollable criminal impulses ought to allow his life to end or cause it to do so. Aristotle held more generally that suicide is wrong, claiming in the Nichomachean Ethics that it is cowardly and treats the state unjustly. The Greek and Roman Stoics, in contrast, recommended suicide as the responsible, appropriate act of the wise man, not to be undertaken in emotional distress but as an expression of principle, duty, or responsible control of the end of one's own life, as exemplified by Marcus Porcius Cato Uticencis (Cato the Younger) (95 BCE–46 BCE), Lucretia (sixth century BCE), and Lucius Annaeus Seneca.

Although Old Testament texts describe individual cases of suicide (Abimilech, Samson, Saul and his armor-bearer, Ahithophel, and Zimri), nowhere do they express general disapproval of suicide. However, the Greek-influenced Jewish soldier and historian Flavius Josephus (37 CE–100 CE) rejects it as an option for his defeated army, and clear prohibitions of suicide appear in Judaism by the time of the Talmud during the first several centuries CE, often appealing to the Biblical text Genesis 9:5: "For your lifeblood I will demand satisfaction." New Testament does not specifically condemn suicide, and mentions only one case: the self-hanging of Judas Iscariot after the betrayal of Jesus. There is evident disagreement among the early Church Fathers about the permissibility of suicide, especially in one specific circumstance: among others, Eusebius Pamphilus (c. 264–340), Ambrose (c. 340–397), and Jerome (c. 342–420) all considered whether a virgin may kill herself in order to avoid violation.

While Christian values clearly include patience, endurance, hope, and submission to the sovereignty of God, values that militate against suicide, they also stress willingness to sacrifice one's life, especially in martyrdom, and absence of the fear of death. Some early Christians (e.g., the Circumcellions, a subsect of the rigorist Donatists) apparently practiced suicide as an act of religious zeal. Suicide committed immediately after confession and absolution, they believed, permitted earlier entrance to heaven. Rejecting such reasoning, St. Augustine asserted that suicide violates the commandment Thou shalt not kill and is a greater sin than any that could be avoided by suicide. Whether he was simply clarifying earlier elements of Christian faith or articulating a new position remains a matter of contemporary dispute. In any case, it is clear that with this assertion, the Christian opposition to suicide became unanimous and absolute.

This view of suicide as morally and religiously wrong intensified during the Christian Middle Ages. St. Thomas Aquinas argued that suicide is contrary to the natural law of self-preservation, injures the community, and usurps God's judgment "over the passage from this life to a more blessed one" (Summa theologiae 2a 2ae q64 a5). By the High Middle Ages the suicide of Judas, often viewed earlier as appropriate atonement for the betrayal of Jesus, was seen as a sin worse than the betrayal itself. Enlightenment writers began to question these views. Thomas More incorporated euthanatic suicide in his Utopia. In Biathanatos, John Donne (c. 1572–1631) treated suicide as morally praiseworthy when done for the glory of God—as, he claimed, was the case for Christ; David Hume mocked the medieval arguments, justifying suicide on autonomist, consequentialist, and beneficent grounds.

Later thinkers such as Mme. de Staël (Anne Louise Germaine, née Necker, the baroness Staël-Holstein)—although she subsequently reversed her position—and Arthur Schopenhauer construed suicide as a matter of human right. Throughout this period, other thinkers insisted that suicide was morally, legally, and religiously wrong: among them, John Wesley (1703–1791) said that suicide attempters should be hanged, and Sir William Blackstone (1723–1780) described suicide as an offense against both God and the king. Immanuel Kant used the wrongness of suicide as a specimen of the moral conclusions the categorical imperative could demonstrate. In contrast, the Romantics tended to glorify suicide, and Friedrich Nietzsche insisted that "suicide is man's right and privilege."

Although religious moralists have continued to assert that divine commandment categorically prohibits suicide, that suicide repudiates God's gift of life, that suicide ruptures covenantal relationships with other persons, and that suicide defeats the believer's obligation to endure suffering in the image of Christ, the volatile discussion of the moral issues in suicide among more secular thinkers ended fairly abruptly at the close of the nineteenth century. This was due in part to Émile Durkheim's insistence that suicide is a function of social organization, and also to the views of psychological and psychiatric theorists, developing from Jean Esquirol (1772–1840) to Sigmund Freud, that suicide is a product of mental illness. These new scientific views reinterpreted suicide as the product of involuntary conditions for which the individual could not be held morally responsible. The ethical issues, which presuppose choice, reemerged only in the later part of the twentieth century, stimulated primarily by discussions in bioethics of terminal illness and other dilemmas at the end of life.

Suicide and Martyrdom in Monotheist Religious Traditions

The major monotheisms, Judaism, Christianity, and Islam, all repudiate suicide though in each, martyrdom is recognized and venerated. Judaism rejects suicide but venerates the suicides at Masada and accepts Kiddush Hashem, self-destruction to avoid spiritual defilement. At least since the time of Augustine, Christianity has clearly rejected suicide but accepts and venerates martyrdom to avoid apostasy and to testify to one's faith. Islam also categorically prohibits suicide but at the same time defends and expects martyrdom to defend the faith. Yet whether the distinction between suicide and martyrdom falls in the same place for Judaism, Christianity, and Islam is not clear. Judaism appears to accept self-killing to avoid defilement or apostasy; Christianity teaches submission to death where the faith is threatened but also celebrates the voluntary embrace of death in such circumstances; some Islamic fundamentalists support the political use of suicide bombing, viewing it as consistent with Islam and its teachings of jihad, or holy war to defend the faith, though others view this as a corruption of Islamic doctrine.

Thus, while all three traditions revere those who die for the faith as martyrs and all three traditions formally repudiate suicide, at least by that name, the practices they accept may be quite different: Christians would not accept the mass suicide at Masada; Jews do not use the suicide-bombing techniques of their Islamic neighbors in Palestine; and Muslims do not extol the passive submission to death of the Christian martyrs, appealing on Quranic grounds to a more active self-sacrificial defense of the faith.

Other Religious and Cultural Views of Suicide

Many other world religions hold the view that suicide is prima facie wrong but that there are certain exceptions. Still others encourage or require suicide in specific circumstances. Known as institutionalized suicide, such practices in the past have included the sati of a Hindu widow who was expected to immolate herself on her husband's funeral pyre; the seppuku or hara-kiri of traditional Japanese nobility out of loyalty to a leader or because of infractions of honor; and, in traditional cultures from South America to Africa to China, the apparently voluntary submission to sacrifice by a king's retainers at the time of his funeral in order to accompany him into the next world. Inuit, Native American, and some traditional Japanese cultures have practiced voluntary abandonment of the elderly, a practice closely related to suicide, in which the elderly are left to die, with their consent, on ice floes, on mountaintops, or beside trails.

In addition, some religious cultures have held comparatively positive views of suicide, at least in certain circumstances. The Vikings recognized violent death, including suicide, as guaranteeing entrance to Valhalla. Some Pacific Island cultures regarded suicide as favorably as death in battle and preferable to death by other means. The Jains, and perhaps other groups within traditional Hinduism, honored deliberate self-starvation as the ultimate asceticism and also recognized religiously motivated suicide by throwing oneself off a cliff. On Mangareva, members of a traditional Pacific Islands culture also practiced suicide by throwing themselves from a cliff, but in this culture not only was the practice largely restricted to women, but a special location on the cliff was reserved for noble women and a different location assigned to commoners. The Maya held that a special place in heaven was reserved for those who killed themselves by hanging (though other methods of suicide were considered disgraceful), and, though the claim is disputed, may have recognized a goddess of suicide, Ixtab. Many other pre-Columbian peoples in the Western hemisphere engaged in apparently voluntary or semi-voluntary ritual self-sacrifice, notably the Aztec practice of heart sacrifice, which was generally characterized at least at some historical periods by enhanced status and social approval. The view that suicide is intrinsically and without exception wrong is associated most strongly with post-Augustinian Christianity of the medieval period, surviving into the present; this absolutist view is not by and large characteristic of other cultures.

Ethical Issues in Contemporary Application: Physician-Assisted Suicide

The right to die movement emerging in the 1970s, 1980s, and 1990s, counting among its achievements the passage of natural death, living will, and durable power of attorney statues that gave patients greater control in decision making about their end-of-life medical care, also raised the question of what role the dying person might play in shaping his or her own death and what role the physician might play in directly assisting the patient's dying. These notions have often appealed to the concept of death with dignity, though the coherence of that notion is sometimes challenged. Public rhetoric quickly labeled the practice at issue physician-assisted suicide although less negatively freighted labels such as physician-aid-in-dying or physician-negotiated death have also been advanced as more appropriate.

Proponents of legalizing the practice have argued in its favor on two principal grounds: (1) autonomy, the right of a dying person to make his or her own choices about matters of deepest personal importance, including how to face dying, and (2) the right of a person to avoid pain and suffering that cannot be adequately controlled. Opponents offer two principal competing claims: (1) that fundamental moral principle prohibits killing, including self-killing, and (2) that allowing even sympathetic cases of physician assistance in suicide would lead down the slippery slope, as overworked doctors, burdened or resentful family members, and callous institutions eager to save money would manipulate or force vulnerable patients into choices of suicide that were not really their own. Pressures would be particularly severe for patients with disabilities, even those who were not terminally ill, and the result would be widespread abuse.

Compromise efforts, launched by bioethicists, physicians, legal theorists, and others on both sides, have focused primarily on the mercy argument from avoiding pain: It is claimed that improving pain control in terminal illness, including accelerated research, broader education of physicians, rejection of outdated concerns about addiction associated with opioid drugs, and recourse to terminal sedation or induced permanent unconsciousness if all else fails will serve to decrease requests for physician assistance in suicide. These compromise views also hold that assistance in suicide should remain, if available at all, a last resort in only the most recalcitrant cases.

However, although proponents of physician-assisted suicide welcome advances in pain control, many reject this sort of compromise arguing that it restricts the freedom of a person who is dying to face death in the way he or she wants. They point out that other apparent compromises, such as the use of terminal sedation, are both repugnant and can be abused, since full, informed consent may not actually be sought. Proponents also object on grounds of equity: It is deeply unfair, they insist, that patients dependent on life-support technology such as dialysis or a respirator can achieve a comparatively easy death at a time of their own choosing by having these supports discontinued—an action fully legal—but patients not dependent on life supports cannot die as they wish but must wait until the inevitable end when the disease finally kills them.

Many opponents of physician-assisted suicide reject attempts at compromise as well, sometimes arguing on religious grounds that suffering is an aspect of dying that ought to be accepted, sometimes holding that patients' wishes for self-determination ought not override the scruples of the medical profession, and sometimes objecting to any resort at all to assisted dying, even in very rare, difficult cases. And some who accept the claim that death is sometimes a benefit to which a person can be morally entitled still object that placing this choice in the hands of patient would make him or her worse off by obliging him or her to choose at all, even if the choice is against. There is little resolution, however, of the competing claims of autonomist and mercy claims on the one hand and wrongness-of-killing and social-consequences views on the other. Like the social arguments over abortion, disagreement continues both at the level of public ferment and at the deeper level of philosophical principle although the raising of the issue itself has meant far greater attention to issues about death and dying.

Ethical Issues in Contemporary Application: Suicide in Old Age

While comparatively rarely discussed in contemporary moral theory, the more difficult applied question concerns suicide in old age for reasons of old age alone though this is said to be an issue that will increasingly confront an aging society. In both historical argumentation and the very small amount of contemporary theorizing, the fundamental issues of suicide in old age concern two distinct sets of reasons for suicide, in practice often intertwined: (1) Reasons of self-interest : suicide in order to avoid the sufferings, physical limitations, loss of social roles, and stigma of old age; (2) Other-regarding reasons : suicide in order to avoid becoming a burden to others, including family members, caretakers, immediate social networks, or society as a whole.

Contemporary reflection, at least explicitly, countenances neither of these as adequate reasons for suicide in old age. With regard to self-interested reasons, modern gerontology maintains a resolutely upbeat and optimistic view of old age, insisting that it is possible to ameliorate many of the traditional burdens of old age—chronic illness, isolation, poverty, depression, and chronic pain—by providing better medical care, better family and caregiver education, and more comprehensive social programs. With respect to other-regarding reasons, including altruistic reasons, contemporary views consider it unconscionable—especially in the wealthy societies of the developed world—to regard elderly persons as burdens to families or to social units or to the society; nor is it thought ethically permissible to allow or encourage elderly persons to see themselves this way. While the notion that the elderly are to be venerated is associated primarily with the traditional cultures of the Asia, especially China, Western societies also insist, though sometimes ineffectually in a youth-oriented culture, on respect for the aged and on enhancing long lives. Simply put, the prevalent assumption in the Western cultures in the twenty-first century is that there can be no good reasons for suicide in old age even though suicide is frequent, especially in men in old age. Daniel Callahan (1930–), although opposing suicide in old age, points to contemporary medicine's relentless drive for indefinite extension of life, arguing that the elderly should forgo heroic life-prolonging care and refocus their attention instead on turning matters over to the next generation. Carlos Prado (1937–), exploring issues of declining competence, raises the issue of preemptive suicide in advanced age. Colorado Governor Richard Lamm's widely (mis)quoted remark that the elderly have a "duty to die," unleashed a small storm of academic and public discussion concerning suicide in terminal illness and in old age (Hardwig 1997).

Hints of real social friction can be seen over both self-interested and other-regarding and altruistic reasons for suicide in old age. Having fully legalized physician-assisted suicide and voluntary active euthanasia, the Netherlands is now considering whether to honor advance directives such as living wills in which a now-competent person requests physician-aided death after the onset of Alzheimer disease, a condition particularly frequent among the elderly. Double-exit suicides, often of married partners in advanced age even though only one is ill, startle public awareness. Disputes over generational equity in the face of rising health care costs question whether life prolongation means merely the extension of morbidity and whether health care ought to be preferentially allocated to the young rather than the old. The issue of whether a person may ethically and reasonably refuse medical treatment in order to spare health care costs to preserve an inheritance for his or her family is already beginning to be discussed; the same issue also raises the question of suicide. And issues about suicide in old age are posed by far-reaching changes in population structure, the graying of societies in Europe and the developed world: As birthrates fall and the proportion of retirees threatens to overwhelm the number of still-working younger people, could there be any obligation, as Euripides (c. 480–406 BCE) put it in The Suppliants nearly 2,500 years ago, go "hence, and die, and make way for the young"?

No party now encourages suicide for the elderly, and, indeed, no party even raises the issue; but the issue of suicide as a response to self-interested avoidance of the conditions of old age and to other-interested questions about social burdens of old age cannot be very far away. Drawing as they might on both Stoic and Christian roots in the West and on non-Western practices now coming to light, the ethical disputes over suicide in old age, independent of illness, are likely to intensify the currently vigorous debate over suicide in terminal illness: Can suicide in old age represent, as one author puts it, the last rational act of autonomous elders, or does it represent the final defeated event in a series of little tragedies of all kinds?

See also Aristotle; Augustine, St.; Consequentialism; Durkheim, Émile; Epistemology; Freud, Sigmund; Hume, David; Kant, Immanuel; More, Thomas; Nietzsche, Friedrich; Plato; Pythagoras and Pythagoreanism; Romanticism; Schopenhauer, Arthur; Staël-Holstein, Anne Louise Germanie Necker, Baronne de; Socrates; Stoicism; Thomas Aquinas, St.

Bibliography

Alvarez, Albert. The Savage God: A Study of Suicide. London: Weidenfeld and Nicolson, 1971.

Améry, Jean. On Suicide: A Discourse on Voluntary Death (1976). Translated by John D. Barlow. Bloomingon: Indiana University Press, 1999.

Thomas Aquinas. Summa Theologiae. 2a2ae, question 64, article 5, translated by Michael Rudick.

Aristotle. Ethica Nicomachea Book III, 1115a-1116a; Book V, 1138a, edited and translated by W.D. Ross. Oxford: Clarendon Press, 1925.

Baechler, Jean. Suicides. Translated by Barry Cooper. Oxford: Blackwell, 1979.

Barraclough, Brian M. "The Bible Suicides." Acta Psychiatrica Scandinavia 86 (1) (1992): 64–69.

Battin, Margaret Pabst. Ending Life: Ethics and the Way We Die. New York: Oxford University Press, 2005.

Battin, Margaret Pabst. Ethical Issues in Suicide. Englewood Cliffs, NJ: Prentice-Hall, 1982.

Battin, Margaret Pabst. The Least Worst Death: Essays in Bioethics on the End of Life. New York: Oxford University Press, 1994.

Battin, Margaret Pabst, and Ronald W. Maris, eds. "Suicide and Ethics." Suicide and Life-Threatening Behavior. Spec. issue 13 (4) (1983).

Battin, Margaret Pabst, and David J. Mayo, eds. Suicide: The Philosophical Issues. New York: St. Martin's Press, 1980.

Battin, Margaret P., Rosamond Rhodes, and Anita Silvers, eds. Physician-Assisted Suicide: Expanding the Debate. New York: Oxford University Press, 1998. Includes Oregon Death with Dignity Act.

Beauchamp, Tom L. Intending Death: The Ethics of Assisted Suicide and Euthanasia. Upper Saddle River, NJ: Prentice-Hall, 1996.

Brandt, Richard B. "The Morality and Rationality of Suicide." In A Handbook for the Study of Suicide, edited by Seymour Perlin. New York: Oxford University Press, 1975.

Brock, Dan W. Life and Death: Philosophical Essays in Biomedical Ethics. Cambridge, U.K.: Cambridge University Press, 1993.

Brock, Dan W. "Physician-Assisted Suicide as a Last-Resort Option at the End of Life." In Physician-Assisted Dying. The Case for Palliative Care and Patient Choice, edited by Timothy E. Quill and Margaret Pabst Battin, 130–149. Baltimore: Johns Hopkins University Press, 2004.

Brody, Baruch A., ed. Suicide and Euthanasia: Historical and Contemporary Themes. Dordrecht, Netherlands: Kluwer, 1989.

Callahan, Daniel. False Hopes: Why America's Quest for Perfect Health Is a Recipe for Failure. New York: Simon and Schuster, 1998.

Cholbi, Michael. "Suicide." Stanford Encyclopedia of Philosophy. (Summer 2004 Edition), edited by Edward N. Zalta. Available at http://plato.stanford.edu/.

Cicero, Marcus Tullius. On Old Age. Trans. Frank O. Copley. Ann Arbor, The University of Michigan Press, 1967.

Daube, David. "The Linguistics of Suicide." Philosophy and Public Affairs 1 (4) (1972): 387–437.

DeLeo, Diego, ed. Suicide and Euthanasia in Older Adults: A Transcultural Journey. Göttingen: Hogrefe and Huber, 2001.

Donne, John. Biathanatos (1647), edited by Michael Rudick and Margaret Pabst Battin. New York: Garland, 1982.

Droge, Arthur J., and James D. Tabor. A Noble Death. Suicide and Martyrdom among Christians and Jews in Antiquity. San Francisco: HarperCollins, 1992.

Durkheim, Emile. Suicide: A Study in Sociology. Translated by John A. Spaulding and edited by George Simpson. New York: Free Press, 1951.

Emanuel, Ezekiel J. "What is the Great Benefit of Legalizing Euthanasia or Physician-Assisted Suicide?" Ethics 109 (3) (1999): 629–642.

Emanuel, Linda L., ed. Regulating How We Die: The Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide. Cambridge, MA: Harvard University Press, 1998.

Euripides. The Suppliants, line 1113. Translated by Arthur S. Way. In Euripides. London: William Heinemann; New York: Macmillan, 1912, vol. 3, p. 589.

Fedden, Henry Romilly. Suicide: A Social and Historical Study. London: Peter Davies, 1938.

Fischer, John Martin, ed. The Metaphysics of Death. Stanford, CA: Stanford University Press, 1993.

Fletcher, David B. "Holy Dying, Assisted Dying? An Anglican Perspective on Physician-Assisted Suicide." Ethics and Medicine 1 (2004): 35–43.

Foley, Kathleen, and Herbert Hendin. The Case against Assisted Suicide: For the Right to End-of-Life Care. Baltimore: Johns Hopkins University Press, 2002.

Francis, Leslie Pickering. "Assisted Suicide: Are the Elderly a Special Case?" In Physician Assisted Suicide: Expanding the Debate, edited by Margaret P. Battin, Rosamond Rhodes, and Anita Silvers, 75–90. New York: Routledge, 1998.

Gentzler, Jyl. "What Is a Death with Dignity?" Journal of Medicine and Philosophy 28 (4) (2003): 461–487.

Griffiths, John, Alex Bood, and Heleen Weyers. Euthanasia and the Law in the Netherlands. Amsterdam: Amsterdam University Press, 1998.

Hardwig, John. "Is There a Duty to Die?" Hastings Center Report 27 (2) (1997): 34–42.

Hill, Thoms E. "Self-Regarding Suicide: A Modified Kantian View." In Autonomy and Self-Respect, 85–103. Cambridge, U.K.: Cambridge University Press, 1991.

Humber, James M., and Robert F. Almeder, eds. Is There a Duty to Die? Totowa, NJ: Humana Press, 2000.

Hume, David. "Of Suicide." (1777). In Essays: Moral, Political, and Literary, 586–596. London: Oxford University Press, 1963.

Humphry, Derek. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Eugene, OR: National Hemlock Society, 1991.

Humphry, Derek, with Ann Wickett. Jean's Way. London: Quartet Books, 1978.

Kamisar, Yale. "Some Non-religious Views Against Proposed 'Mercy-Killing' Legislation." Minnesota Law Review 42 (1958): 969–1041.

Kamm, F. M. "Physician-Assisted Suicide, the Doctrine of Double Effect, and the Ground of Value." Ethics 109 (3) (1999): 586–605.

Kant, Immanuel. Lectures on Ethics. Translated by Louis Infield. Indianapolis, IN: Hackett, 1980.

Kant, Immanuel. Ethical Philosophy: The Complete Texts of the Grounding for the Metaphysics of Morals, and Metaphysical Principles of Virtue, Part II of the Metaphysics of Morals. Translated by James W. Ellington. Indianapolis, IN: Hackett, 1983.

Kant, Immanuel. The Critique of Practical Reason. Translated by Lewis White Beck. New York: Macmillan, 1993.

Kass, Leon. "Death with Dignity and the Sanctity of Life." Commentary (March 1990): 33–43.

Korsgaard, Christine M. The Sources of Normativity. Cambridge, U.K.: Cambridge University Press, 1996.

Landsberg, Paul-Louis. The Experience of Death; The Moral Problem of Suicide. Translated by Cynthia Rowland. New York: Philosophical Library, 1953.

Maris, Ronald W., Alan L. Berman, and Morton M. Silverman. Comprehensive Textbook of Suicidology. New York: Guilford Press, 2000.

McIntosh, John L. Annual updated U.S. suicide statistics. Available from www.iusb.edu/~jmcintos/. Official data also available in hardcopy from National Vital Statistics Reports, National Center for Health Statistics, Hyattsville, Maryland.

Minois, George. History of Suicide. Voluntary Death in Western Culture. Translated by Lydia G. Cochrane. Baltimore: Johns Hopkins University Press, 1999.

More, Thomas. Utopia. Book II. Translated by Ralph Robinson, in Three Early Modern Utopias, edited by Susan Bruce. Oxford University Press, 1999, pp. 89-90

Murray, Alexander. Suicide in the Middle Ages: The Violent against Themselves. Vol. 1. Oxford: Oxford University Press, 1998.

Narveson, Jan. "Self-Ownership and the Ethics of Suicide." Suicide and Life-Threatening Behavior 13 (4) (1983): 240–253.

Nietzsche, Friedrich. The Day of Dawn (Morgenrote) Original edition, 1881. Stuttgart: Kroner Verlag, 1953, p. 210.

Oregon Health Department. Annual data on the Death with Dignity Act. Available from http://www.oregon.gov/.

Perlin, Seymour, ed. A Handbook for the Study of Suicide. Oxford: Oxford University Press, 1975.

Plato. The Dialogues of Plato. Phaedo 61B-69E, 116A–118A; Republic III 405A–410A; Laws IX 853A-854D, 862D-863A, 872D–873E. Translated by. Benjamin Jowett. New York: Random House, 1892, 1920, vol. I, pp. 444–453 and 499–501; 669–674; vol. II, pp. 599–600, 608, 617–618.

Prado, Carlos G. The Last Choice: Preemptive Suicide in Advanced Age. Westport, CT: Greenwood Press, 1990.

Putnam, Constance E. Hospice or Hemlock? Searching for Heroic Compassion. Westport, CT: Praeger, 2002.

Quill, Timothy E. A Midwife Through the Dying Process: Stories of Healing and Hard Choices at the End of Life. Baltimore: Johns Hopkins University Press, 1996.

Quill, Timothy E., and Margaret P. Battin, eds. Physician-Assisted Dying. The Case for Palliative Care and Patient Choice. Baltimore: Johns Hopkins University Press, 2004.

Raymond, Diane. "'Fatal Practices': A Feminist Analysis of Physician-Assisted Suicide and Euthanasia." Hypatia: A Journal of Feminist Philosophy 14 (2) (1999): 1–25.

Regan, Donald H. "Suicide and the Failure of Modern Moral Theory." Suicide and Life-Threatening Behavior 13 (4) (1983): 276–292.

Sartorius, Rolf. "Coercive Suicide Prevention: A Libertarian Perspective." Suicide and Life-Threatening Behavior 13 (4) (1983): 293–303.

Seneca, Lucius Annaeus. Ad Lucilium Epistulae Morales (Moral letters to Lucilius). Vol. 2. Letters 70 ("On the Proper Time to Slip the Cable"), 77 ("On Taking One's Own Life"), 78 ("On the Healing Power of the Mind"). Translated by Richard M. Gummere, 57–73, 169–199. New York: G. P. Putnam's Sons, 1920.

Shneidman, Edwin S., ed. Suicidology: Contemporary Developments. New York: Grune and Stratton, 1976.

Shneidman, Edwin S., and Norman I. Farberow, eds. Clues to Suicide. New York: McGraw-Hill, 1957.

Seneca, Lucius Annaeus. "Letter on Suicide" and "On the Proper Time to Slip the Cable." In Ad Lucilium Epistulae Morales. Translated by Richard M. Gummere. London: Heinemann, 1920.

Sprott, Samuel E. The English Debate on Suicide: From Donne to Hume. La Salle, IL.: Open Court, 1961.

Steinbock, B. "The Case for Physician-Assisted Suicide: Not (Yet) Proven." Journal of Medical Ethics 331 (2005): 235–241.

Thomasma, David C., Thomasine Kimbrough-Kushner, Gerrit K. Kimsma, and Chris Ciesielski-Carlucci, eds. Asking to Die: Inside the Dutch Debate About Euthanasia. Dordrecht, Netherlands: Kluwer, 1998.

van der Maas, Paul J., Gerrit van der Wal, et al. "Euthanasia, Physician-Assisted Suicide and Other Medical Practices Involving the End of Life in the Netherlands, 1990–1995." New England Journal of Medicine 335 (22) (1996): 1699–1705.

Velleman, J. David. "Against the Right to Die." Journal of Medicine and Philosophy 17 (1992): 665–81.

Velleman, J. David. "A Right of Self-Termination? Ethics 109 (1999): 606–628.

Wellman, Carl. "A Legal Right to Physician-Assisted Suicide Defended." Social Theory and Practice 29 (1) (2003): 19–38.

Werth, James L. Jr. Contemporary Perspectives on Rational Suicide. Philadelphia: Taylor and Francis, 1999.

Windt, Peter, "The Concept of Suicide." In Suicide: The Philosophical Issues, edited by M. Pabst Battin and David J. Mayo, 39–47. New York: St. Martin's Press, 1980.

Margaret Pabst Battin (2005)