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FEATURES / The suicide conundrum The elementary sin? For Pope John Paul II, suicide was always as morally objectionable as murder. As the UK Parliament considers proposals to change the law to allow terminally ill adults to be assisted to end their own lives, a psychiatrist who has cared for many suicidal patients considers some of the ethical issues around the deliberate taking of one’s own life / By JULIAN C. HUGHES IREMEMBER A WOMAN who had been admitted because of the risk of suicide. We did all we could for her and gave her discharge a good deal of thought. She seemed much brighter. But as she left the ward, she glanced back at me and her expression changed. Within a day she was found dead. Of course, we felt guilty. Her family could have been forgiven for thinking we had been negligent. Surprisingly, they took a different view and said they considered her suicide was vindictive. Although a little shocking, this thought was not a complete surprise. Her death brought to mind the philosopher Ludwig Wittgenstein writing to an acquaintance in 1920: “I know that to kill oneself is always a dirty thing to do … suicide is always a rushing of one’s own defences .” Wittgenstein knew a lot about suicide. He thought of it himself on many occasions. In all probability, three of his four brothers took their own lives. We know the phenomenon of copycat suicides is very real, which is why broadcasters are implored to follow strict codes in their portrayals of suicide. It is likely that one of Wittgenstein’s brothers killed himself in imitation of the notorious death of Otto Weininger, a young philosopher who died in fin de siècle Vienna from suicide at the age of only 23. In 1917, Wittgenstein wrote: “If suicide is allowed, then everything is allowed. If anything is not allowed, then suicide is not allowed. This throws light on the nature of ethics, for suicide is, so to speak, the elementary sin.” He added a doubt: “Or isn’t suicide too, in itself, neither good nor evil?” Well, Catholic teaching has long been of the view that suicide is a grave sin. In Evangelium Vitae, Pope John Paul II wrote that suicide “is always as morally objectionable as murder”. He continued: “In fact, it involves the rejection of love of self and the renunciation of the obligation of justice and charity towards one’s neighbour, towards the communities to which one belongs, and towards society as a whole. In its deepest reality, suicide represents a rejection of God’s absolute sovereignty over life and death …” Over the years, the teams in which I worked looked after many people who were suicidal. We knew that several of these people would one day be successful in their attempts. Our job was in a sense palliative. We intervened when we could and supported as we could. But we knew that the lonely old man who could see no purpose to his existence, whose friends had all moved away, whose family was estranged, who turned down offers of help, would one day be found dead from his own hand. It proved to be so. Was he, however, a sinner? IN A FAMOUS study published in 1974, which involved interviews with the surviving relatives of 100 people who had ended their lives by suicide, Brian Barraclough and colleagues demonstrated that 93 per cent had mental disorders, mostly depression and alcoholism. Many (80 per cent) were being seen by a doctor and were on medication. About half of the people studied had given warnings that 4 | THE TABLET | 26 OCTOBER 2024 For more features, news, analysis and comment, visit www.thetablet.co.uk
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ILLUSTRATION: ALAMY/BRAIN LIGHT with a stake through the hearts of those who had died by suicide. And yet, I have it on good authority that there are still countries where the bodies of those who have died by suicide are abused as a warning to others. suicides is low. Yet the idea that suicide is a rational response to one’s circumstances underpins and will grow with the demand for assisted suicide. they might undertake suicide. The study helped to push the idea that some suicides should be preventable by medical intervention. Many have also been prevented by making the means of suicide less available – removing carbon monoxide from private gas supplies, wrapping tablets in individual foil blister packs – or by putting obstacles in the way of those contemplating suicide. Barraclough’s study started with a quote from Forbes Winslow’s 1840 The Anatomy of Suicide, which stated that “self-destruction” often “originates in derangement of the brain and abdominal viscera”. Leaving aside the abdominal viscera, if brain disease and mental disorder are the underlying explanations of suicide, then it seems unjust to condemn its victims as sinners. Similarly, it seems barbaric to inflict punishment on the mortal remains of those who have succumbed to suicide. The death of Lord Castlereagh in 1822 by suicide, almost certainly in the middle of a psychotic depression, helped to bring to an end burials at crossroads The Suicide Act of 1961 established that suicide was no longer a crime. It was a humane and commonsense measure. But in no sense did it suggest that suicide was a good thing. Indeed, its continuing stipulation that a person is criminally liable for complicity in another’s suicide suggests the reverse. THERE IS A small but remarkable fact in the Living and Dying Well survey carried out in June 2024. Of the 2,001 respondents, 36 per cent thought that if a person “intentionally ingests poison with the intention of dying, even if given to them by someone else”, this should not be described as “suicide”; and 16 per cent did not know or preferred not to say whether this constituted suicide. It turns out the word “suicide” is a bit of a battleground. On the whole, research shows that those who practise their religion tend to be less likely to die by suicide. But as many will know, being religious is in the end not a guarantee against suicide. So it is a relief to find that the Catechism is more lenient when it comes to suicide. There is still clear condemnation: “We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of ” (2280). But then we read, “grave psychological disturbances, anguish or grave fear of hardship, suffering or torture can diminish the responsibility of the one committing suicide” (2282). Moreover, “God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives” (2283). In November 2023, the Federal Court of Australia determined that “suicide” applied to “voluntary assisted dying”, that is, assisted suicide. This had to go to court because there is an inconsistency between the criminal code, which says you must not counsel or incite suicide in a telephone or video consultation, and Victoria’s Voluntary Assisted Dying Act, which allows assisted suicide, just not by using telehealth. This was a worry for doctors in rural areas. Moreover, people just do not like the stigma that attaches to the word “suicide”. Unfortunately, “suicide” does mean killing oneself, etymologically and in common parlance. But 36 per cent of people in Great Britain do not wish to accept this, and 16 per cent do not know it or do not Even if the person lacks culpability, suicide is always at some level an insult to our shared dignity In 2022, in England and Wales, 5,642 deaths by suicide were recorded, which was just under one in a hundred deaths overall. The suicide rate has been falling since 1981. Remarkably, according to the Office of National Statistics, suicides did not increase during the coronavirus pandemic. About 75 per cent of suicides were in men, with the highest age-specific rate in 2022 being in those over 90 years old. In women, the highest rate was in those aged between 50 and 54 years. Since 1981, however, the greatest increase in the suicide rate (albeit low) has been seen in women aged 24 and younger. Geographically, the rate is lowest in London and highest in the north-east of England. A unique study, covering all the countries of the United Kingdom, “The National Confidential Inquiry into Suicide and Safety in Mental Health”, has been run by Manchester University for more than 20 years. Its most recent report confirms the common risk factors for suicide: previous self-harm, alcohol or drug misuse, multiple mental health diagnoses, living alone and unemployment play a role. In previous years, the “Confidential Inquiry” has highlighted the worrying possible influence of material online encouraging suicide, especially in the young. In any case, we should accept that most people who die from suicide have “grave psychological disturb ances”. wish to say it. Those who advocate changes in the law to allow people to be assisted in killing themselves tend to object to the term “assisted suicide”, preferring “assisted dying”. But assisting people who are dying is straightforwardly good clinical practice and the bread and butter of palliative care. Assisted suicide puts health care, certainly mental health care, in a bind. Compassion and charity demand that we try to find ways to help people to see life as worthwhile. In countries where “assisted dying” is lawful, we see suicide prevention tussling with suicide promotion; and, strikingly, we see the rates of non-assisted suicide rise. Yet, perhaps discomfort can be alleviated, loneliness can be attended to, the burden of frailty can be lessened and old age can be celebrated. There remains the argument from Aquinas that we are all part of the whole: to kill yourself is to injure the community. It is difficult to avoid John Donne: “All mankind is of one author, and is one volume.” Even if the person lacks culpability, suicide is always at some level an insult to our shared dignity, “and therefore never send to know for whom the bell tolls; it tolls for thee”. But what of “rational suicide”, where people with all their faculties and without a treatable mental disorder make the decision that life, for whatever reason (e.g. discomfort, loneliness, frailty or just very advanced old age), holds nothing further for them? Research tends to suggest that the number of rational Julian C. Hughes was an NHS consultant and professor of old-age psychiatry. He remains honorary professor at the University of Bristol. His book, The Reality of Assisted Dying: Understanding the Issues, co-edited with Baroness Ilora Finlay, is published by Open University Press. For more features, news, analysis and comment, visit www.thetablet.co.uk 26 OCTOBER 2024 | THE TABLET | 5

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FEATURES / The suicide conundrum

The elementary sin?

For Pope John Paul II, suicide was always as morally objectionable as murder. As the UK Parliament considers proposals to change the law to allow terminally ill adults to be assisted to end their own lives, a psychiatrist who has cared for many suicidal patients considers some of the ethical issues around the deliberate taking of one’s own life / By JULIAN C. HUGHES

IREMEMBER A WOMAN who had been admitted because of the risk of suicide. We did all we could for her and gave her discharge a good deal of thought. She seemed much brighter. But as she left the ward, she glanced back at me and her expression changed. Within a day she was found dead.

Of course, we felt guilty. Her family could have been forgiven for thinking we had been negligent. Surprisingly, they took a different view and said they considered her suicide was vindictive. Although a little shocking, this thought was not a complete surprise. Her death brought to mind the philosopher Ludwig Wittgenstein writing to an acquaintance in 1920: “I know that to kill oneself is always a dirty thing to do … suicide is always a rushing of one’s own defences .” Wittgenstein knew a lot about suicide. He thought of it himself on many occasions. In all probability, three of his four brothers took their own lives. We know the phenomenon of copycat suicides is very real, which is why broadcasters are implored to follow strict codes in their portrayals of suicide. It is likely that one of Wittgenstein’s brothers killed himself in imitation of the notorious death of Otto Weininger, a young philosopher who died in fin de siècle Vienna from suicide at the age of only 23.

In 1917, Wittgenstein wrote: “If suicide is allowed, then everything is allowed. If anything is not allowed, then suicide is not allowed. This throws light on the nature of ethics, for suicide is, so to speak, the elementary sin.” He added a doubt: “Or isn’t suicide too, in itself, neither good nor evil?” Well, Catholic teaching has long been of the view that suicide is a grave sin. In Evangelium Vitae, Pope John Paul II wrote that suicide “is always as morally objectionable as murder”. He continued: “In fact, it involves the rejection of love of self and the renunciation of the obligation of justice and charity towards one’s neighbour, towards the communities to which one belongs, and towards society as a whole. In its deepest reality, suicide represents a rejection of God’s absolute sovereignty over life and death …”

Over the years, the teams in which I worked looked after many people who were suicidal. We knew that several of these people would one day be successful in their attempts. Our job was in a sense palliative. We intervened when we could and supported as we could. But we knew that the lonely old man who could see no purpose to his existence, whose friends had all moved away, whose family was estranged, who turned down offers of help, would one day be found dead from his own hand. It proved to be so. Was he, however, a sinner?

IN A FAMOUS study published in 1974, which involved interviews with the surviving relatives of 100 people who had ended their lives by suicide, Brian Barraclough and colleagues demonstrated that 93 per cent had mental disorders, mostly depression and alcoholism. Many (80 per cent) were being seen by a doctor and were on medication. About half of the people studied had given warnings that

4 | THE TABLET | 26 OCTOBER 2024

For more features, news, analysis and comment, visit www.thetablet.co.uk

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