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4.4. Suicide as a Natural Death

- Takao ITO, M.D.
Aghibetsu Seiryoin Hospital
rojesera 902 5 jo 18 chome Asahikawa Hokkaido , JAPAN


Since 1998, there have been more than 30,000 people who commit suicide annually, and the phenomenon has become a social problem in Japan. The number used to be more or less 20,000 before that. The current situation is quite alarming when compared to other countries. For this reason, suicide prevention is a big issue in the field of Health and Medical Services.

There are three preventive ways against suicide. The first prevention is to enrich and empower each individual's mental health. In addition, social values and norms in relation to suicide have to be changed. However, the subject is beyond the discourse here. The second prevention is to find the symptoms of suicide among those who are on the high-risk level and intervene. Currently, a various studies are taking place about the issue.

The third prevention is focused on patients' mental health and effective way of Intervention in order to treat patients who have impeding suicide-wishes or hold some unsuccessful suicide records. In the third suicide prevention, medical treatment takes a considerable part to take care of the needy, more than health or education or sociology or such field of professional services.

The third preventive method is a combination of medical treatment and revitalization of individual strengths. Expectations for medical treatment are quite high, especially, for the psychiatric treatments are enormous. In fact, the expectation is so great that one may wonder about the capability of mental healthcare to do the task. At the same time, such expectations put huge pressures on the medical profession, and as a result, there has been a tendency to over treat their patients among the medical professionals, including psychiatrists.

Traditionally, suicides such as double suicide and self-immolation were seen as a positive act in Japan. Once, suicide caused by mental disorders used to be diagnosed as pathological death, but no longer so when suicide prevention is concerned.

Suicide is generally considered as exogenous death, and it is an indisputable fact. On the other hand, there ought to be alternative aspects toward suicide as far as preventive treatments are discussed. A death by suicide can be a pathological death or a natural death. Perhaps, we should reconsider the significance of suicide, and search for the possibilities of alternative views to recognize part of suicide as a natural death. It is not cutting off the people who need medical treatment for their mental health, nor is it a defeat for medical professionals who are unable to save their patients. Rather, it will be a positive way to prevent the over treatment of suicidal patients.

1. Suicide on the psychiatric scene

In the strict sense, suicide is self-killing. However, in clinical psychiatry, we tend to take a wide view over the suicide issue. We consider it a suicide if someone dies while having a death wish. We have no clear definition for this type of death, though. Of course, there are people against this point of view. I consider the idea of "self-dying" as a useful tool to discuss the existence of suicide caused by other reasons except exogenous death. "Self-dying" wishers refuse medical treatments while knowing full well that their illness is treatable and even curable. There are cases of "para-suicide" among the persons who are not so serious or in the state of ambivalence toward death, and there is a sort of accidental suicide, as well. It is said that many suicides are connected to mental disorders. Some studies report that in about 90 percent of cases, the individuals concerned previously suffered from depression and/or drug dependency.

For this matter, there is a wide bias in our society telling that healthy people and people in the state of well being do not commit suicide, and that suicide-wish is a treatable disease. If the disease is cured, the person can be free from the thought of self-killing. This view is focused on each individual's living condition rather than death itself.

When a suicide is accomplished, people who are left behind and the medical professionals feel themselves remorse and powerless for being unable to prevent the suicide. By the way, what is the purpose of treating patients who have death wish? Should the medical treatment to be focused on the person's self-killing thoughts or on the individual's life per se?

Technically, it is possible to keep a person physically alive by medical treatment. Unfortunately, it is a different story whether the individual is actively living or not. Sometimes, death can be a welcome thought than a miserable existence for the unfortunates.

If life is something that can be changeable by the hand of human being, does the medical profession have the right to juggle human life? Or is the medical treatment to be considered same as technology that can save or lose human lives? Many issues such as above concerning suicide prevention have to be carefully studied.

There is another consideration over the subject of suicide prevention. Is it possible to foresee and prevent suicide? In other words, can anybody predict the action of other people easily? Is suicide can be manageable like traffic accidents? Surely, we can manage to avoid many traffic accidents if the condition of cars and roads are improved.

I also wonder if the prevention of suicide is just the matter of technical issue same as traffic accident prevention. Suppose, if it is so, people may think that the unsuccessful treatment on a suicidal patient is a result of failure caused by the psychiatrist's inability to handle it? Public opinions seem to take side with the belief connecting a successful prevention and a capable psychiatrist. What the use of psychiatrists anyway, if they cannot give their patients hopes and dreams to live for, and on the way, to prevent suicides? Is it also critical if the treatment does not involve empowerment of each individual patient? And finally, is the medical profession alone holding the responsibilities of reducing individual pain suffered by the suicidal patients?

2 Case Presentations

"Case 1: A 70-year-old male, Schizophrenia"
Onset of the disorder is when he was about 20 years old. He tried unsuccessful suicide attempts several times in order to escape from the symptoms of delusional persecution. He was taken to the hospital against his will each time he tried. Finally, he had to stay in the hospital forever.

While hospitalized, he became accustomed to live in the delusional world. He invented an immortality machine and believed that he would live an eternal life. He was often annoyed by the invented Russian spy who wanted his immortality machine.

He looked like a gentleman and was able to manage everyday life. His behaviors were mild, and he built a good rapport with people around. Through the hospitalization, he kept his decisional capacity intact. Then, he had a tumor and the result of CT scan found renal cancer affecting his body. Naturally, a surgical operation was recommended, but he refused it while understanding well his condition was serious enough to be fatal.

"I thought I was immortal" "I believed I could not die" "Now I want to die as a whole person with a dignity, not as a mentally disabled" with these last words several months later, he welcomed his death in the Internal Department of the hospital.

"Case 2: A 60-year-old female, Schizophrenia"
Onset of her disorder is when she was at the age of about 20. She suffered from delusion of persecution and auditory hallucination. As a result, she tried to commit suicide. After repeating the process of in and out of the hospital because of her persisting suicidal wishes, she was in full remission when she was approaching 40. She worked as a cleaning lady at the hospital for 20years after that. She retired at 58 and lived in a group home and went to the daycare center in the Psychiatric Department. She was introvert, and loved music and drawing. She had a few friends but was never isolated.

She sometimes talked about her anxiety toward reduced income after retirement, and was a little nervous of spending plentiful time without work or concerned about life in general at the old age. However, she did not seem to be acting negatively, nor was expressed.

Nevertheless, one afternoon, she succeeded to commit suicide, and her body was found under the bridge. The day, she was absent from the session at the daycare center without any notice, but the staff and the members did not find it unusual.

Her will, a bankbook, a photo for her funeral were found in her room. It was a well-planned suicide commitment prepared several days in advance.

3 Discussion

Both cases above are related to Schizophrenia. In the case 1, the man was an inpatient in the state of incomplete remission. The man died from his illness, cancer, therefore, his death was diagnosed as pathological death. He knew he would be dead unless he received a surgical operation, but his refusal of accepting the medical treatment prompted his death.

This can be interpreted as a form of suicide or even dying by himself intentionally. A natural death occurred while the person did not want to live but die can be understood as a suicidal death.

He tried to commit suicide several times in the early stage of his disorder, and his life was saved by the medical treatment. After that, everyday living made him feel like immortal and inhuman, and he believed that his right to die was violated, and instead, he was given the eternal life. It encouraged him building up the delusional world to rationalize his thoughts.

While living, he was dying slowly and in the state of iatrogenic Cotard syndrome. When he realized that he was mortal and human, he chose death happily and had a satisfied self-dying. In that sense, the death can be seen as a natural death for him.

Perhaps, it was possible to keep him alive by forcing an operation to treat his cancer, but it was doubtful if the method work to save his soul and give him the purpose to live. Even the surgical operation was successful, there might still be a possibility he would have tried to kill himself when he was recovered from the effect of anesthesia.

In Case 2, the woman had a mental disorder but she was capable of living and kept her competency at the time of suicide. She expressed some anxiety about old age, but her living condition was not so bad because of the income from savings and social security. She went to the daycare center willingly. She went there when she was up to it, never forced. She lived alone but was not socially isolated, either.

Was it her subtle way to inform others about her intention to die by stating her anxiety toward old age? Could anyone perceive it as a clear indicator of suicidal attempt when she was absent from the daycare center? Suppose, someone was able to catch the sign of her death wish and asked her about it, she could simply deny and probably would try again.

At least, it would have been almost impossible to diagnose her condition as suicidal and force a medical treatment on her. And again, if something has done to keep her alive against her wish, it would be a meaningless life for her. What better way could the medical treatment have done? Any medical intervention at this point might be taken as an overtreatment.

It will be difficult and insignificant to look for something in common between the case 1 and the case 2, except that the man and the woman were in their moratorium for death. In both cases, the individuals could be said having no purpose to live and they wanted to die. They were in the preparatory stage for death.

They could not wait for their time to die naturally. Death was in the far a way and coming too slowly for their way of thinking. The woman brought her death in silence and the man grabbed the opportunity to die.

If I were the medical doctor or a psychiatrist in charge, I would hesitate to give the man and the woman some medical treatment because it could not give them any hope to continue their lives willingly. I believe that in the world of medicine, there is certain form of death performed by oneself that any medical treatment would fail to save. However, the current social norms toward medicalization of suicide prevention with people suffering from mental disorders demand that they should force treatments on the unwilling persons who have suicidal wishes.

Unfortunately, staying alive does not the same thing as living actively. Without understanding the difference, forced medical treatment may only produce a disastrous result on the patients' lives. And their living may become a bottomless iatrogenic infinite moratorium for death. The death in the two cases had taken the form of pathological death and suicide. On the other hand, if their death could be accepted as a natural death, by introducing a double orientation, it might avoid falling into the abyss of discrepancy between life and death.

The concept of suicide, part of it, as being taken a sort of natural death may allow psychotic persons to live or die at their free will, and therefore, not to drive them into a corner by forcing them into unwanted medical treatment. Needless to say, the concept does not mean to abandon those unfortunates who may want to have medical treatments to resist their suicidal impulse.

4. Conclusion

The manner of suicide will be divided into two ways: the direct way and the indirect way of killing oneself. No need to mention, but the direct way is intentional killing by oneself. On the contrary, the indirect way welcomes death that can be avoided if the certain medical or other wise interventions are applied. In a sense, indirect suicide can be a natural death for the individual who preferred to die to live. It is a form of dying by oneself, and also quite similar to the form of natural death. If the person was suffering from mental disorders, it could be perceived as a pathological death, as well.

Being alive is not the same as living a full active life. Forced medical treatment on the patients can certainly keep the persons physically alive, but it may only torment them if it cannot give them the reason and the purpose to live for, especially, with those who suffer from mental disorders and think seriously about death. Unnecessary medical over treatment will only prolong patient's life, and moreover, increase unnecessary sufferings onto the individual. In that case, life will be like an eternal moratorium for death without an exit, and the feeling of hopelessness and despair may overwhelm them.

Regrettably, the current medical treatment system does not have ability to treat suicidal persons with its full capacity. On the contrary, there is a tendency in the Japanese society to apply medical treatment to prevent suicide. In this atmosphere, medical care for the suicidal patients is going to be over treatment for the sake of just keeping them alive, physically anyway.

Finally, I would like to point out the possibility if the society can accept "dying by oneself" as part of natural death, such tragedies can be avoidable.

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