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).