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Sick to Death?

Is suicide a disease to be treated, or a choice to be respected? Justin Busch tackles the problem by analysing the concept of disease.

To be, or not to be: that is the question:
Whether ’tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them? To die: to sleep;
No more; and by a sleep to say we end
The heart-ache and the thousand natural shocks
That flesh is heir to, ’tis a consummation Devoutly to be wish’d.
(Hamlet, Act III, scene 1)

Referring to this very speech, George Santayana commented on “the positivism that underlies Shakespeare’s thinking.” Santayana found this attitude striking; “Shakespeare,” he wrote, “is remarkable among the greater poets for being without a philosophy and without a religion.”1

Hamlet’s stance toward the world, and Shakespeare’s approach to religion, become all the more powerful with the audience’s realization that the act being contemplated is that of self-destruction, or what we would now call suicide. (According to the Oxford English Dictionary, the word suicide dates from about 1651, almost half a century after Shakespeare wrote Hamlet.) When Shakespeare gave the famed soliloquy to the melancholy Dane, “Suicide was regarded as a heinous crime,” as Michael MacDonald has reminded us, “a kind of murder committed at the instigation of the devil.”2 Suicide was a sin, a specific abrogation of the authority of God, and a certain ticket to Hell.

It hadn’t always been seen this way, though, and today even in much of what is loosely dubbed the ‘Christian’ world, this attitude toward suicide is once again out of favour. The reasons, however, are quite different. As the place of suicide within society has changed, so too have the considerations concerning its exact meaning, and the definition has grown ever more vague. Blowing my brains out with a gun surely counts if anything does, but what about blowing my lungs out with cigarette smoke? Suicide through emphysema strikes us as an odd concept, at least as we normally mean the word suicide. In a similar fashion, if I steer my car into a tree while sober, it’s suicide; if I’ve tipped a few beforehand, it’s an accident – even if I knew in advance that I would be driving. And so on. Ever since Freud’s work on the unconscious, the relation of our acts to our intentions has been questionable, and therefore so has the character of suicide.

For the purposes of this article, I shall adopt Emile Durkheim’s definition of the term, in his treatise on Suicide. Durkheim says that

the term suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result.3

Suicide may therefore be defined simply as conscious and intentional self destruction. What this implies, though, for any given society and for the act itself, is not so easily settled.

Suicide is not forbidden specifically in either the Old or New Testaments. Jewish law forbade it, but there were exceptions. The most famous example in Old Testament mythology, if only because of modern Hollywood, is the death of Samson, who pulled away the pillars of the temple in which he was chained, taking his captors with him into “the undiscovered country from whose bourn no traveller returns.” The story is found in Judges 16:28-31; earlier in the same text (9:54) is a less admirable example, at least by modern standards: the tale of Abimelech, who avoided the stigma of being killed by a woman (who had already injured him fatally) by taking his own life. There are other examples. In New Testament mythology, the case of Judas is paramount; in one version of the story (Matthew 27:5) he is reported to have hanged himself, and good riddance. The suicide is not condemned by the author reporting it (although admittedly the nature of Judas’s death is not entirely clear; in Acts 1:18, an obscure passage to be sure, he seems to have exploded instead, which would remove his death from the category of suicide).

In Greek culture, suicide was acceptable and even, under the appropriate circumstances, honourable, as witness the death of Socrates. In Roman culture it even became sometimes a duty, as with the death of Seneca. Opposing views existed, but the matter was at least regarded as open for rational discussion. Only in the later Empire did economic considerations (revolving generally around the suicides of costly or even irreplaceable slaves and soldiers) begin to bring about more restrictive laws. Even then, the issue was the cost to the slaveowner or to the state, not a moral question about the act itself.

This changed as Christianity, with its visions of demons, the devil, angels, and God, consolidated its hold on Europe. With a brief exception during the reign of Charlemagne (768-814, during which, incidentally, what we would now describe as the ‘insanity defence’ was used for the first time), the lands subject to Christian control were legally and morally opposed to suicide no matter what the situation. Strictures increased, as did the number of peculiar practices: burial of the corpse of a suicide at a crossroads, with or without a stake in the heart, or the rule in Danzig, where

the body of a suicide was not permitted to go out through the door but rather had to be taken out through a window. Sometimes a hole had to be knocked in the wall when there was no window.4

Suicide remained a sin, and the posthumous penalties remained severe, for some time.

When this situation began to change, it was in large part through a process Michael MacDonald has yclept ‘medicalization’; there was an increasing tendency to regard suicide as either a symptom of an illness (usually mental), and thus beyond moral censure, or as a sort of illness in its own right, and thus again having no moral significance. Considered thus, suicide began to be seen as something treatable by physical means, such as drugs or restraint, or, more recently, through preventative measures such as drugs or therapy. In any event, suicide came to be approached as something specific to a patient, rather than an indication of trafficking with demons or succumbing to a complete lapse of moral fortitude.

In the last century and a half, then, suicide has increasingly been seen as a medical problem. With this tendency has come a horde of intriguing and complex questions, beginning with the very definition of suicide. When suicide is a sin, and religious authority is strong, defining it is easy: it is whatever the church says it is. When it is a crime, the same is true for the courts. But medicine cannot treat definition so cavalierly; precision is desired, in order that treatment may be precise as well. Further, there are the lawyers and insurance brokers who are constantly looking over the shoulders of the doctors. They, too, want a clear and precise definition, albeit more for reasons of finance and possible malpractice suits than for medical purposes.

“Disease,” Gunter Risse tells us, “has been defined as person-centered, discontinuous, and undesirable.”5 This is broad, perhaps too broad; suicide appears to fit here, but so do unrequited love (which, in fact, was at one time accepted as an illness) and a single loud hiccup during the slow movement of the Ninth Symphony. If we accept this definition even provisionally, we shall still require further classifications which acknowledge the disparity of impact among the three contingencies (suicide, unrequited love, and the hiccup).

Following Risse’s later distinctions, we may see suicide as physiological (if it is indeed a disease), since it is certain that it is commonly viewed “as a consequence of disturbed functions operating within individual human beings.” However, its only symptom would appear to be absence of life; therefore, it cannot meet another of Risse’s criteria: that it be “a specific and objective reality distinct from the patient harboring it,” since the patient harboring it is the corpse at hand. Without this, there could be neither symptom nor sign. Nor, indeed, disease.

Yet this suggests a further problem. If suicide is the disease, one which can be diagnosed only through the presence of death, what cure, even in principle, is possible? Resurrection? The concept has a venerable place in many mythologies, but a dubious one in medicine. Suicide, it seems, is a disease which needs to be cured before it manifests itself. Nor will it do to suggest that suicide is in fact a symptom of some other disease, say ‘death wish’. What is then being discussed is not suicide at all; suicide is an act, not an intention or a desire.

It should be pointed out, however, that many serious attempts have been made to predict and prevent suicide. It has become a matter of some urgency to make these efforts productive both scientifically and humanistically. This in turn has led to resourceful, if perhaps not entirely convincing, formulations such as that found in Marvin Farber’s 1968 Theory of Suicide, in which he presents “the basic proximal sociological equation for suicide,” (see box below)6

But the reaction one tends to feel toward the spirit that led to this equation, or to a slightly later attempt to develop Suicidal Intent Scales,7 raises what I take to be the most important question of all: is there in fact any reason whatever for seeing suicide as a disease?

Suppose we accept a strict ‘social construction’ model of disease: we say that a disease is a disease only if society recognizes it as such. We still need to find out how such a recognition or designation is made. If it is made, say, by a group of doctors or insurance brokers acting on a whim, then the recognition of a particular thing as a disease needs only an effective lobby group in its favour. If such recognition is done democratically, the same holds true, but with more emphasis on the mass media. And so on. Nonetheless, in all these cases, there must be some sort of reason for deciding for or against; at some point even an apparently random decision-making process presumably comes to rest on at least one criterion, even if it be only the number of coin tosses deemed decisive.

So, if social decisions about what counts as a disease are in any way rational, then we can find the criteria on which these decisions, consciously or unconsciously, are based and test their applicability to suicide. The social construction model of disease is, by definition, concerned primarily with the points at which a sufferer interacts with society. To show that a condition is a disease on this model is to at least suggest strongly that on any other, more ‘naturalistic’, view of disease, those points must be considered. That is to say, whatever causes a society to consider X a disease is likely to be some observable fact about the effect of X on the relationship of the afflicted individual to the external world. Where an observer can make no possible distinction between one state and the other, it is hard to imagine what would allow one state of being to be described as healthy and the other as sick. There needs to be some distinction, even if it is only hearing the words, “I feel sick”. This, of course, is not to say that hearing such a statement automatically entails accepting its truth. Thus both a social construction model and a naturalistic, or physiological, theory of disease rest in the end on the same idea, phrased slightly differently: that some sort of discovery leads to a particular state or set of states being designated as a disease. The former makes social recognition of those states the important thing, whereas the latter places emphasis on the disease, whether called such or not, being somehow objectively real. The two models overlap, in that both allow that some sort of a relation to the world leads to x being designated as a disease. The problem, then, is to find the respective criteria of the two models, especially in relation to suicide.

I want to suggest that the only relevant criterion is one which holds true for either model, and that that criterion is the very thing which lies at the heart of medicine. A disease is a disease to the degree that it interferes with the functioning of society. Cancer, for example, is a disease because it produces multitudes of infirm, bed-ridden, pain-wracked and (at least as seen from outside the immediate circle of family and friends) often repulsive individuals. It also costs a fortune in the process. Unrequited love, on the other hand, is not presently seen as a disease because it occasionally results in great art, or finds another object. It also enriches the purveyors of insipid cards and vapid pop music. It does cause disruptions, but seldom at the level of society; when it does, it is usually described as obsession rather than love.

On this view, suicide can’t be a disease. Suicide is a choice; as Schopenhauer remarked, “as soon as the terrors of life reach the point at which they outweigh the terrors of death, a man will put an end to his life.”8 It is a choice which denies any validity to society’s demands, and which asserts the absolute primacy of the individual will over any possible social constraint. Hence the perceived urgency of preventing the action and its accompanying, even if only implicit, statement; suicide annuls social requirements regarding the value of life. Laws and penalties mean nothing here; any sort of sanction, to quote Schopenhauer again, “is punishing the want of skill that makes the attempt a failure.” It is punishing a lapse in autonomy.

But isn’t the object of medicine, at least at the level of treatment, the maintenance of autonomy? Psychiatry attempts to free us from mental problems which impede our ability to make fully free choices; physical therapy attempts to remove or ameliorate restraints on our mobility, and the pantheon of other medical disciplines exists in order to remove constraints on our freedom and dignity. Even where distortions appear (as in Soviet psychiatry), they appear in the guise of restoring the proper state whence to make determinations of one’s own goals. Where systemic abuses occur, they are almost invariably based on a utilitarian calculus: that members of one group (poor black women in the United States, say) should lose a portion of their autonomy in order to free up valuable and scarce resources which may then be more fully utilized by members of another group (whites, in this case). That this calculus is specious, and the outcome vile, is true but irrelevant here; what is important is to note that the arguments always hinge on increasing the autonomy of the group in whose interest the dominant medical model, and establishment, is currently working. This would remain true even if, and perhaps especially, the benefited group came to include everybody.

If this argument holds, then suicide, which is an act asserting absolute autonomy, can never be a disease despite the fact that its very existence denies any validity to medical concerns as well as social ones. If medicine strives toward a maintenance, or restitution, of autonomy, then on its own grounds it must accept suicide as a legitimate choice, unless, as did the physicians William Rowley in 1788 and, again, J.E.D. Esquirol in 1838, it defines all individuals committing suicide as insane and incapable of autonomous choice. Yet to do this is also to remove suicide from the category of disease, since by making it related to mental illness, it is being made into a symptom, and is thus not a disease. Q.E.D.

Even the objection that suicide interferes with social functions in some way (perhaps through the pain it can bring to surviving friends and family members) is not very strong medically. It creates a very odd situation: the illness affects this person, yet the symptom appears in that person. This would entail the medical right of a person to have another treated in advance for a disease which has not yet manifested itself. This is surely a singular definition of both rights and medicine’s role.

It is also difficult to see how medicine would fit in here, since a suicide by me does not restrict your, or anyone else’s, autonomy (that which medicine, on this account, attempts to preserve or restore for you). At most my suicide exposes you to a certain social opprobrium; as Nietzsche commented, “The relatives of a suicide resent him for not having stayed alive out of consideration for their reputation.”9 Again, this may be an unfortunate condition, but it is not one which medicine can address without becoming self contradictory.

Illnesses and diseases are occasions in the lives of individuals and the eyes of society. But “Death is not an event in life,” as Wittgenstein said; “we do not live to experience death.”10 Nor can we even in theory cure suicide. If it exists it is beyond cure; if it is prevented, it never existed, and what never existed, perforce, can be nothing.

Suicide is neither sin nor crime, illness or disease. It is simply an act which puts an end to all definitions, and as such is beyond the reach of medicine altogether.

© J Busch 1998

Justin Busch is completing a doctorate in philosophy at McMaster University, Ontario

1) Santayana, George lnterpretations of Poetry and Religion. New York City, Harper, 1957, p.149.
2) MacDonald, Michael ‘The Medicalization of Suicide in England.’ in Rosenberg, Charles E., and Golden, Janet, eds., Framing Disease: Studies in Cultural History. Rutgers University Press, 1992 pp.85-103.
3) Durkheim, Emile Suicide. New York City, The Free Press, 1951, p.44.
4) Farberow, Norman, ed. Suicide in Different Cultures. Baltimore, University Park Press, 1975, p.7.
5) Risse, Gunter B. ‘History of the Concepts’ in Encyclopedia of Bioethics. New York City, The Free Press, 1978, Vol.2, pp.579-585.
6) Farber, Maurice L. Theory of Suicide. New York City, Funk & Wagnalls, 1968, p.75.
7) See Beck, A.T., Resnik, H.L.P., and Lettieri, D.J., eds. The Prediction of Suicide. Bowie, The Charles Press Publishers, 1972.
8) Schopenhauer, Arthur Complete Essays of Schopenhauer. New York City, Willey Book Co., 1942, Book 5, p.30, p.26
9) Nietzsche, Friedrich Human, All Too Human. Univ. of Nebraska Press, 1984, p.180.
10) Wittgenstein, Ludwig Tractatus Logico-Philosophicus. Routledge, 1978. 6.4311.

Farber’s Theory of Suicide

in which:
S=Probability of Suicide
PIC=Frequency of Production of Personalities Injured in Their Sense of Competence
DEC=Demands for the Exercising of Competence
DIG=Demands for Interpersonal Giving
TS=Tolerance of Suicide
Su=Availability of Succorance
HFT=Degree of Hope in the Future Time Perspective of the Society

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