Suicide is recognised internationally as being a major public health issue. Defined by the World Health Organization (WHO) as ‘the result of an act deliberately initiated and performed by a person in the full knowledge or expectation of its fatal outcome’, suicide accounts for an average of 16 per 100000 deaths, or one death every 40 seconds (WHO 2001a, 2007c). According to WHO, over the past 45 years, suicide rates have increased by 60% and are among the top three leading causes of death in people (male and female) aged 15–44 years. Although suicide occurs in all ages across the life span (including the very young and the very old) and in people from all walks of life, it stands universally as a leading cause of death among young adults. Although the probable ‘causes’ of suicide vary across cultures and countries, depression and substance abuse have both been implicated as critical factors leading to suicide (Rudnick 2002; Taylor et al 2007; WHO 2001a).

The figures given above do not include attempted suicide rates. While reliable data on the incidence of attempted suicide are difficult to obtain, the WHO estimates that suicide attempts occur up to 20 times more frequently than completed suicides (WHO 2007c). According to Australian estimates, for every male suicide there are approximately 30–50 attempts; and for every female suicide there are approximately 150–300 attempts (Suicide Prevention Victorian Task Force 1997: 21).It has been further estimated that of those who engage in suicidal behaviour (attempt suicide), 15% will ultimately succeed in ending their own lives (Suicide Prevention Victorian Task Force 1997: 21). Some studies (e.g. in Canada and Australia) suggest that around 5% of the population may be at lifetime risk of suicide ideation and behaviour, and that around 70% of people with suicide ideation may make no contact with medical or related service providers (de Leo et al 2005; Taylor et al 2007; Pridmore et al 2007).

Suicide is ranked as a leading cause of death in many countries (other leading causes of death are: ischaemic heart disease; cerebral vascular disease; cancer of the lung, trachea and bronchus; cancer of the stomach; female breast cancer; bronchitis, emphysema and asthma; chronic liver disease; and motor vehicle accidents). In the Australian state of Victoria, suicide deaths were once reported to have even outnumbered the state’s road fatalities (Ryle 1993). The probability that some road fatalities are also ‘autocides’ — that is, deaths as the result of premeditated suicidal automobile accidents — increases the significance of these statistics (Murray & de Leo 2007).

According to the most recent Australian suicide statistics, for the year 2004 there were 2098 registered deaths from suicide, being 1.6% of all deaths for that year (Australian Bureau of Statistics [ABS] 2007). These figures represent a decline over time in suicide deaths, notably from 2720 in 1997, and 2213 in 2003 (ABS 2007). Figures show that males (1661) were almost four times more likely than females (437) to die by suicide, and that the highest number of deaths occurred in males between 30 and 34 years, followed by males 40–44 years (ABS 2007). It should be noted that Australia once had one of the highest rates of suicide among young people aged 15–24 years, with rates in this age group tripling over the past 40 years (National Advisory Council on Youth Suicide Prevention 2000: 6). According to recent research, however, suicide rates in this population has declined significantly over the past 5 years, notably from 40 per 100000 in 1997–98, to approximately 20 per 100000 in 2003 (Morrell et al 2007). Nonetheless, suicide data show that youth suicide (particularly among males) is over-represented in remote and rural areas; and that youth suicide is also over-represented among gay and lesbian youth (especially those living in remote and rural areas), possibly accounting for up to 30% of all completed youth suicides each year (Suicide Prevention Victorian Task Force 1997: 19, 40). Explaining this statistical over-representation among gay and lesbian youth, one commentator has written that ‘homosexual orientation, cultural homophobia and geographical/social isolation are clearly a lethal mixture’ (Christian 1997: 9). Other high-risk groups include: men over 80 years of age, Aboriginal and Torres Strait Islander people (rates have been estimated to be approximately 40% higher than the general population), the homeless, people with HIV/AIDS, and prisoners (National Advisory Council on Youth Suicide Prevention 2000: 7; O’Driscoll et al 2007; Suicide Prevention Victorian Task Force 1997: 38–40).

Suicide figures in the United States (US) are comparable with those in Australia. According to official estimates, there are approximately 30000 certified suicides (being 1.3% of all death) in the US each year, with many other probable suicides classified as ‘accidental deaths’ (Beauchamp & Childress 2001: 188). Suicide is the third leading cause of death in young people aged 15–24 years, and the fifth leading cause of death in children 5–14 years (Caruso 2001). As is the case in Australia, males are four times more likely to die from suicide than females, and there is consistent evidence showing ‘unusually high rates of attempted suicide among gay [and lesbian] youth, in the range of 20–30%, regardless of geographic and ethnic variability’ (Remafedi 1994b: 7; see also Caruso 2001). As in Australia, gay and lesbian youth may comprise ‘up to 30% of completed youth suicides annually’ in the US (Gibson 1994: 15). These rates are thought to be causally linked to these youths’ traumatic experiences of coming to terms with their sexuality in contexts (such as families, communities, society as a whole) that are for the most part unsupportive, alienating and aggressively homophobic (see in particular Remafedi 1994a).

The magnitude of the child suicide problem in the US was highlighted in 1993 with the reported suicide of a 6-year-old girl, believed to be the youngest recorded suicide in the State of Florida (Power 1993: 9). The child was killed after she deliberately placed herself in front of an oncoming train. Her death was witnessed by three other children aged six, seven and eight years old respectively — all of whom ‘tried to move her as the train approached’ (p 9). The engineer was unable to stop the train ‘until nearly a kilometre after impact’ (p 9). It is believed that the little girl wanted to die so that she could ‘become an angel and be with her mother’, who was dying of cancer (p 9).

(As a point of interest, contrary to popular thought, child suicide is not an isolated or new phenomenon. During the late Middle Ages and early modern period, for instance, children under the age of 15 years were regarded as being at increased risk of suicide owing to the violent and abusive ways in which they tended to be treated during this period [Williams 1997: 153]. Today, while suicide rates are relatively low in children under 15 years of age, there has been some suggestion these may be increasing. In 1995, for example, in the Australian state of Victoria, four deaths by suicide were of children aged between 10 and 14 years [Suicide Prevention Victorian Task Force 1997: 16].)

A new and unusual dimension of the suicide problem to emerge in recent years has been the increasing incidence of cyberspace suicide pacts or ‘cybersuicide’ — that is, ‘suicides or suicide attempts influenced by the internet’ (Rajagopal 2004: 1299; see also Thompson 1999). Suicide pacts (defined as ‘an agreement between two or more people to commit suicide together at a given time and place’) are not a new phenomenon, although their incidence is relatively rare accounting for less than 1% of all suicides (Rajagopal 2004: 1298). Whereas most suicide pacts are between people who are well known to each other (e.g. spouses, siblings, friends), what has been particularly unusual about the recent spate of cybersuicide pacts is that they have been between complete strangers who, as stated by Rajagopal (2004: 1298) ‘have met over the internet and planned the tragedy via special suicide websites’.

Commentators are worried that the new cyberspace suicide networks will become ‘breeding grounds for real-life tragedies’ (Dubecki 2007a, 2007b) and will spark an epidemic of internet death pacts as despondent young people in particular — especially those immersed in a youth sub-culture of online networking — will ‘log out of life’ (Cameron 2005, 2006). The news media reported suicide pact deaths of 13 people in just 1 week in Japan in 2006 (where group suicides reportedly claimed 91 lives in 2005, eight of whom were young people aged between 10 and 19, and 40% of whom — both men and women — were in their 20s), and a similar spate of suicide pact deaths in Korea (where 191 group suicides were reported in the news media between 1998 and 2006). Reports such as these have underscored public health concerns about a cybersuicide epidemic (Cameron 2005, 2006; Sang-Hun 2007).

Australia has not been immune from the tragedy of cybersuicide. In 2007, the bodies of two teenage girls, both aged 16 years, were discovered in the Dandenong Ranges National Park east of Melbourne (Dubecki 2007a: 1). The two girls were apparently part of an ‘“emo” (short for emotional) subculture’ — named after a kind of music that is characteristically ‘emotional and confessional’ in tone (Dubecki 2007b; Oakes 2007). Young people who identify as ‘emos’ are thought to regard themselves as being emotional or depressed, prefer mixing in their own group, have particular preferences in music (e.g. post-punk, ‘emotive hard core’ or heavy metal styles), clothes, makeup and hairstyles (Martin 2006: 2). Like other dark sub-culture movements (e.g. goth), the emo sub-culture has been linked by youth mental health experts to self-harm, including suicide attempts (Martin 2006).

Suicide, by its very nature, is an extremely difficult and complex issue to address. At a personal level, the suicide of a loved one, a friend or an associate can be a devastating experience. Those ‘left behind’ may find themselves struggling ‘to make sense of the suicidal act and the causes of suicidal behaviour’ (Davis 1992: 90). They may also find themselves overwhelmed by feelings of grief, shame, remorse, anger, despair, and possibly even guilt at the thought that ‘perhaps they could have done more’ or that ‘if only they had been there … it might never have happened’. It has been estimated that for every suicide, between six and ten people (including family, friends and co-workers) are directly and strongly affected by the event (Suicide Prevention Victorian Task Force 1997: 25; Williams 1997: 224). Significantly, people bereaved by suicide are themselves 10 times more likely than the general population to die from self-inflicted deaths (Suicide Prevention Victorian Task Force 1997: 25).

Suicide is also difficult to address at a professional/therapeutic level. Even the very best of psychotherapies may still fail to prevent a person from completing a suicide; and even the very best of medical and nursing care may still fail to restore someone who has attempted suicide to a life that person regards as being ‘worthwhile’ and worth living. Equally if not more problematic are the difficulties of addressing the suicide issue at a moral level. Included among these difficulties is the challenge suicide and attempted suicide pose to fundamental moral notions about the value, sanctity and meaning of life. An important question here is not ‘how to achieve a better more fruitful [good] life’ — a central question in Western moral philosophy — but, as Heyd and Bloch (1981: 185) point out, ‘whether to live at all’. More seriously, suicide challenges morality itself, and not least the values, standards and principles comprising it which might otherwise be appealed to for guiding deliberation on such issues as the entitlements and responsibilities of people contemplating suicide; the moral permissibility and impermissibility of suicide prevention; the entitlements and responsibilities of others towards those contemplating or attempting suicide; and other similar issues. Compounding the moral complexity of these issues is the additional consideration that, unlike other causes of death, suicide (or, more specifically, death from suicide) is relatively preventable (Baume 1988: 43).

Nurses who have either cared for a person who has attempted suicide, or who have been involved in the care of family members and friends of someone who has attempted suicide or succeeded in suiciding, will be only too familiar with the deep emotional agony that inevitably comes with this kind of situation. They will also be very aware of the complex moral problems that are commonly associated with implementing interventions aimed at preventing suicide, with caring for those who have attempted unsuccessfully to suicide, and with the difficulties of addressing these problems in a satisfying and helpful way.

It is not the purpose of this discussion to examine or present a treatise on the clinical aspects of suicide (its underlying causes and means of prevention), or, indeed, on the philosophy or sociology or anthropology of suicide. Such a task would require major works in their own right — as has already been undertaken (see, e.g. Battin 1982, 1996; Battin & Mayo 1980; Clemons 1990; Colt 1991; Durkheim 1952; Farberow 1975a; Firestone 1997; Hendin 1998; Kaplan & Schwartz 1993; Miller 1992; Stengel 1970). Rather, the task here is to assist nurses to gain an understanding of the moral aspects of suicide and suicide prevention, and the nature of nurses’ moral obligations when caring for people who are contemplating or who have attempted suicide. In undertaking this task, attention will be given to examining briefly:

Concepts of and attitudes towards suicide have varied enormously across different cultures and throughout time (see in particular Farberow’s [1975a] Suicide in different cultures). Just what was regarded as an act of suicide and whether suicide was approved or disapproved depended on a range of factors, including cultural norms and mores, religion, law, politics, and personal and social morality (Alvarez 1980; Amundsen 1989; Battin 1982, 1996; Beauchamp 1989; Beauchamp & Childress 2001; Beauchamp & Perlin 1978; Brody 1989b; Cooper 1989; Farberow 1975b; Ferngren 1989; Hendin 1998; Miller 1992; Stengel 1970). These factors have seen Western attitudes towards suicide shift dramatically from those of socio-cultural approval through to religious prohibition, criminalisation, and ultimately the medicalisation of suicide (see Figure 11.1).

Before examining some of the moral issues raised by the suicide question, it is necessary first to establish at least a working definition of suicide — a term which, incidentally, entered the English language only in 1651 (Wennberg 1989: 17; Battin 1982: 22–58).

The word suicide comes from the Latin sui, ‘of oneself’ and cidium, ‘a slaying’ (from caedere, ‘to kill’). Like many other terms used in moral discourse, suicide is not easy to define; indeed, there is no universally agreed definition of what suicide is, or of what criteria should be met in order for an act to count as an instance of suicide. As Margolis (1978, reprinted in Beauchamp & Perlin 1978: 92–3) explains, the ‘culturally variable character of suicide’ has given rise to many competing views on what it is, with the unhelpful consequence that some acts have been included as suicide and others firmly excluded. This, in turn, has had some important practical consequences, including the difficulty of ascertaining accurate and comparable statistics on the incidence and causes of suicide (Beauchamp 1980: 68–9).

For Wennberg (1989: 17), wrestling with the problem of defining suicide is to be taught a lesson in ‘linguistic humility’. Nevertheless, our commonsense notions of what suicide is, our ability to recognise instances of suicide and to distinguish these from other kinds of death (e.g. homicide, patricide, matricide, fratricide, sororicide, infanticide, regicide and euthanasia or euthanatic suicide [Battin 1982: 20]), and the very existence of terms in our language which make it possible to speak of suicide as a distinctive kind of death, all provide grounds for optimism about our ability to achieve at least a working — if not a universal — definition of suicide.

According to Stengel (1970: 77), a commonsense notion of suicide can be expressed in the following terms:

This definition is not, of course, without controversy. For example: What constitutes a ‘genuine’ suicide attempt? When is a suicide attempt to be regarded as ‘half-hearted’ as opposed to ‘whole-hearted’? (see also Knight 1992). Further, as Stengel himself points out, the definition may not do justice to what has become ‘a very common and varied behaviour pattern’ (1970: 77). Nevertheless, it provides an important insight into the kinds of criteria that should be met in order for an act to count as suicide. One such criterion is that of intention — specifically, the intention to end one’s life (Margolis 1975, reprinted in Beauchamp & Perlin 1978: 95). As Beauchamp points out (1980: 70), central to what is called the ‘prevailing definition’ of suicide is the following premise: ‘Suicide occurs if and only if there is an intentional termination of one’s own life.’

Beauchamp suggests that other criteria should be met in order for an act to count as suicide, including the following:

Windt suggests similar criteria of suicide (all of which have been mentioned in the suicide literature). These are:

At first glance, these and similar criteria of suicide appear helpful. On closer analysis, however, a number of problems quickly become apparent — not least the problem of so-called ‘exceptional cases’, and whether the criteria listed are relevant to or can be applied appropriately and meaningfully to these cases. Consider, for example, the cases of people engaging in dangerous and potentially life-threatening (‘suicidal’) sports (for instance, bungee jumping, mountain climbing, racing car driving, hang gliding); dangerous work activities (being a member of a bomb disposal squad or a combat soldier are paradigm examples here); or other life-threatening activities such as cigarette smoking, eating and drinking excessively, illicit drug taking, and so on. In all these cases, it is probably true that the people concerned: chose the activities in question; were aware of the potential threats the activities posed to their lives and wellbeing; voluntarily engaged in the activities chosen; and, were they to die as a result of engaging in these activities, were ‘responsible for their own deaths’, insofar as they were willing accomplices to the activities and their associated risks. Further, while the people concerned might not have intended their own (accidental) deaths, they nevertheless foresaw their deaths as a possibility associated with the risky activities they had engaged in, and thereby, ipso facto, can be said to have intended their own demise. Given the criteria for suicide outlined above, it seems we are committed to accepting that people who die as a result of their deliberately engaging in dangerous sporting activities, work activities or lifestyles have, in essence, suicided. Yet, this does not seem to accord with our intuitions on the matter — nor does it sit comfortably with what we would perhaps ordinarily regard as suicide. Let us examine another example to see if this will clarify the matter.

In 1982, Barney Clark, aged 62, became the first human being to receive an artificial (mechanical) heart (Beauchamp & Childress 2001: 188; Rachels 1983). Recognising that this medical experiment had the potential to make Mr Clark’s life burdensome, his doctor, Willem Kolff, gave him a key that could be used to turn off the compressor sustaining the artificial heart’s action. Defending his decision to supply this key, Dr Kolff argued that if Mr Clark:

The conceptual dilemma which arises here is this: if Mr Clark had chosen to use the key he had been given, and had turned off the compressor driving his artificial heart, which of the following statements would have been the most accurate description of his action and the cause of his death:

To complicate the issue, as Beauchamp and Childress point out (2001: 188):

And, to complicate the issue still further, what if Mr Clark had consented to receiving the heart in the belief that the risks associated with the experiment were so great that a hastened death would be assured? Could this be classified as a kind of suicide?

Part of the difficulty in sorting out the conceptual confusion surrounding the development of an adequate definition of and criteria for suicide can be linked to the lingering legacy of varying socio-cultural historical and religious taboos against suicide. Beauchamp and Childress (1989: 223) suggest, for example, that we often shield acts of which we approve (or at least acts of which we do not disapprove) from the stigmatising label of ‘suicide’ — preferring instead to use terms that are more socially acceptable, such as ‘euthanasia’ or ‘withdrawing extraordinary life-saving treatment’, and similar notions. If this is correct, it is ironic, considering that the term ‘suicide’ was first adopted in the 17th century as a more ‘acceptable’ alternative to the then contemporary usages ‘self-murder’ and ‘self-slaughter’, which were regarded by more liberal-minded people of the day as having unacceptably negative connotations (Battin 1982: 22, 58).

In light of these considerations, perhaps an important first step in developing a workable definition of and criteria for suicide is to demystify suicide, and to strip it of the taboos and stigmatisations which still seem to linger around it — and which may encourage people to be less than intellectually honest when speaking of its incidence and cause. A second and related step is to modify the negatively connoted language that tends to be used in referring to and discussing suicide. In this instance, the problem of language is highly significant, and should not be underestimated. As Wennberg explains (1989: 17):

The lesson here is important: the use of the phrase ‘committed suicide’ (as opposed to using the phrase ‘completed suicide’ or the term suicided) is misleading and unhelpful — not least because it seems to imply the commission of a crime, or even a sin, when clearly there has been none.

A third and final step towards developing a working definition of and criteria for suicide is to reinstate the authority of our own ordinary commonsense experience of the world, and our collective experience-based knowledge of what is and is not an act of suicide or attempted suicide. One reason for this is that, in the ultimate analysis, the distinction between suicide and other types of death (e.g. euthanasia) may rest not on sophisticated philosophical criteria, but on our fine intuitions informed by life experience. I suspect, however, that in the main, conceptual clarity in regard to what is and is not an act of suicide will rest on something far more substantial than abstract criteria or even well-informed intuition. Rather, the matter will be decided by appealing to:

The problem remains, however, that ascertaining these things may be just as difficult as establishing reliable criteria for suicide. Nevertheless, it is important that suicide be defined. One reason for this is that without an adequate definition of suicide it will remain extremely difficult to assess accurately the incidence, cause and appropriate means of preventing suicide. It will also be difficult to eradicate the spurious distinction which is sometimes drawn between ‘genuine’ and ‘non-genuine’ suicide attempts, with the tragic consequence that some who are suffering and needing help will be dismissed as malingerers, and worse, as not suffering or needing help at all.

(To advance understanding on the raw suffering and despair that suicidal people experience, see in particular: Williams [1997] Cry of pain: understanding suicide and self-harm; Heckler [1994] Waking up alive: the descent to suicide and return to life; and Knight’s [1992] discussion on the suffering of suicide.)

Finally, without an adequate definition of suicide it will make it difficult to engage in substantive moral debate on the ethical aspects of suicide, and to respond effectively and appropriately to the many moral problems raised by the suicide question, some of which are considered below.

Before continuing, however, a brief clarification is required on the working definitions of the terms ‘suicide’ and ‘parasuicide’ to be used in the remainder of this chapter, and on the distinction which might otherwise be drawn between ‘suicide’ (as presently being considered in this chapter) and ‘euthanasia’ (as considered in the previous chapter).

Although there is no universally agreed definition of suicide, and, as shown, the term itself is difficult to define (see also Soubrier 1993), suicide is generally recognised as being one of the five medical–legal classifications of modes of death, which are taken to include (in addition to suicidal death): accidental, natural, homicidal and undetermined death (Colt 1991: 263–4). Furthermore, while acknowledging the many difficulties associated with formulating a precise and universally agreed definition of suicide, there is a strong sense in which suicide (at least in the Western world) can be meaningfully understood as:

A more elaborate explication of this view is as follows (advanced by Edwin Shneidman [1993: 3], popularly regarded as the ‘father’ of contemporary suicidology [Leenaars 1993: xi]):

Parasuicide (a term which came into usage in the late 1960s in an attempt to overcome the confusion associated with using the term ‘attempted suicide’ [see Kreitman 1969; Williams 1997: 68]) can, in turn, be defined as:

For the purposes of this discussion, both suicide and parasuicide are taken here as being the ‘unequivocal expression of raw suffering’ (and it might be added ‘psychache’ [Shneidman 1993]) of individuals — a suffering from which, for a variety of reasons (not always known or understood by others), these individuals have not been able to secure relief (Heckler 1994: xxiv). Suicide ideation (suicidal thoughts) and suicidal behaviour are also taken here as being ‘the result of extreme and unusual human predicaments’ which require our deepest and most empathic understanding (Heckler 1994: xxv), not our derision as has so frequently been the case (see Bailey 1994, 1998).

Suicide, as being considered in this chapter, is taken here as referring to a different kind of death that might otherwise be brought about by voluntary active euthanasia or physician-assisted suicide. While euthanasia, physician-assisted suicide and ‘unassisted’ suicide (the topic of this chapter) share many features in common, as we will go on to see, there are also some significant differences between them. One such difference was captured recently by the following insightful comments made in class by an on-site overseas student undertaking a Bachelor of Nursing (post-registration) degree at RMIT University in Melbourne, Australia:

Other differences will become more apparent as the discussion in this chapter is advanced. One key difference, however, warrants mention here: whereas euthanasia and physician-assisted suicide tends to be conducted in the context of a breakdown in physical health and wellbeing, suicide (as being considered here) tends to occur in the context of a breakdown in mental health and wellbeing; that is, it is linked in important ways to a lethal combination of the psychogenic distress states of depression, hopelessness, despair and apathy (Colt 1991; Firestone 1997; Heckler 1994; Hendin 1998; Leenaars 1993; Lester & Tallmer 1994; Remafedi 1994a; Shneidman 1993; Williams 1997).

As discussed earlier under the subheading ‘Socio-cultural attitudes to suicide: a brief historical overview’, the Judaeo–Christian traditions have, for the most part, regarded suicide as the gravest sin imaginable, and as constituting the most serious violation of one’s duties to oneself, to others and to God. These views have been extremely influential and, not surprisingly, the subject of much philosophical debate. Today, however, as Knight (1992: 262) correctly points out, ‘religiously speaking, the notion of suicide as an unforgivable sin has few, if any, defenders in contemporary moral philosophy’. Further, unlike the days when religious prohibition saw suicide condemned as a grossly immoral act, it is difficult today to find tenable moral arguments against the suicide of people who are able to choose autonomously to end their own lives (Knight 1992: 262). Nevertheless, a number of troubling questions remain about the ethics or morality of suicide, such as: Is there a right to suicide? If so, what conditions must be satisfied before this right can be claimed? What are the obligations of others in regard to those contemplating or attempting suicide? Is there a duty to prevent suicide? If so, under what conditions should a suicide be prevented? It is to briefly answering these questions that the remainder of this discussion now turns.

Some may find it amenable to view suicide as the manifestation of a mental illness, and hence something that is ‘irrational’ and ‘irresponsible’ and ipso facto quite beyond the realms of moral inquiry (see, e.g. Beauchamp & Childress 2001; Heyd & Bloch 1981; Margolis 1978; Stengel 1970; Wennberg 1989). This discussion has shown, however, that even if suicide is the product of mental illness or extreme emotional distress, depression or other psychogenic pain states, it still has a profound moral dimension, and still requires those involved in suicide prevention and intervention to justify their views and actions, and not to merely assume that these are in themselves morally correct just because they have as their end the preservation of life or the maximisation of autonomy.

Suicide and parasuicide are issues of importance and concern to all nurses, not just to those working in the area of mental health. How well nurses and others respond to the moral issues raised depends, however, on a variety of factors — including the success with which suicide is stripped of the taboos which still surround it, and the degree to which suicide is demystified as a desperate act aimed at transcending a situation which a distressed person has come to perceive as hopeless.

Some years ago I was involved in the care of a woman who had attempted suicide by pouring a can of petrol over herself and setting fire to it. She arrived in casualty with 100% burns to her body. Incredibly, despite the horrendous injuries her body had sustained, her eyes were unharmed. The extent of her burns made it impossible to insert an intravenous line in the usual way, and a cut-down (which involves a surgical incision to expose a deeply situated vein) had to be performed. I remember the doctor looking at me while he was performing the cut-down, and gasping in horror as the woman’s burnt flesh parted in his hands. Nevertheless, this compassionate man succeeded in inserting the intravenous line, and consoled the woman as he did so. As we all worked diligently to retrieve this injured life, the woman looked on smiling, and reassuring us all with the words, ‘Don’t worry dears, I will be all right’. I remember looking up at this woman and, on observing her terrible injuries, thinking how desperate she must have been to have engaged in such an act. She, however, looked back at me with eyes that were clear and shining, and, bizarre as this whole scene was, I could see that she had found incredible peace within herself. The image of her burnt and tortured body did not sit well with the peace expressed in her eyes, but I knew that she had achieved her goal, and that it would be only a matter of time before she would be released from the suffering that had motivated her to undertake such a desperate act. Her death a day or two later was no surprise. Yet I still cannot help thinking that this woman paid a terrible price for the peace she eventually found in death, and could not find in life.

During the same year, I was involved in the care of a man who had also attempted suicide, in this instance by placing the muzzle of a gun in his mouth and shooting himself. He failed in his attempt to kill himself, however, and succeeded only in destroying one side of his face. After receiving plastic surgery to repair the serious gunshot wound sustained, he was admitted to intensive care. Unlike the woman who had set fire to herself, however, he was not at peace within himself. As he lay corpse-like on his bed, I remember noting that his eyes were like the eyes of a dead man — fully dilated, dull, and unresponsive to light. It was as though his soul had died, and nothing mattered any more. Once, when his plastic surgeon visited to check his wounds, the man handed the doctor a note. Written on the note were the words: ‘Dear Dr X — did you do this [the surgical repair] for your sake or mine?’ Understandably, the surgeon, who was a compassionate and gentle man, was devastated. Shortly after being transferred out of the intensive care unit to a general ward, the man climbed out through a toilet window and plunged to his death several storeys below. Many of the staff were left feeling that they had failed this man. The circumstances motivating his initial suicidal attempt had not seemed insurmountable to them, and they sincerely believed he was ‘better’. But he was not better, and eventually he too achieved his goal of death. As I recall the case of this desperate and hopeless man, I cannot forget the costly suffering and distress of those he left behind — especially his wife and young children. How different things would have been if he, like the people caring for and about him, could have perceived that his problems were not as overwhelming as he thought, and that it was not necessary to take the desperate action that he ultimately took. To this day, I am reminded by this case of the importance of never underestimating the capacity of human beings to feel deeply and to suffer profoundly on account of things which seem (though they may not necessarily be) insurmountable, and of how feelings of desperation and hopelessness associated with problems perceived as insurmountable can so easily override the desire to go on living. ²

In June of 1993, a Victorian coroner’s court was reported to have found that the suicide of five severely depressed patients at Larundel Hospital (decommissioned and closed in the late 1990s) was, among other things, a regrettable consequence of a well intended but nevertheless misguided priority being given to upholding patients’ rights to confidentiality (i.e. the ‘right’ not to be observed too closely) at the expense of patient care. Further, there had been a less than optimal level of commitment to ‘patient-centred continuity of care rather than changes in treating medical personnel due to patient progress’ (Pegler 1993: 26, [emphasis added]). The coroner is reported to have also found that ‘the most important issue arising from the inquests was family and carer involvement in treatment’, and that ‘a policy needed to be developed on the conflict between patient rights and patient care’ (Pegler 1993: 26).

Whether matters such as these can — or, indeed, should — be the subject of institutional policy is a debatable point. As experience tells us, even the very best of policies may still fail to prevent this kind of situation from occurring. Nevertheless, it is clear that there is room for improvement in the care and treatment of those contemplating or attempting suicide, and, more importantly, in understanding the moral issues involved in caring for those who, for whatever reason, are unable to care about themselves. It is also clear that, in securing these improvements, nurses must ensure that, in attempting to uphold the moral rights of their emotionally distressed, severely depressed and mentally unwell patients, they do not lose sight of the importance of also protecting and promoting their patients’ welfare and wellbeing — something which may not always be secured by paying homage to abstract moral rights and principles. By doing this, nurses, and others involved in caring for people who are contemplating suicide or who have already attempted suicide, may well succeed in helping to prevent and remedy the terrible sufferings and tragedies that have become so characteristic of the whole phenomenon of suicide in our community and in the world.