The suicide hierarchy

[摘要] The morning I wrote this, I read my post. I had received five letters informing me that clients had attended the Emergency Department because of drug overdoses. All of them had been discharged without any intervention. It was remarked in two letters that the clients had reported a sense of hopelessness. This reminded me of so many of my clients who repeatedly overdosed and who, when I emphasised the risk of death with them, told me that they did not care.The taking of one’s life whether intentionally or through one’s own reckless actions is a tragedy. All victims, young and old, deserve our sympathy. Unfortunately, as a society we do not deal this compassion out equally. There is a hierarchy of empathy that has resulted in an unequal provision of care to those who subsequently die through their own actions. Those who gain most sympathy are the men and women who go on to take their life having had a clear and unambiguous intention to die by their own actions. Usually, they take their own lives as they feel a deep depression and hopelessness about their prospects for happiness. This person can come from any background or class. By contrast, those to whom we mete out the least sympathy are those who act recklessly by taking an overdose of drugs, aware that it may result in their loss of life, but not actively seeking to die. Usually, they also feel a deep depression and hopelessness about their future prospects for happiness. This person usually comes from a background of poverty and (in the US) is more likely to be black.1 In 2020 there were 5224 deaths in England and Wales due to suicide. This represented a rate of 100 deaths per million of the population.2 In the same year there were 2996 registered poisoning deaths related to drug misuse, which represented a rate of 52.3 deaths per million.3SO WHY DO WE DISTINGUISH BETWEEN THESE TWO TRAGIC SELF-INFLICTED WAYS OF DYING? We distinguish not based on outcome but because of intentionality. Intentionality is of importance to philosophers, particularly ethicists, and lawyers. If a person commits an act, then to determine their moral or legal culpability, it is important to know if they intended to commit that act or not. If they committed the act totally accidentally, then they are ‘innocent’. If they committed the act intentionally, they are ‘guilty’. If they acted recklessly, that is, they knew that their actions may result in the undesired outcome but still acted irrespective of the risk, then they are usually ‘guilty of a lesser crime’. In the Middle Ages right up to the late 19th century, suicide was viewed through the lens of religion as a sin of such magnitude that often the deceased was denied a burial on church grounds. In this circumstance, it was important to decide whether a person had committed intentional suicide as it had implications for the destination of their corpse and celestial soul. It is still often important from a legal perspective to decide whether someone acted intentionally, for example, in the case of life insurance. In the late 19th century, the emphasis shifted from morality. Despite this shift from a moral to a psychosocial understanding of suicide, the concept of intentionality was maintained as a core requirement.Nowadays, views of suicide are more nuanced — the act is no longer simplistically illegal or immoral. It is a tragedy of unquantifiable proportion, which leaves a devastated family and community behind. And the knowledge that the person was highly depressed and did not envision a future of joy and hope offers little or no relief. However, the loss of someone who died recklessly because of an illicit-drug overdose is equally a tragedy, leaving devastation behind that is also not relieved by the knowledge of the person experiencing hopelessness.

[学科分类] 卫生学