How Can Research Prevent Suicide? Stephen H

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Introduction Looking to the future: how can research prevent suicide? Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff

Suicide is a leading cause of mortality and morbidity. making subject availability low; (b) there is no accurate Suicide represents a major public health problem method to determine if any individual is going to take based on the fact that there are more than 1 000 000 their own life in the next day(s) or year(s); and suicides worldwide and approximately 40 000 in the (c) potential suicide is based on a variety of factors United States per year. Many people throughout the which includes signs and symptoms and assessment of world have therefore had direct experience with a high-risk cognitive states or high-risk behavior, but suicide by having a relative, friend, or acquaintance there are obvious differences between suicide attempts solve their problems by taking their own life. This is a and completed suicides. Studying the brains of sub- devastating experience, which on the surface is hard to jects who have taken their life ensures that your sample understand and hard to recover from. Reducing the is from a suicide; however whether the biology under- suicide rate and ultimately preventing suicide is a lying suicide is transient or lasting and the debate as to challenging task. The chapters in this Guide were whether there is a unique biology of suicide that cuts developed to provide state of the art information on across diagnostic categories versus suicide as a symp- what is known about suicide, how we currently study tom of various disorders with their own unique biol- it, and how we can reduce its frequency. The latter is ogy remain unresolved. One of the most important the most important goal. Currently most preventive areas for research is obviously the development of an efforts are aimed at erecting physical barriers to sui- accurate, sensitive, and specific method to detect suicide and/or hospitalization. None of these efforts are cide potential. This can be a behavioral measure, clin- totally effective. ical signs or symptoms, or a biological marker. All of We designed this Guide for several audiences includ- these are active areas of research. ing clinicians and researchers but also others interested Promising data is offered from genetics research. in this topic. The chapters that comprise this monograph Current major approaches, all with advantages and are purposefully concise but are sufficiently comprehen- disadvantages, include Genome-Wide Association sive. It has been organized into sections on a common Studies (GWAS), candidate gene studies, and epige- theme starting with a series of reports on understanding netics. GWAS is an examination of many common suicide that provide a context for the remainder of the genetic variants in large populations to determine if book. This Guide goes on to provide information any variant is associated with a trait. GWAS typically ranging from specific psychiatric disorders of unique focus on associations between single nucleotide poly- “special” at risk populations highlighting the context morphisms (SNPs) and disease traits. Candidate gene of suicide and treatment within these illnesses and studies focus on SNPs in systems previously implicated populations, through mediators and moderators of sui- to be involved in the pathogenesis of suicide, such as cide from societal to biological mechanisms, including serotonin. Epigenetics focuses on genes that are genomics, and ending with suicide prevention. impacted and changed due to the environment. Both What makes suicide prevention and research so GWAS and epigenetics studies can be conducted from difficult? This theme is focused on throughout this completed suicides. Here the biggest challenge again is volume. The answer is manifold and includes: (a) the the relative low incidence of suicide in the general incidence of suicide is low compared to other illnesses population compared to, for example, diabetes or

A Concise Guide to Understanding Suicide, ed. Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff. Published by Cambridge University Press. © Cambridge University Press 2014. 1

© in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-03323-8 - A Concise Guide to Understanding Suicide: Epidemiology, Pathophysiology, and Prevention Edited by Stephen H. Koslow, Pedro Ruiz and Charles B. Nemeroff Excerpt More information

Introduction: looking to the future

hypertension, rendering it difficult to get the large sam- currently used to assess suicidality in subjects who ples needed for GWAS. Similarly epigenetics reports are are deemed at risk. These include hopelessness, help- more often based on small numbers of subjects and use lessness, described suicidal behaviors or intention to postmortem brain tissue. Additional research in this carry out suicide, comorbid substance abuse, and/or area is warranted given the paramount importance of alcohol abuse as well as specific alterations in cognitive identifying a biological marker for suicide. Clearly large functions including decision-making. Understanding sample GWAS studies, candidate gene studies, and the neural network and processes involved in decision- more epigenetics studies on well-defined patient popu- making may start to provide insights into the altered lations and controls are warranted. thinking and decision-making that often occur in Another major research goal is to integrate find- suicidal individuals. Other important risk factors ings across high-risk populations including patients discussed in this volume include age, trauma history, with mood and anxiety disorders, schizophrenia, per- family history, past personal history of suicidality, and sonality disorders, substance abuse, eating disorders, of most promise biological markers including genet- epilepsy, and child and adolescent disorders as well as ics. It is paramount to develop a standardized objective specific high-risk populations such as the armed assessment to be used in all studies. If this is accom- forces, emergency room, bereavement and grief, col- plished we can begin to create databases to achieve lege students, other medical illnesses, pregnancy, post- adequate analytical statistical power. partum depression, LGBT, and older adults in order to Currently two drugs which appear efficacious in distill core mediators and moderators leading to sui- preventing suicide in specific populations are lithium cide and understand the biology underpinning these and clozapine. Whether these drugs have specific anti- changes. To do this effectively and efficiently we need suicidal properties or reduce suicide because of their to develop and agree upon developed standard instru- superior efficacy remains unresolved. Should these ments to use in common in all these studies which are drugs be used in other populations specifically for quantitative and objective. Subjective assessments are suicide prevention? To address this question requires often biased and affected by the rater’s experience and a large-scale clinical trial of both drugs. The question do not provide acceptable inter-rater reliability of the dose required to produce an antisuicidal effect is between individual raters. An excellent example of important because at the doses they are currently the ability to integrate among and between studies clinically used they are often poorly tolerated and are the emerging imaging studies. These studies have have unacceptable side effects. Low doses of either of different diagnostic groups; the selection of suicidal these drugs may be effective in suicide prevention. subject is based on various criteria including suicidal Equally important is determining which psychothera- behavior, previous attempters, suicidal ideation, and pies are most likely to reduce suicide. seriousness of the attempt. Different imaging modal- In summary and conclusion the research on sui- ities have been employed including structural MRI, cide should focus on: fMRI, DTI, SPECT, and PET. All of these are a rich 1. Development of a valid, easily usable algorithm source of direct brain data and we need to integrate predicting suicide risk with high sensitivity and these data across population and structure, function, specificity neural circuitry and receptor/transporter binding 2. Definition of biological markers that correlate with which have yielded and will continue to yield new the predictor algorithm (1) above insights into the underlying neural suicide circuit. These could then be the groups studied for neuro- 3. Mapping the neural circuitry and the biological regulatory systems and genomic expressions yielding mechanisms involved in suicide fi both new information for understanding the processes 4. Development of effective and speci c antisuicide involved in suicide, as well as new targets for pharma- treatments including pharmacological and/or cological, genetic, or other interventions. psychotherapeutic In this Guide specific sections focus on the behav- 5. Establishment of an objective standardized ioral assessments and clinical signs and symptoms assessment to be used in all studies on suicide.

Section 1 Understanding Suicide Chapter Brief history of suicide in Western cultures 1 Leonardo Tondo

Introduction suicide of a young healthy person is likely not to be “understood,” whereasthatofanelderlypersonwitha Western culture has never been completely indifferent terminal illness may seem more reasonable. toward those who take their own lives. Attitudes and Judgments concerning suicide changed when beliefs concerning suicide have been complex ancient Greek philosophers became interested in the and varied over the centuries. Some suicides were primacy of reason over the emotions. Their influence considered heroes, but mostly suicide was considered became dominant and continued to influence an offense against God, an insult to the state, or a Western culture and the great religions to modern particularly painful gesture toward those left behind times. The dominant view has been that suicide was after an an unexplained death. Yet, considerable toler- an immoral or criminal act. Early philosophers based ance toward suicide is evident in ancient times when their prohibition of suicide primarily on the basis of death was more frequently encountered in everyday its incomprehensibility or irrationality. It was viewed experience than in modern times. Nevertheless, suici- as an aberration against the natural urge of the indi- de was punished as a criminal act in many cultures for vidual to survive, and became interpreted in the centuries before becoming a medical-psychological Jewish, Christian, and Moslem religions as an insult issue in our current society and culture. to God. Many cultures of ancient times as well as of today have tried to subject the emotional side of the The contest between reason individual to rational control. This fundamental principle has guided many laws and customs seeking and passion to impose limits on the expression of emotion-driven Since ancient Greece, suicide was not accepted, though behaviors. Religions borrowed the thinking of the most cases were not explicitly blamed for having Greek philosophers and transformed many passions committed a criminal act. Since the fourth century into sins with the simple equation that rational BCE, suicides usually were denied burial or traditi- behavior is directed by God, and the irrational by onal pre-burial preparation or cremation and were con- the Devil (Tondo, 2000). sidered to have committed a greviously antisocial act. In Athens, for instance, the hand of a suicide was cut off andburiedawayfromtherestofthebody(Manson, Ancient cultures 1899). Only suicides in which it was possible to find A possibly first recorded suicide dates from the era of sufficient reason for self-destruction were deemed com- Egyptian Pharaoh Ramses II (1303–1213 BCE), in a prehensible; such reasons might include heroism, love- written description of the story of two brothers who rejection, or serious and painful illness. Other suicides had committed suicide nearly two centuries previ- were considered to be unjustified and were punished; ously. At that time, death was often actively sought examples include soldiers who had deserted or criminals for various reasons, to the point that groups gathered avoiding punishment or prison. The standard of “under- to discuss the least unpleasant ways to die, and it seems standing” was – and largely still is – considered the key to likely that was sufficiently frequent as often to pass assessing suicide as a justified action. Even nowadays, the unnoticed (Moron, 1976).

A Concise Guide to Understanding Suicide, ed. Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff. Published by Cambridge University Press. © Cambridge University Press 2014. 3

Section 1: Understanding Suicide

The spirit of ancient Greece (mainly from the 5th than being subjected to Caesar; they included Cato and 4th centuries BCE) highlights a widespread mel- Uticensis, Appius Claudius, Atticus, Crassus, Anthony, ancholy toward life that encouraged appreciation for Brutus, Cassius, and Quintilio Publius Varus. Even the its end, in contrast with limited acceptance of suicide. Roman emperors Marcus Cocceius Nerva and Nero A rejection of life, joined with a deep spirit of freedom killed themselves. In 69 CE, the year following the characterized the Epicurean, Stoic, and Cynical philo- death of Emperor Nero, 32 politicians committed sophical schools to support decisions to die. Many suicide. Suicides in Imperial Rome included many celebrities of the time killed themselves, including the famous writers and philosophers, including Diodorus, philosophers Empedocles, Democritus (to avoid old Seneca, Petronius, Lucan, and Lucretius. The two age), Diogenes, Zeno (held his breath after falling at prominent philosophical schools of ancient Rome, the age of 98 years), Hegesias, Cleanthes (held deep Epicureanism and Stoicism, approved of suicide for contempt of life), Socrates (forced to kill himself), and different reasons. The Epicureans stated that the goal poets including Sappho (love pain), Aristodemus of man was the pursuit of happiness and, when this (remorse), Cleomenes (honor), Demosthenes and could not be achieved, life lost its purpose. The Stoics Isocrates (both for patriotic reasons). Heroic suicide placed reason, virtue, and morality above pleasures and or self-sacrifice was almost unanimously approved in common interests, sometimes to the point of reaching a ancient Greece, and often was considered an example state of detachment and a lack of interest in life. This to follow. Kodros, the last legendary king of Athens, philosophy influenced the laws so that weariness for probably would have killed himself to avoid loss of a life (tædium vitæ) leading to suicide was approved if it battle with the Dorians, as prophesied by the oracle of resulted from incurable diseases, accidents, deaths of Delphi, but was killed by the Dorians. Themistocles, others, or even from squalor or wounded pride according to some historians, killed himself because of (Manson, 1899). guilt resulting from his betrayal of Athens to join the Although suicide was culturally accepted, Seneca service of the Persian king. considered death as a refuge against the evils of life, but Plato (424–347 BCE), however, was opposed to did not support suicide. He emphasized control of the suicide. He claimed that men are social individuals emotions and submission to the will of superiors, with responsibility to others and therefore property according to the light of reason, but these principles of a state that could not afford loss of its citizens. Along led to his own suicide when ordered to do so by the same line, Aristotle (383–322 BCE) disapproved of Emperor Nero for alleged treason. suicide, seeing it as a transgression against a civic duty The Neo-Platonic philosophers saw suicide as the and an act of cowardice. He states (Moore, 1790): result of a disturbance. However, Plotinus (204–270 CE), the most important leader of the movement, The law never commands a man to kill himself; but what it does not command, it forbids. Moreover, argued that this type of death prevented the soul when any one hurts another contrary to law, hav- from breaking away from the body, making it impos- ing received no previous injury from him, he vol- sible to reach the Elysian Fields. untarily commits an injury against that man ... In general, in ancient Rome free men (but not slaves) Now when anyone, impelled by anger or resent- could choose to commit suicide without problems. ment, kills himself, he does this voluntarily against In fact suicide was praised for widows who followed right law, because the law does not permit it ... their husbands after death, or had been raped (e.g., But [against] whom? Rather to the state than to Lucretia), and for men who wanted to avoid dishonor ... himself To die only in order to avoid poverty, or or were becoming old (Minois 1999). Nevertheless, [for] love, or uneasiness of any kind, is not the suicide was widely considered dishonorable or a crime character of a brave, but rather of a servile spirit. from the 6th century, particularly by soldiers (as well as in For it is the part of an effeminate mind to fly from calamitous and laborious situations. feudal Japan), slaves, and embezzlers. Despite several exceptions, the general attitude In ancient Rome, suicide was not a rare event. Grisé toward suicide in ancient Greece and Rome was rela- (1982) describes 314 suicides among prominent tively tolerant, and suicide was considered legitimate Romans between the 5th and 2nd centuries CE. For in many circumstances, especially when life was no different reasons, but always with a character of integrity, longer considered worth living, based on philosophical many prominent politicians killed themselves rather principles or even individual judgment.

Chapter 1: Brief history of suicide in Western cultures

Early Christianity Hebraism Christianity spread easily, especially among the most Old Testament (probably written between the 9th and wretched, offering hope for a better life, at least in the 5th centuries BCE) reports on five suicides not associ- next world. At the same time, it had to stand against ated with a sinful judgment. However, it required that reaching them too early in order to avoid losing the body of a suicide could not be buried until sunset too many of the faithful too quickly. Initially, Church and without the usual rites. Laws and customs had attitudes about death resulted in a propensity toward it been continued through oral tradition, and were tran- so that for several centuries, religious writings counted scribed by rabbinical scholars in the Mishnah between enthusiastic stories of martyrs. However, in ca. 420, the 2nd and 3rd centuries. It taught that a suicide’s St. Augustine (353–430) forbade suicide in his City of body should not receive respect from family and God, considering it an act against God as an extension friends. However, this prohibition was enforced only of the fifth Commandment to Moses (Thou shalt not if the act was intentional and without external pres- kill). Suffering, rather than being deemed a reason to sure, whereas suicide was considered as natural death commit suicide, became a positive value that only if the act was induced by a mental illness or by the fear increased the worthiness of those who would bear it of a terrible torture. (Manson, 1899). The Committee of Jewish Law and Standards With Roman Emperor Constantine (272–337), (1998) affirmed the prohibition of suicide, but Christianity became the official religion of the supported an obligation of understanding why some Roman Empire, and was supported by law from the people think of suicide, so as to ameliorate those 4th century. Sanctions by the church and the state circumstances. Even for terminally ill patients, against suicide gradually became increasingly strict increased pain control is recommended. and punitive, including confiscationofpropertyif Despite that suicide is forbidden in Judaism suicide was a means of avoiding a legal trial (inter- through the same arguments proposed by Christians, preted as an admission of guilt). It is likely that early there may be some extreme circumstances where a legal and religious views were very similar – probably choice other than suicide is impossible. Such was the less spiritual and more practical, if not partly eco- case in the mass suicide at the siege of Masada (73–74 nomic. It was important, even for the civil power of CE) when more than 900 Jews killed themselves Rome, to encourage interest in life, given the high instead of falling prisoner to the Romans. mortality of the times and life expectancy of less than 40 years, and concern about maintaining the population of a vast empire that needed an enormous Islamism amount of labor. In fact, in the year 374, infanticide As in the other Abrahamic, monotheistic religions, for was banned by Roman law, and soon suicide by Islam suicide is one of the worst possible sins. Unlike servants or slaves also was outlawed, as well as for the Old Testament in which there is no explicit condem- themilitary,whowereconsideredpropertyoftheir nation of suicide, the Koran warns: “Do not kill your- owners or of the state. selves, certainly Allah will be more merciful with you.” In However, a problem of no small importance arose: several other passages of the holy Islamic text, there are how to punish criminal suicides after their death? warnings against suicide. In fact, most early Islamic Gradually increasingly imaginative and dramatic scholars forbade suicide eveninthecaseofterroristic forms of brutality to the bodies of suicides arose, not attacks, citing that Koranic verse. This prohibition seems only for a symbolically directly punitive effect, but also not to have prevented Islamic fundamentalists from kill- for a spectacular and hopefully deterrent effect upon ingthemselvesthroughtheagesaswellascurrently, onlookers. Legal authorities collected the assets of sometimes while killing scores of other persons. suicides, and the Church increasingly attempted to Muhammad (570–632) taught that it is necessary avoid the loss of the faithful by discouraging the prac- to submit to divine will under any circumstance. For tice of voluntary martyrdom. It is also surely not a this same reason, the Islamic religion does not allow coincidence that, in the same era, the Church empha- any form of euthanasia. Suicide is so sinful in Islamic sized the sacredness of marriage, the blessing of procre- countries that it would explain why official data on it ation of many children, as well as the repression of all are lacking or extremely low – much lower than non-procreative sexuality as a sin. among Muslims living in Western countries. 5

Section 1: Understanding Suicide

Middle Ages their real estate. In the same document, a difference was drawn between suicides resulting from felo de se Mass suicides occasionally occurred at the end of (crime against himself) versus non compos mentis. banquets in Scandinavia as a means of gaining entry In England, consideration of the issue of confiscating to Valhalla, possibly close to Odin’s seat – normally, a the property of suicides became increasingly sophisti- concession granted only to those who had died violently cated following its first application (MacDonald & but courageously in battle, but then extended even to Murphy, 1990). those who self-inflicted death (Moore, 1790). The Gauls MacDonald and Murphy (1990) report evidence and Visogoths sometimes elected suicide to avoid being from the King’s Bench which show a steady increase enslaved by the Romans and to reach heaven (Moron, in suicides in England from 1510 to 1590, and an 1976). Yet, through their contact with the Romans, initial criminal (felo de se) judgment in 95% of such these northern peoples eventually absorbed Roman cases. There was an evident conflict of interest in laws regarding voluntary death (Manson, 1899). the certification of suicide. It is quite likely that this Perhaps in part to avoid legal penalties, suicide was increase reflected payment of a fee to coroners in the replaced by medieval knights with violent and dange- case of a verdict of voluntary or criminal suicide rous practices, such as tournaments or duels. Indeed, resulting in the confiscation of goods by the Crown. the Church synods of 813 (Châlons), 829 (Paris), and However, coroners could sometimes be persuaded to 855 (Valence) in France declared that duel to death make judgments of mental illness after receiving was prohibited. bribes greater than their “commission,” and these Theodore of Tarsus (602–690 CE), Archbishop of were gladly paid by the families of many suicides. Canterbury, acknowledged the Roman tradition of legal With the passing of centuries, English laws gradually non-liability in cases involving obvious lack of ration- were interpreted less strictly and mental illness was ality at the time of suicide. This tradition was incor- recognized more frequently among suicides, to the porated into English law and later accepted by the point of recognizing the very act of suicide as an Church of England following the reign of King Henry indication of mental illness after 1600. VIII (1491–1547). Early English laws against suicide are Laws concerning confiscation of property of sui- attributed to King Edgar I of England (943–975) and cides gradually spread across Europe and were applied were promulgated in 967 CE, including the distinction unless the suicide was associated with insanity. maintained over the centuries between those who Starting in about 1600, attitudes in European legal committed suicide when of sound mind or were systems toward suicide became more indulgent and insane (non compos mentis). That is, suicide was not less punitive. In the 1700s, the majority of suicides considered a sinful or criminal act in cases of insanity. were judged to be based on mental illness (non compos English laws of that time also included the provision mentis). It is also likely that the accuracy, recording, that the goods of a suicide had to be forfeited to the and reporting of data from the English courts since the state, and did not exclude other forms of punishment or Middle Ages led to increased awareness of the issues defilement carried out on the dead bodies of suicides. surrounding suicide, and may have contributed to the During the brief Viking conquest of England steady decrease in suicides from about 1700 to modern (1013–1042), the Danish rulers supported the confis- times. Even today, the English suicide rate is far less cation of goods from suicides. In De Legibus et than that in other European countries, although sui- Consuetidinibus Angliae (Treatise on the Laws and cide rates vary markedly among countries, within Customs of the Kingdom of England; ca. 1188), Henry regions, and over time (Baldessarini et al., 2007). of Bracton formulated the relationship between crime Throughout Europe between the 18th and 20th cen- and intent in suicide by importing Roman law as turies, many ordinary people entangled hopelessly in interpreted by the school of Bologna. He stated that: wretched living conditions committed suicide, evidently (a) a suicide could not have heirs, and his goods were in despair (Minois, 1999). Hanging was a prevalent to be confiscated by the Crown because his act was an method among both commoners and aristocrats. If admission of criminal guilt; (b) this measure could not they were publicly acknowledged at all, such acts com- be implemented if the suicide had not been accused of mitted by aristocrats might be considered honorable. crimes, (c) movable assets were confiscated from those However, for the poor, suicide usually was considered who suicided for apparent weariness of life, severe cowardly and a way of avoiding responsibility, calling for physical pain or grief, but the family would inherit 6

Chapter 1: Brief history of suicide in Western cultures

selective and furious punishment and retribution. It was able to evoke anger and despair in those who came in also deemed noble and understandable when Christians contact with them. Of note, it was believed that suicide who did not want to fall into Ottoman hands carried out was a result of anger (more than melancholy), which collective suicides, or for a woman to take her life in could be aimed at the survivors (Kushner 1989). order to avoid sexual assault. In addition, deaths in In France, suicides were hanged by their feet and war were considered heroic even when preceded by the dragged through the streets as a warning to others killing of many other human beings. (Minois, 1999). Similar procedures were followed in The clergy could arrange for suicides to avoid Germany, and included exposure of the unburied punishments or refusal of burial in consecrated corpse, as well as removal of stones on which a suicide ground by ascribing suicide to physical or mental had walked. In Zurich, the Swiss stipulated, precisely, illnesses, again often citing suicide itself as evidence that a person who had stabbed himself was to have an of mental illness (Minois, 1999). In addition, many awl driven into his head, those who had drowned were Christians enacted mystical forms of suicide with to be buried in the sand two meters from the lake their isolation from the world until dying of starvation shore, and those who had died by jumping off a cliff or thirst. should be buried under a pile of stones. MacDonald and Murphy (1990) reported that sui- Although spectacular, the retributions inﬂicted on cide rates among the rich in early modern England the bodies of suicides apparently did not have a desired (18th and 19th centuries) were much lower than in the deterrent effect. Nevertheless, such fury continued for lower classes, which increased during periods of poor centuries. The last known abuse of the bodies of suicides harvest, hunger, and disease. Ironically, people who occurred in Paris in 1749 and London as recently as were punished for suicide most often were laborers or 1823 (Minois, 1999). peasants with little property to conﬁscate, leaving their families impoverished even further. The Italian Dominican priest, Thomas Aquinas Renaissance and Enlightenment (1225–1274) adduced several reasons to condemn During the Renaissance (14th to 17th centuries) living suicide: it was an act against nature and against the conditions and culture improved markedly, and there benevolence we should have toward ourselves, and was a renewed interest in the teachings of the classical therefore considered a mortal sin. It was also an insult Mediterranean world. This renewal of scholarship and against the community to which we belong and to learning was greatly facilitated by rapid adoption of the which we have duties. Finally, it represents an act of printing press in the 16th century. This process brought usurpation of the laws of God who gave us life and is reminders that suicides had included many prominent the only one who may decide to take it back (Manson, ancient leaders or philosophers, as reviewed above, and 1899). Aquinas concluded that, Whoever kills himself their popularization tended again to cast doubt about sins against God (Clark, 2000). the sinful or criminal nature of suicide. Following strong ecclesiastical condemnations of Growing interest in humanism resulted in frank suicide from the 12th century onwards, jurists viewed admiration for suicide in which intellectuals found an suicide as requiring punishment in addition to the implicit message of freedom. The revaluation of sui- eternal damnation expected by canon law. This view cide in that period manifested itself in the appreciation led to severe sanctions concerning disposition of the for Lucretia (in the early Roman Republic, 5th century bodies of suicides: often they were not buried, were BCE), whose suicide after being raped was featured in dismembered or left as food for the animals, exposed De Claris Mulieribus (Of Famous Women) by Giovanni at crossroads, buried under large boulders, dragged Boccaccio (1313–1375), in the Divina Commedia through the streets face-down, taken out of the house (Divine Comedy) by Dante Alighieri (1265–1321) through a window or a passage under the threshold of among the noble spirits of Limbo, and in more than the house, or nailed to a barrel and left to drift at sea one hundred paintings produced between the 1360s (Minois, 1999). It was believed that the body of a and the early 20th century (Cutter, 1983). suicide could contaminate the land, lakes or rivers, In addition, the Protestant Reformation stimu- that if a pregnant woman approached the burial site lated growth of individual thinking and efforts to of a suicide, her offspring would follow the same fate. set aside the rules and rigidity of the Catholic The spirits of suicides were considered vengeful and Church, as notably manifested in the Inquisition.

Section 1: Understanding Suicide

This development strongly favored a more liberal and to commit suicide and not contrary to reason. questioning attitude toward suicide. Civil and reli- Moreover, Roman law had not condemned it for a gious convictions resisted acceptance of suicide, but long time. Donne also rejected the persisting argument one could discuss the matter more openly and rela- that suicide deprives the army of a soldier, since tively freely. soldiers could retire from military life without being Sebastian Brant (1457–1521) in his poem The Ship condemned. A further point concerned the develop- of Fools (1494) justifies suicide as a means of eliminat- ment of the divine law. Donne had no difficulty in ing the suffering of life. Desiderius Erasmus of arguing that the Bible did not condemn suicide, Rotterdam (1466–1536) in his Praise of Folly (1511) though murder was deemed sinful. A further irony expressed sympathy for suicide as a way out of a life is that many more men die during wars and are full of problems and evils, although he still considered considered patriotic or even heroic than those who suicide an insane act. die by their own hand. In this period a high number of suicides were English political philosopher, Thomas Hobbes recorded throughout Europe. Nevertheless, doubts (1588–1679) saw suicide as a destructive act against remain about the accuracy of the reports since esti- natural law, and therefore should not be allowed. mated rates of suicide were easily distorted or misrep- However, suicide could not be considered illegal, resented, including being inflated, perhaps in response even accepting the Platonic position on the loss of an to increased attention afforded to the phenomenon by individual belonging to the community. Also the rel- philosophers, writers, and moralists. atively moderate French philosopher, René Descartes In 1594, William Shakespeare (1564–1616) wrote (1596–1650) argued against suicide pragmatically, in the poem The Rape of Lucretia, which stresses the considering that leaving the safe for the uncertain did political effect of her suicide during the transition not make sense, that life is not always happy but often from monarchy to republic in ancient Rome. In offers consolation, and that good things may be even the following 40 years in the early 1600s, more more frequent than bad ones. He rejected the idea of than 200 suicides of characters appeared in British sin and punishment with regard to suicide. He theatrical works. The dramatic effect of suicide fits believed these considerations to be unnecessary, since very well in a play associated with special events, suicide is a punishment by itself. Finally, in a letter, often romantic in nature, and suicide was sometimes Descartes expressed doubts about the mental health of used for the conclusion of a drama, with cathartic suicides (Minois, 1999). effect. In Shakespeare’splays,suicidesinvolved Robert Burton (1577–1640) of Oxford, in his famous characters of the classical world (Anthony Anatomy of Melancholy (1621) saw suicide in a much and Cleopatra), or were for love (Romeo and more modern view than his contemporaries. For the Juliet), blame (Othello) or despair (Ophelia), and first time, he suggested the presence of mental illness Hamlet debated whether to live or die. These works behind suicidal behavior, considering melancholy anticipated an association between suicide and of the Hippocratic and Galenic traditions. He put melancholy. suicide in a non-religious, contemporary perspective The most intense expression of the English debate and described conditions contributing to suicide, on suicide was by clergyman John Donne (1572–1631) including agitation, hopelessness, and impulsivity. in an essay on the topic, Biathanatos (Violent Death), Nevertheless, most writers of the next century contin- where he wrote about the “paradox” that self-murder ued to oppose suicide, supported by ecclesiastical is not a sin against nature (1647). Donne, despite being powers (Brown, 2001). an Anglican clergyman and the Dean of Saint Paul’s In 1788 English physician William Rowley (1742– Cathedral in London, justified suicide. Nevertheless, 1806) wrote A Treatise on Female, Nervous, evidently owing to its controversial content, his book Hysterical, Hypocondriacal, Bilious, Convulsive initially was shown only to close friends and finally Diseases; Apoplexy and Palsy with Thoughts on published 16 years after Donne’s death. In it, he argued Madness, Suicide, et cetera, in Which the Principal that suicide was not contrary to nature, as there Disorders are Explained from Anatomical Facts, and were other ways of mortification of human nature the Treatment Formed on Several New Principles.It imposed by civilization. Human nature was guided reiterated the views of previous centuries, arguing by rationality and it could be considered appropriate that suicide was an act against religion and so a

Chapter 1: Brief history of suicide in Western cultures

crime against civil society because it deprived others liberalism, defending self-destruction in cases of of expected physical and mental services, and extreme necessity. was immoral for being contrary to the individual’s Another tolerant view of suicide was expressed duties to maintain relational ties. Following such by Scottish Enlightenment philosopher David thinking, Rowley attacked the ideas of Jean-Jacques Hume (1711–1776) in his Essays on Suicide and Rousseau (1712–1778) as expressed in Julie, la the Immortality of the Soul (1755). He stated that Nouvelle Héloïse (Julie, The New Eloise; 1761): suicidecouldnotbeseenasanoffenseagainst God. It was not condemned in the Bible and Seeking good and avoiding evil when you do not he considered the Augustinian interpretation of cause harm to others, it is a law of nature. When life suicide as homicide and therefore against the fifth becomes bad for us and it is not good for anyone, fi we can get rid of it. Commandment, as not justi ed. He noted that the commandment, Thou shalt not kill “evidently has Rowley’s position was mainly utilitarian in seeing only sense only to exclude the killing of others over the duties of men toward one another. However, he whose lives we have no authority and that many introduced advanced ideas concerning remote causes precepts derived from the Scriptures should be of suicide, which might include mental illness changed by reason and common sense.” (insania) or bodily pain. In addition, he described During the 17th and 18th centuries, suicide was proximate causes, including not being sufficiently sufficiently common in England as to be called la brave or balanced as to endure misfortunes, or basi- maladie anglaise (the English disease) by the French, cally, not being of sound mind (non compos mentis). evidently following the still-present tendency for He noted that, “In every violent passion there is each country to attribute eccentric, outrageous, or a degree of madness.” He concluded that, when an distasteful customs to the other. It is likely that suicide individual contemplates suicide, his mental status was not at all more common in London than in Paris, must necessarily be compromised. although the British press reported on suicides Rowley’s condemnation of suicide was out of more frequently. The first weekly publication, The keeping with contrary trends that had been evolving Gentleman’s Magazine, appeared in London in 1731, on the Continent. For example, two centuries earlier, and frequently reported news about suicides. In French Renaissance writer, Michel Eyquem de contrast, in France the subject was considered private Montaigne (1533–1592) spoke in his Essais (Essays; or shameful and not often reported in publications. 1580) quite favorably about suicide: “death makes life Later, however, evidence was uncovered that the precious, but at the same time decrees its vanity.” suicide in France was nearly three times higher than Following the footsteps of suicides in the classical in England at the same time (Minois, 1999). period, he argued that “the wise man lives as much as A particularly harsh position against suicide he ought to, not as much as he can” and even if he was taken by Prussian philosopher Immanuel Kant thought that “death ...is the remedy for every illness.” (1724–1804) who, in his Metaphysics of Ethics (1786), Nevertheless, in his essays, Montaigne did not encou- reasoned that suicide is contrary to the love we owe rage anyone to commit suicide, and moreover, to ourselves. In addition, he claimed that suicide although he became very ill and was in a constant could not be considered an act of free choice since it pain, he did not hasten his own end. His point of limited the universal duty of acting as if individual view is close to that of those who must deal with a actions belonged to the universal law of nature. person at risk of suicide: understanding the wish to English clergyman Charles Moore (1771–1826) die, but at the same time making all efforts to avoid it. wrote a treatise, A Full Inquiry on the Subject of Charles-Louis Baron de Montesquieu (1689–1755) in Suicide (1790). The introduction of his comprehensive his Lettres Persanes (Persian Letters; 1721) spoke of book on the topic states: legal convictions for suicide as an injustice because, Though many excellent sermons and short essays “if the gift of life is a blessing, it is justifiable to give it ” have been written on the guilt of suicide, yet it has up when it seems no longer to be a blessing. French never been treated (as far as the author’s knowl- Enlightenment philosopher Voltaire (François-Marie edge extends) on a large and comprehensive scale, – Arouet [1694 1778]), more than many other writers so as to unite all its several parts branches in one influenced thinking about suicide in the direction of and the same work.

Section 1: Understanding Suicide

Moore leaned toward then prevalent religious ideas, Massachusetts, Chief Justice Samuel Sewall (1652– but added that “the usual arguments brought in favor 1730) was unconditionally opposed to suicide and of suicide will be proposed and answered.” He discussed applied full sanctions against people who attempted or Donne’s Biathanatos, Hume’s Essay on Suicide,and“the committed suicide (Kushner, 1989). For the Justice it book of most pernicious influence, called The Sorrows of was the worst kind of murder and melancholy – even Young Werther” (Die Leiden des jungen Werthers; 1774) when recognized – instead of being considered a by German writer-politician Johann Wolfgang von defense added culpability because it made one vulner- Goethe (1749–1842), as well as works of famous philos- able to Satan’s temptation of suicide. Puritans insisted ophers of his time, including Beccaria, Montaigne, that suicide was an individual act and punishments had Montesquieu, More, Rousseau, and Voltaire. to be directed to the individual suicide and not to their families so that, contrary to English custom, there was no confiscation of goods (Kushner, 1989). Also in col- Nineteenth century onial New England, attempted suicides were punished A court case in London in the early 19th century shook with whipping and incarceration. prevailing moral opinion. It involved the suicide in Puritan values in the British colonies resisted the 1822 of Robert Stewart (Lord Castlereagh, Second evolution of thought in 17th century England that viewed Marquis of Londonderry [1769–1822]), a very power- melancholy as a disease. Even the recognition of a non ful and conservative man. The London coroner had to compos mentis was left to interpretation. The English decide between the act as a crime or the product of county Justice Michael Dalton (1564–1644) stated in an unsound mind. If the death were adjudged to be a 1619: “If a lunatike person killeth himselfe” while lucid crime, a member of the ruling class had to be buried “he shall forfeit his goods” (Dalton, 1618). Although ignominiously under a crossroad; if it was considered there were isolated cases in which the law against the product of mental illness, that information would suicide was strictly enforced, in other colonial jurisdic- become public. The coroner decided in favor of tions such as Providence Plantantions (today part of mental illness, noting his recent expression of suicidal Rhode Island), Pennsylvania, New Jersey, Maryland, thoughts and persecutory ideas, and Lord Castlereagh North Carolina, and Virginia, as well as in some was granted a funeral at Westminster Abbey. His coroners’ juries in Massachusetts, suicide associated funeral provoked angry reactions from the public with melancholy was considered a mental illness and and many of his colleagues, but also consideration not punished. However, in most cases a suicide was still that suicide could be a noble act. The debate raised a a sinner and thus denied religious burial. range of considerations about suicide, prominent The 19th century German philosopher Arthur among which was the frequent connection of suicide Schopenhauer (1788–1860) was not in favor of suicide with mental disorder. and argued that it did not really offer a plausible escape In the following year (1823), Abel Griffiths, a from difficulties intrinsic to an essentially irrational 22-year-old law student, clad only in underwear, world. Suicides indeed want to live, but not on terms socks and a winding sheet, was interred at the cross- that are offered; they need to give up life because they are roads formed by Eaton Street, Grosvenor Place, and unable to give up the will to live better. Schopenhauer’s the King’s Road in London. His bloodied, unwashed suggestedsolutioninhisbook,On Suicide, in The World body was quickly dropped into a hole following as Will and Representation (1818), was to reach a neg- removal of a stake driven into his chest. The young ation of life through asceticism. man had killed himself after killing his father. A neig- The French Enlightenment philosopher Paul- hbor reported that he had suffered “depression in the Henri Thiry (Baron of Holbach [1723–1789]) even brain.” Nevertheless, despite this and other evidence, a more vigorously proclaimed the legitimacy of suicide, jury decided that Griffiths had been in a sound state considering it neither an act against nature nor an act of mind. Remarkably, there was no public resistance of cowardice. At the same time, he rejected the idea of to this outcome. However, in the same year, a law philosophical suicide to be attributed to moral or was promulgated to prohibit further burials under physical suffering, whether conscious or unconscious. crossroads (Gates, 2013). During the 19th century, while old ideas were In the British colonies in America, laws pertaining to still present, the prevailing attitude seemed to be that suicide were the same as in England. For instance, in suicide was a result of an altered mental state. Modern