Communications Department

Part I: Suicide and Mental Illness

Jan 1, 2013 | Medical Ethics

Why We Shouldn’t Legalize Assisting Suicide

Part I: Suicide and Mental Illness

By Burke J. Balch, J.D., and Randall K. O’Bannon, M.A.

Under the banners of compassion and autonomy, some are calling for legal recognition of a “right to suicide” and societal acceptance of “physician-assisted suicide.” Suicide proponents evoke the image of someone facing unendurable suffering who calmly and rationally decides death is better than life in such a state. They argue that society should respect and defer to the freedom of choice such people exercise in asking to be killed.

But what would be the consequences of accepting this perspective? Let us examine the facts.

Accepting a “right to suicide” would create a legal presumption of sanity, preventing appropriate mental health treatment.

If suicide and physician-assisted suicide become legal rights, the presumption that people attempting suicide are deranged and in need of psychological help, borne out by many studies and years of experience, would be reversed. Those seeking suicide would be legally entitled to be left alone[1] to do something irremediable, based on a distorted assessment of their circumstances, without genuine help.

An attempt at suicide, some psychologists say, is often a challenge to see if anyone out there really cares.[2] Indeed, seeking physician assistance in a suicide, rather than just acting to kill oneself, may well be a manifestation, however subconscious, of precisely that challenge. If society creates a “right to suicide” and legalizes “physician-assisted suicide,” the message perceived by a suicide attempter is not likely to be, “We respect your wishes,” but rather, “we don’t care if you live or die.”

Almost all who commit suicide have mental health problems.

Few people, if any, simply sit down and make a cool, rational decision to commit suicide. In fact, studies have indicated that 93-94% of those committing suicide suffer from some identifiable mental disorder[3]. In one such study, conducted by Dr. Eli Robbins of suicides occurring in St. Louis, Missouri, 47% of those committing suicide were diagnosed as suffering from either schizophrenic panic disorders or from affective disorders such as depressive disorders, dysthymic disorders, or bipolar disorder. An additional 25% suffered from alcoholism while another 15% had some recognizable but undiagnosed psychiatric disorder. 4% were found to have organic brain syndrome, 2% were schizophrenic, and 1% were drug addicts[4]. The total of those with diagnosable mental disorders was 94%. An independent British study came up with a remarkably similar total figure, finding that 93% of those who commit suicide suffer from a diagnosable mental disorder[5].

Persons with mental disorders make distorted judgments.

Suicide is often a desperate step taken by individuals who consider their problems so intractable as to make their situations hopeless. But experts in psychology recognize the evaluations these individuals make of their personal situations are flawed.

The suicidal person suffering from depression typically undergoes severe emotional and physical strain[6]. This physical and emotional exhaustion impairs basic cognition[7], creates unwarranted self-blame, and generally lowers overall self esteem[8], all of which easily lead to distorted judgements[9]. These effects also contribute to the sense of hopelessness that is the primary trigger of most suicidal behavior[10].

Studies have shown that during the period of their obsession with the idea of killing themselves, suicidal individuals tend to think in a very rigid, dichotomous way, seeing everything in “all or nothing” terms; they are unable to see any range of genuine alternatives[11]. Many seem to be locked into automatic thoughts and responses, rather than accurately to understand and respond to their environment[12]. Suicide attempters also tend to maximize their problems, minimize their achievements, and generally to ignore the larger context of their situations[13]. They sometimes have inordinately unrealistic expectations of themselves[14]. During the period of their disorders, these individuals usually see life as much more traumatic than it actually is and view temporary minor setbacks as major permanent ones[15].

Most of those attempting suicide are ambivalent; often, the attempt is a cry for help.

Studies and descriptions of suicide attempters who were prevented from committing suicide by outside intervention (or in some cases, because the means used in the attempt did not take complete effect) demonstrate that most suicidal individuals have neither an unequivocal nor an irreversible determination to die. For example, one study conducted by two psychiatrists in Seattle, Washington found 75% of the 96 suicide attempters they studied were actually quite ambivalent about their intentions to die[16]. It is not actually a desire to die, but rather the desire to accomplish something by the attempt that drives the attempter to consider such a drastic option. Suicide is the means, not the end.

Often, suicide attempters are apparently seeking to establish some means of communication with significant persons in their lives[17] or to test those persons’ care and affection[18]. Psychologists have concluded that other motives for attempting suicide include retaliatory abandonment (responding to a perceived abandonment by others with a revengeful “abandonment” of them through death)[19], aggression turned inward[20], a search for control[21], manipulative guilt[22], punishment[23], escapism[24], frustration[25], or an attempt to influence someone else[26]. Communication of these feelings — rather than death — is the true aim of the suicide attempter. This explains why, paradoxically but truthfully, many say after an obvious suicide attempt that they really didn’t want to kill themselves[27]. Psychiatrists have long advanced the opinion that underlying a suicidal person’s ostensible wish to die is actually a wish to be rescued[28], so that a suicide attempt may quite accurately be described, not as a wish to “leave it all behind,” but as a “cry for help.”[29] To allow or assist in a suicide, therefore, is not truly fully respecting a person’s “autonomy” or honoring an individual’s real wishes[30].

The disorders leading many to attempt suicide are treatable.

Depression can be treated. Alcoholism can be overcome. The difficult situations and circumstances of life which, at the moment, seem permanent and pervasive, often dissolve or resolve in time. The emotional and cognitive patterns of thought and emotion which cloud the suicide attempter’s judgement and lead to feelings of utter despair and hopelessness, with proper psychiatric care, can be rechanneled in more rational, positive ways[31].

Crucial to such turnarounds is intervening to stop the suicide attempt and getting the attempter professional psychological assistance. Encouraging or validating the disturbed individual’s feelings or misperceptions in fact makes it less likely the individual will get the help he or she needs and subconsciously probably wants.

Few of those rescued from suicide attempts try again.

Proof that most individuals attempting suicide are ambivalent, temporarily depressed, and suffering from treatable disorders is the fact that so few, once rescued and treated, ever actually go on to commit suicide. In one American study, less than 4% of 886 suicide attempters actually went on to kill themselves in the 5 years following their initial attempt[32]. A Swedish study published in 1977 of individuals who attempted suicide at some time between 1933 and 1942 found that only 10.9% of those eventually killed themselves in the subsequent 35 years[33]. This suggests that intervention to keep an individual alive, is actually the course most likely to honor that individuals true wishes or to respect the person’s “autonomy.”

Burke J. Balch is the Director of the Department of Medical Ethics for the National Right to Life Committee. Randall K. O’Bannon is a Research Associate for the Department of Medical Ethics.



1. A. Sullivan, Voluntary Active Euthanasia for the Terminally Ill and the Constitutional Right to Privacy, 69 CORNELL L. REV. 363 (1984).


3. Barraclough, Bunch, Nelson, & Salisbury, A Hundred Cases of Suicide: Clinical Aspects, 125 BRIT. J. PSYCHIATRY 355, 356 (1976) and E. Robins, THE FINAL MONTHS 12 (1981).

4. E. Robins, supra note 3.

5. Barraclough, et al, supra note 3.

6. American Psychiatric Association, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS III 210-211; 214-15; 223, 364 (3d ed. 1980); See also H. Kaplan & B. Saddock, MODERN SYNOPSIS OF COMPREHENSIVE TEXTBOOK OF PSYCHIATRY IV 367, 369, 373 (1983); S. Dubovsky & M. Weissberg CLINICAL PSYCHIATRY AND PRIMARY CARE 25 (1983); Klerman, Affective Disorders HARV. GUIDE TO MOD. PSYCHIATRY 253, 255 (1979); Baker, Dorzab, Winokur & Cadoret, Depressive Disease: Classification and Clinical Characteristics, 12 COMPREHENSIVE PSYCHIATRY 354 (1971); Woodruff, Murphy & Herjank, The Natural History of Affective Disorder — I: Symptoms of 72 Patients At The Time of Index Hosp. Admission, 5 J. PSYCHIATRIC RESEARCH 255 (1967).

7. Beck, Thinking and Depression, 9 ARCHIVES GEN. PSYCHIATRY 324, 326 (1963).

8. Id. at 321.

9. Id. at 327.

10. Minkoff, Bergman, Beck & Beck, Hopelessness, Depression and Attempted Suicide, 130 AM. J. PSYCHIATRY 455 (1973).

11. Neuringer, Dichotomous Evaluations in Suicidal Individuals, 25 J. OF CONSULTING PSYCHOLOGY 445, 445 (1961).

12. Beck, supra note 7.

13. Id. at 328.

14. Neuringer, supra note 12; A. Alvarez, THE SAVAGE GOD 199 (1972) cites the case of the suicide of 17th century poet Thomas Chatterton as an example, according to some critics, of an individual possibly overrating his talent and possessing unrealistically high expectations for immediate success.

15. Larremore, Suicide and the Law, 17 HARV. L. REV. 331, 333 (1904); Marzen, O’Dowd, Crone & Balch, Suicide: A Constitutional Right?, 24 DUQUESNE L. REV. 1, 127 (1985).

16. Dorpat & Boswell, An Evaluation of Suicidal Intent in Suicide Attempts, 4 COMPREHENSIVE PSYCHIATRY 117 (1964).

17. Rubinstein, Meses & Lidz, On Attempted Suicide, 79 A.M.A. ARCHIVES NEUROLOGY AND PSYCHIATRY 103, 111 (1958).

18. Stengel, supra note 2.

19. Jensen & Petty, The Fantasy of Being Rescued, 27 PSYCHOANALYTIC Q. 327, 336 (1958).

20. H. Hendin, SUICIDE IN AMERICA 223 (1982).

21. Peretz, The Illusion of Rational Suicide.

22. Marzen, et al, supra note 15, at 125.

23. K. Menninger, MAN AGAINST HIMSELF 50 (1938). 24. Marzen, et al, supra note 15, at 125-26.

25. Stengel, supra note 2.

26. Id, at 113-14.

27. Id.

28. Jensen & Petty, supra note 19.

29. Rubinstein, supra note 17, at 109.

30. Stengel, supra note 2, at 73.

31. Silverman, Silverman & Eardley, Do Maladaptive Attitudes Cause Depression? 41 ARCHIVES GEN. PSYCHIATRY 28, 29 (1984).

32. Rosen, The Serious Suicide Attempt: Five Year Follow Up Study of 886 Patients, 235 J.A.M.A. 2105, 2105 (1976).

33. Dahlgren, Attempted Suicides 35 Years Afterward, 7 SUICIDE AND LIFE-THREATENING BEHAVIOR 75, 76, 78 (1977).

Categories: Medical Ethics