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“Suicide Kits” for Sale

photograph of Amazon search bar

This article discusses suicide. Following common journalistic ethics practice, precise details about means or resources for committing suicide may have been deliberately left out or altered.

Method matters. Depending on the study, between 80% and 90% of people who attempt suicide and fail do not go on to attempt suicide again. The public health implication is that by regulating the availability of popular and effective means of suicide – mainly firearms and select chemicals and pharmaceuticals – deaths from suicide can be prevented.

Given this, what should we make of the fact that highly purified sodium nitrite, an increasingly popular option for suicide, has been readily available for purchase on Amazon in the United States? A lawsuit filed on September, 29th accuses Amazon and Loudwolf – a sodium nitrite manufacturer featured on Amazon – of “promoting and aiding” the suicide of two teenagers. A Twitter thread by Carrie Goldberg, a lawyer working on the case, characterized Amazon as a “serial killer.”

The case will likely turn on a number of details alleged by the plaintiffs: that Amazon recommendations packaged together sodium nitrite with other supplies and informational materials in so-called “suicide kits”; that Amazon failed to enforce its own policies; that Loudwolf failed to include FDA-required warning labels on sodium nitrite; that Amazon was previously warned and did nothing about sodium nitrite sold on its platform being used in suicides; that no information was included about methylene blue (the recommended treatment for sodium nitrite poisoning); that there is no compelling reason to allow household purchases of pure sodium nitrite; and, of course, that both deaths were minors.

Abstracting away from the details, however, the case is part of a decades-long pattern of the internet facilitating suicide – from providing community, to disseminating information, to assisting the purchase of supplies.

It began in 1990 with alt.suicide.holiday, a Usenet news group (similar to an internet discussion forum). Users would frankly discuss suicide and share tips and resources. While that group is now defunct, there have been multiple variants. The popularity of sodium nitrite as a means of suicide is attributed to a recent iteration. In many U.S. jurisdictions, advising or encouraging suicide is illegal, so these sites’ relationship with the law is complex – so too is their relationship with the media. Such forums begin as niche communities of the suicidal for the suicidal, and end up as New York Times exposés (most recently in December of 2021). Once aware, grieving families and the broader public often push (successfully) for these sites to be shut down or hidden from internet search results.

In contrast to the prevailing public health or prevention narrative of suicide, the leitmotif of these communities is, in their words, “pro-choice.” The idea is that the right to suicide is simply an extension of our personal autonomy and right to self-determination.

Especially in liberal individual rights-oriented contexts, autonomy is an enormously important ethical principle and people are given broad latitude to make their own decisions as long as they do not negatively impact the rights of others.

In American medicine, for example, patients have an almost unlimited license to refuse treatment. However, humans are not always autonomous actors. Children for instance are not allowed to make their own medical decisions. Being intoxicated is another common exception. In rare cases, people have been known to commit sexual assault or other crimes under the influence of the sleep aid zolpidem (Ambien). The defense is that these were not autonomous actions; that they did not flow from the authentic reasons and desires of the offender.

Can suicide be an autonomous act? Under the prevailing medical account of suicide, in which suicide results from serious mental illness, it almost definitionally cannot. In American law, risk of harm to self or others is grounds for violating patient autonomy and forcibly administering treatment.

That a person is suicidal is treated as evidence that they are not in sound mind and not an autonomous decision maker. Suicidality discounts autonomy.

Those in the online suicide “pro-choice” community challenge this logic and hold that suicide can be a reasonable reaction to a person’s life and circumstances, and people should have access to the knowledge and means to kill themselves relatively painlessly. In this they have at least some philosophical company. Thomas Szasz, a controversial Hungarian-American philosopher and psychotherapist, long asserted that suicide was simply a choice as opposed to an expression of sin or illness.

Szasz is an extreme case and was broadly skeptical of the very designation of mental illness. However, in contrast to a previous Christian sanctity-of-life framing, there is growing acceptance in the Western world that suicide may not always be unreasonable. Instead, it can be an understandable response to circumstances in which someone’s quality of life is below some personal threshold. A good case in point is the right-to-die movement, which advocates for medical-aid-in-dying and physician-assisted suicide. Ten states currently have medical-aid-in-dying in which a terminally ill person with six months or less to live is able to request a lethal medicine they can ingest. Supporters of medical-aid-in-dying stress that the practice is distinct from suicide, partly to escape the stigma associated with suicide, but the conceptual distinctions are slippery.

America is comparatively conservative, but several nations have far more permissive laws when it comes to assisted suicide. Belgium, the Netherlands, and Canada, among other countries, allow for voluntary euthanasia on the basis of extensive and untreatable mental suffering even absent terminal illness or, indeed, any physical illness whatsoever. (The ethics of this have been previously discussed here at the Prindle Post.) The 2018 case of Aurelia Brouwers, who was voluntarily euthanized in the Netherlands after years of failed mental health treatment, brought broader attention to the practice. She was the subject of a short film documentary.

Once it is accepted that unbearable suffering alone is an adequate basis for suicide, then distinctions about how long someone has left to live, or whether that suffering is mental or physical become secondary.

The process of seeking assisted suicide on the basis of mental suffering is supposed to have extensive safeguards, yet critics worry that slip-ups happen. Note, though, that the locus of discussion shifts from the act of suicide to the process of doing it responsibly and ethically.

Surprising to some, among the staunchest critics of the right-to-die movement are segments of the disability rights movement. The concern is that people may be pressured into choosing assisted suicide due to discrimination against people with disabilities or inadequate medical care, i.e. that these decisions are not fully autonomous. Of course, there will always be reasons for suicide, and these reasons may often be due to larger social and economic failings. Poverty is a known contributing factor to suicide. How reasonable this is may depend on where one is standing. In individual cases it is partly the environmental factors – poverty, debt, personal tragedy, discrimination – that can make suicide seem an appropriate response to circumstance. And yet, it may appear ghoulish to have a state-sanctioned process that facilitates suicides partly driven by these factors that the state itself perpetuates (or at least is often in the best position to address.)

Negotiating the appropriate policy prescription remains an impossible task. Mental health professionals, suicide prevention advocates, the American right-to-die movement, disability rights activists, and the online suicide pro-choice community can all share a broader commitment to self-determination and yet disagree vehemently about specific issues: when suicide is an autonomous act, what kind of safeguards need to be in place, what counts as unbearable suffering (or a lack of possibility of improvement), and what action is justified to prevent suicides.

Still, vanishingly few people would consider 16-year-olds killing themselves with online instructions and chemicals purchased on the internet as anything other than a tragedy.

It is statistically likely that had the teens in the lawsuit against Amazon attempted suicide with a less lethal method, they could have been successfully treated and their suicide attempt would have been a thing of the past.

Without speculating on the details of the specific case, it is nonetheless worth acknowledging that Amazon, whatever its failing as a corporation, cannot be the sole cause of this or any suicide. People are seeking information and supplies. And at least some suicides will default to known, highly lethal methods like firearms. It is also true that while the majority of those who attempt suicide and fail do not attempt again, previous suicide attempts are the single biggest risk factor for a later successful suicide. Put cynically, there is a demand. Regulating supply, while important given the relevance of the method, can only do so much. Suicide often exists at the intersection of means, mental health, and personal and environmental circumstance.

One relatively radical way to think about suicide would be as a regulated right – something permitted but tightly controlled. The provision of medical care and mental health care would presumably be part of seeking state-sanctioned suicide. People would need to have good reasons (whatever society decides those reasons are) for seeking materials-for or aid-in suicide, and undergo an appropriate approval process.

As countries like the Netherlands and Canada illustrate, negotiating what this approval process should be like is fraught. The balancing point of different communities with an interest in suicide including the suicidal, their families, mental health professionals, disability rights activists, religious communities, and the state will undoubtedly be a precarious one. Nonetheless, taking seriously the demand for suicide could plausibly help to bring suicidality out of the dark as something that people can talk seriously about and potentially get treated for. Surely a society ought to inquire as to why its citizens wish to take their own lives.

If you or someone you know is struggling with thoughts of suicide, (prevention-focused) resources can be found at SpeakingOfSuicide.com/resources.

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Death Row Inmates, Execution, and Choice

photograph of drug vials and vintage syringe

On October 28th, 2021, the state of Oklahoma executed John Marion Grant. This was the first execution the state had carried out for six years, after placing a moratorium on executions following a case where a prisoner was given the wrong drugs (and another prisoner narrowly escaped the same fate). The drug of choice in nearly all modern federal executions had, until that point, been sodium thiopental. But issues with batch contamination shut down the sole factory producing and supplying it to prisons. Additionally, shortly after discovering a therapeutic alternative to sodium thiopental — pentobarbital — the drug company’s CEO imposed distribution restrictions on the product, prohibiting prisons from buying it.

Since then, most states have lost access to their first and second execution drug of choice, nearly slowing federal executions to a stop. In the last couple years, states have managed to re-access both sodium thiopental and pentobarbital, but the humaneness — and, therefore, constitutionality — of their use remain a matter of dispute, with several lawsuits across many states protesting their use in federal executions. Prisoners and their lawyers frequently use these lawsuits to try to achieve stays of execution. After all, if the jury is literally still out on whether a certain drug is a cruel and unusual means of execution, that seems a good reason to delay its use. However, since Justice Alito’s 2014 Supreme Court opinion arguing that “because capital punishment is constitutional, there must be a constitutional means of carrying it out,” states have been forced to come up with some way to perform executions. Oklahoma devised a compromise: take all of the contested methods of execution, and let the prisoners choose their preferred method.

There was a further deceptive aspect of the choice prisoners were given: several of the execution methods had active lawsuits against them. Therefore, if a prisoner chooses one of those drugs, their execution is put on hold indefinitely, at least until the lawsuit is resolved. The prisoners could choose between several different methods: pentobarbitol, sodium thiopental, non-FDA approved compounded versions of either of the first two drugs, firing squad, or a three-injection method that utilized a benzodiazepine, a paralytic, and potassium chloride to end lives.

But there were some prisoners who believed that selecting the method of their execution would be akin to participating in their own death (i.e., suicide). John Marion Grant was one of those prisoners.

Grant’s refusal to choose an execution method, on the grounds that it violated his deeply-held beliefs that this act would be morally wrong, meant that he was, by default, given the three-injection drug execution – a method not without controversy, given that dosing for these drugs represents a sort of guessing game. That is: nobody really knows how much of each drug any particular inmate will require for complete sedation, so they tend to give prisoners massive amounts rather than risk not giving them enough. Grant’s execution did not, however, go as planned. The aftermath of the injections saw him gagging, convulsing, and vomiting for at least 12 minutes before he was officially declared dead. In an op-ed for The Atlantic, Elizabeth Bruenig characterized Oklahoma’s ruling in the following headline: “Oklahoma Tortured John Grant to Death Because He Wouldn’t Commit Suicide.”

But is this a fair characterization of Oklahoma’s law? Is allowing inmates to choose their preferred method of execution really on a par with forcing them to commit suicide? Initially, the answer seems to be no. Merely having some active role in your own execution is surely not sufficient to render one’s actions “suicidal.” As far as John Marion Grant knew, he was going to die no matter what. All the state was offering him was a chance to choose what he would experience in his final moments.

But rhetoric aside, we may still wonder whether having prisoners take this active role presents an ethical problem. Elizabeth Anderson, in her Tanner Lectures entitled “Private Government,” argues that there are many instances in which a choice only superficially increases someone’s autonomy. She uses the example of laws regarding marriage, specifically the changes in the law when divorce became legal. This newly granted “freedom” of entry into (and exit from) a marriage which, on its surface, appeared to grant more autonomy to women within marriage, actually did the opposite. Because women still lost all property rights upon entering into a marriage contract with their husband, choosing to divorce would, for most women, result in almost certain destitution. It was an “option” that was not really an option at all. Such a choice did little to help improve the overall situation for domestic women. Anderson argues that, “Consent to an option within a set cannot justify the option set itself.” That is, a woman who consents to stay in the marriage, because her other option is homelessness, does not, by that acquiescence, justify the situation. Similarly, one might argue that the Oklahoma law only gives a superficial appearance of prisoner choice and autonomy, and does nothing to make the bare set of execution options permissible.

From a consequentialist perspective, however, an argument could be made that allowing prisoners to choose their method of executions maximizes net good. One may argue that this choice improves the lives of prisoners by alleviating some anxiety they may have otherwise experienced in the lead-up to execution, and that it does this without making anyone else worse-off. For example, if a prisoner had a particular fear of sodium thiopental, they may be relieved to have the option to avoid the drug entirely. Of course, this net gain in utility is not a guarantee — choosing their means of death could exacerbate the anxieties of the prisoner, allowing them to imagine their death in vivid detail in the days before their execution. It may also, as in the case of John Marion Grant, weigh on their conscience as a morally impermissible act of self-harm.

From a Kantian perspective, there may be entirely different reasons to avoid offering this choice to inmates. Kant’s theory of punishment is commonly held to involve a view of justice as primarily retributive — that is, justice is realized when people are rewarded for doing good, and punished for doing bad. Kantian retributivists like the philosopher Igor Primoratz hold that the punishment has to fit the crime in order of magnitude. A crime of murder, therefore, requires for justice that the murderer’s life be taken. The longer we wait to end the life of the murderer, the longer justice waits to be served.

One can, then, imagine a retributivist objection to the Oklahoma law on the grounds that it sometimes results in unnecessary stays of execution. Additionally, one could argue that granting this autonomy of choice to people who are charged with brutally taking innocent lives renders their punishment too light to actually serve justice. After all, the murder victims certainly were not allowed to choose their own means of death.

And so, it seems that, from all normative perspectives, the Oklahoma law regarding choice of means of execution appears morally questionable, at best. We can hope that the law will be replaced with one that is more just — whatever that may look like.

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Banned Books: Why the Restricted Section Is Where Learning Happens

photograph of caution tape around library book shelves

The books included on high school reading lists have not been discussed nearly as widely as the books not included on those very lists. For years teachers and parents have debated which texts students should be able to read, and what parameters should be utilized to determine whether a text is appropriate for a certain age group. However, this debate has moved far beyond whether books are appropriate and has begun to explore how this form of censorship affects students. An article published in The New York Times discusses the banned books of 2016 and how their banned status reveals important facets of the current American psyche. In fact, the author states that the most prominent themes associated with the banned books of 2016 related to gender, LGBTQIA+ issues, and religious diversity, all of which were themes heavily discussed during the election year.

James LaRue, the director of the Office for International Freedom, illustrates his experience receiving reports from concerned parents who worry about the appropriateness of certain texts in their children’s school libraries. However, LaRue does not agree with this method of parenting and states, “They are completely attached to the skull of the child and it goes all the way up through high school, just trying to preserve enough innocence, even though one year later they will be old enough to marry or serve in the military.” This point is echoed by author Mario Tamaki who expresses that deeming books as inappropriate marginalizes groups of individuals and can adversely hurt students who relate to their characters. He states, “We worry about what it means to define certain content, such as LGBTQ content, as being inappropriate for young readers, which implicitly defines readers who do relate to this content, who share these experiences, as not normal, when really they are part of the diversity of young people’s lives.”

Both of these individuals relay their concern for the influence of banning books on young readers and this point is reiterated by Common Sense Media a non-profit organization which seeks to provide education to families concerning the promotion of safe media for children. Despite their specialization in appropriate media for children they encourage parents with the article, “Why Your Kid Should Read Banned Books,” which outlines how the most highly regarded pieces of literature were at some point banned in mainstream society. However, their banned status says nothing of the important messages held between those pages. They make the statement, “At Common Sense Media, we think reading banned books offers families a chance to celebrate reading and promote open access to ideas, both which are key to raising a lifelong reader.” This organization’s support for encouraging  a conversation regarding censorship and the importance of standing up for principles of freedom and choice is a critical facet of this continued debate.

On the other side of this debate are concerns of not only violence, language, and substance abuse, but questions about how explicit stories of suicide and self harm may influence young readers who are depressed or suicidal themselves. This concern was heightened due to literature such as the popular young adult book Thirteen Reasons Why, which revolves around a teenage girl’s suicide. Author Jay Asher has been outspoken regarding why censorship of his book specifically is harmful to teenagers. In an interview he describes knowing that his book would be controversial: “I knew it was going to be pulled from libraries and contested at schools. But the thing about my book is that a lot of people stumble upon it, but when it’s not on shelves, people can’t do that. Libraries, to me, are safe spaces, and if young readers can’t explore the themes in my book there, where can they?” Asher acknowledges that it is nearly impossible to create a book which will be appropriate for all readers. He outlines his experience talking to a student who was overwhelmed by the contents of the story. The student decided to refrain from finishing the remainder of the book until she felt completely comfortable, effectively self-censoring.

These attitudes towards censorship reveal troubling social implications when considering which books are chosen for exemption from libraries, as an article published in The Atlantic describes. There is a clear separation themes of violence and fantasy in comparison to the highly-censored themes referencing race or sexuality, which reveals a larger issue of the struggles of minority authors getting children’s books published. According to The Atlantic, “this means the industry serves those who benefit from the status quo, which is why most scholars see children’s literature as a conservative force in American society.” The author reinforces the ideas discussed by adults concerned about the limited access to a broad range of ideas in children’s literature, and concludes by stating,“This shared sensibility is grounded in respect for young readers, which doesn’t mean providing them with unfettered access to everything on the library shelves. Instead it means that librarians, teachers, and parents curate children’s choices with the goals of inspiring rather than obscuring new ideas.”

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Gun Ownership and Suicide: An Overlooked Health Crisis  

A photograph of a gun on a table

Warning: this article contains content, information, and discussion about suicide which may be upsetting to some readers.

If you are in a crisis, help is available.

Mass shootings have become numbingly routine in the United States. When Americans think of gun violence they tend to picture high-profile shootings and the polarizing debates over gun control that follow. Yet, most tragic gun deaths occur in lonely isolation. Of the thousands of people who die by gunshot each year in the United States, suicides make up the majority.

A growing number of people are dying by suicide committed with a firearm and the issue has gone mostly unreported. In a USA Today article, Robert Spitzer, author of The Right to Bear Arms and other books on gun control says, “Gun suicides continue to be kind of an underreported story in the sense that when people think of gun violence, they think of homicides, they think of gangs or mass shooters or personal violence.”

As with gun deaths caused by homicide, accident, and mass shootings, the topic of gun control arises with suicide. Are policies regulating the manufacture, sale, transfer, possession, modification, and use of firearms an effective means of addressing the problem of gun suicide? Studies would say yes. Mandatory purchase delays on handguns have been linked to a reduction in firearm suicides and no corresponding increase in suicide by other means. Further, a cross-sectional study found that states with stronger firearm laws had a lower overall suicide rate (not simply a shift from firearm to non firearm suicide) than states with weaker firearm laws.

Firearm suicide is not limited to adults; in fact, there has been an increase in firearm suicide by youth in recent years. A January 17, 2019 study found a strong association between the prevalence of household gun ownership and the overall youth suicide rate at the state level. “For each 10 percentage-point increase in household gun ownership, the youth suicide rate increased by 26.9%.” More guns lying around means a greater risk of young people falling victim to suicide. States with Child Access Prevention (CAP) laws, which require guns to be stored in a manner that prevents unauthorized access by young people, reported overall youth suicide rates eight percent lower than states without CAP laws.

While suicide is complicated and many risk factors can play a role in the decision to carry out an attempt, evidence suggests that preventing access to firearms is one effective method of reducing overall suicide rates because, of all suicide methods, firearms are the most lethal. The New England Journal of Medicine reports that most suicides tend to be impulsive (occurring with little planning or forethought) and are a reaction to immediate stressors: “As the acute phase of the crisis passes, so does the urge to attempt suicide.” Reducing exposure to lethal means, even temporarily, can prevent suicide by reducing one’s ability to carry out an attempt. Even if someone decides to substitute a different means, they are more likely to survive a less lethal attempt. This is significant because 90% of attempt survivors will not go on to die by suicide.  

Despite the fact that gun control legislation is a fiercely debated topic within the U.S., an unlikely partnership between the medical community and gun industry is emerging in an attempt to address the issue of firearm suicide. A growing number of gun dealers, firearm instructors, and range owners are working with mental health professionals to produce educational campaigns geared toward making people more aware and comfortable talking about guns and suicide.

Programs like the New Hampshire based Gun Shop Project have created training modules that educate gun shops workers on how to spot and help potentially suicidal customers. The suicide prevention coordinator for Washington County, Utah has helped create public service announcements encouraging the family and friends of those in an emotional crisis to talk to their loved one about temporarily storing firearms away from home. Even the Firearms Industry Trade Association has released statements working to help prevent suicide by firearm. While the effectiveness of such educational programs has not been studied, Brian Mann of NPR says, “the debate over guns and violence in America is really polarized, and this is a rare collaboration. Supporters hope voluntary education and outreach will save lives.”

Media attention surrounding high-profile mass shootings and firearm homicide have focused the ongoing debate about gun control policies in the U.S. around the prevention of such tragedies. While these are issues that must be addressed, suicides make up nearly two-thirds of all gun deaths in the U.S. and the nation ranks second internationally for the highest worldwide gun suicide rate. For America to most effectively move forward with efforts to reduce gun violence, adequate attention must be given to suicide prevention.  

If you or someone you know is in crisis, call the National Suicide Prevention  Lifeline at 1-800-273-8255 OR Text SIGNS to 741741 for 24/7, anonymous, free crisis counseling.

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Reflection on Responsibility: National Suicide Prevention Month

Photo of a sign at the Golden Gate Bridge that says "Crisis counseling - There is hope - Make the call - The consequences of jumping from this bridge are fatal and tragic".

Content warning: discussion of suicide

September is National Suicide Prevention month, and September 10th marked World Suicide Prevention Day.  Organizations such as the Suicide Prevention Lifeline, American Foundation for Suicide Prevention and the International Association for Suicide Prevention all hosted social media hashtags and encouraged everyone to spread awareness of suicide and how to prevent it. Suicide has long been considered an epidemic in the United States, but a recent study published by the CDC in July showed that the rate of suicide in the U.S. has increased dramatically in the past 20 years. By and large, suicide is considered negative in our society, often framed as tragic due to its preventability. Several pop culture idols have committed suicide since the beginning of 2018, including chef and TV personality Anthony Bourdain and fashion designer Kate Spade. During this month, it is pertinent to examine exactly what our culture’s stance on suicide truly is. Does framing suicide as negative require us to make judgements about those who commit it? Does an anti-suicide stance require us to also oppose assisted suicide? And finally, who should we hold accountable for fixing and preventing the suicide epidemic; our culture, ourselves, or our public institutions?

As quite literally a life or death matter, the way that we talk about suicide is a delicate matter. In an article titled “Is Suicide Selfish?” Senior Director of Suicide Prevention and Postvention Initiatives, Shauna Springer, examines from a psychological perspective if we can truly hold those who attempt or commit suicide can considered selfish. While Springer doesn’t deny that suicide has consequences on those other than the victim, she holds that it ultimately is not a selfish act, due to the fact that “suicidal mode is an altered state of consciousness.” Because those suffering from suicidal thoughts “often have distorted perceptions of reality,” we cannot make judgements about their character and actions in a similar way that we would a healthy person. Others however, feel differently. In an article titled “I Still Think Suicide Is Selfish And No, I’m Not Ignorant For Believing So” Lesly Salazer defends her position by using her personal experience with depression and suicidal thoughts. Salazer explains that growing up, she was told “‘There’s more to life than yourself and your sadness. You can’t let your emotions overpower your common sense. God has a plan for you, and killing yourself is just plain stupid.’” She believes that this attitude toward suicide saved her life, because she felt she was doing a moral wrong by killing herself. The traditional methods of hotlines and therapy did not work for Salazer, though she acknowledges they may help some. In conclusion, Salazer defends her belief that suicide is selfish on the basis that such a belief might prevent people from killing themselves. However, one could argue that such an attitude towards suicide might actually hinder people from finding help, because they do not feel like they can talk about their suicidal thoughts. While it might help some like Salazer, it has the potential to hurt many others.

If we decide as a culture and society to take a negative stance toward suicide, can we also consistently advocate for methods that make ending one’s life easier or less painless? The legalization of physician assisted suicide has been a debate in recent years, with states like Oregon and California passing legislation to legalize physician-assisted suicide. But how do suicide prevention organizations view physician assisted suicide? In October of 2017, the American Association of Suicidology released an article clarifying that they, as an organization, do not considered assisted suicide as suicide, but instead as “death with dignity’ or “physician aid in dying.” The article explains that the organization “ does not assume that there cannot be ‘overlap’ cases, but only that the two practices can in principle be conceptually distinguished and that the professional obligations of those involved in suicide prevention may differ.” The organization goes on to list 15 key differences between physician-assisted suicide and the type of suicide that the AAS aims to prevent. The key distinctions AAS claims exist between suicide and physician-assisted death are medical and conceptual. One observation is that those seeking assisted suicide are often facing physical chronic illness, whereas those seeking to commit suicide are often plagued by mental illness, impairing their judgement and ability to make reasonable decisions. However, those against physician-assisted suicide argue that taking such a stance worsens the stigma associated with mental illness as not as serious or legitimate as physical diseases and conditions. Should the decision to end one’s life be treated differently or more dignified on the basis of physical or mental conditions? A previous Prindle Post article by Amy Elyse Gordon examines this issue. One could surely argue that in the case of terminal illness, physician-assisted suicide provides relief and control to those facing death. Additionally, this type of ending one’s life may not have the same adverse effects on family and friends as other forms suicide do.

If we accept that suicide is detrimental to society, whose responsibility is it to prevent it? This question is a difficult one, because it, in a way, assumes that suicide can be influenced by others, and that they in some way hold a moral responsibility to prevent it. At what level we hold people accountable can be difficult to determine. Giving the government the complete burden of preventing suicide may lead to its criminalization. Indeed, suicide was considered a crime in the U.K. until 1961, when suicide became framed less as a sin or moral wrong and more of a medical and psychological problem. However, the government can help prevent suicide in more ways than criminalization. A 2016 study found that rising poverty rates were highly correlative of rising suicide rates during the 2008-2009 economic recession. This study suggests that poverty and economic burden can influence the rate of suicide and if our goal is to prevent suicide, perhaps we should hold our politicians and government accountable for supporting those that are impoverished or enforcing stricter regulations on financial institutions to ensure economic stability. On the other hand, some might argue this alone is not enough.

Suicide is undoubtedly influenced by mental illness in many cases, regardless of external factors. Perhaps it is the responsibility of organizations such as the American Foundation for Suicide Prevention to help support those who feel suicidal and raise awareness about the topic. Some might argue this still is not effective enough alone because those who are considering suicide may not have access to these resources or may not have the motivation to seek out help.

So, we might then believe that it is every individual’s responsibility to prevent suicide. One example of the application of this type of thinking is the involuntary manslaughter sentencing of Michele Carter in 2017. Carter was a teenager suffering from mental illness, whose boyfriend, Conrad Roy III, committed suicide in 2014 (discussed in detail in this Prindle Post article). Text messages minutes before his Roy’s death show that Carter encouraged him to kill himself, texting him to get back in the carbon monoxide car after he had second thoughts about killing himself. Carter’s verdict implies that people can be held legally and morally responsible for their loved one’s decision to commit suicide. In the case of Carter, it was not just her failure to stop Roy, but also her encouraging attitude toward suicide that made her guilty,  according to the judge. If we decide to hold individuals accountable for preventing suicide, we may have to accept verdicts such as the one in the Michele Carter case. This becomes difficult, because it implies that those surrounding suicidal people, including loved ones, could be held legally and morally responsible for their death. Additionally, is assigning blame in the case of suicide really necessary or morally correct?

Suicide is not an easy topic, and probably never will be. The decision to take one’s own life cannot be boiled down to one or even a few causes. During September, we should all collectively think critically about suicide and how we are failing as a society to prevent it.

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“Unbearable Suffering” and Mental Illness

Photograph of a single bed with a curtain and chair

Trigger warning: suicide attempts, multiple mental illness mentions

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

List of international suicide hotlines: http://ibpf.org/resource/list-international-suicide-hotlines

Aurelia Brouwers’ Instagram bio is terse and pointed: “BPD, depression, PTSD, anxiety etc. Creative. Writer. Gets euthanasia Januari [sic] 26. Fights till then for this subject.”

Brouwers was a twenty-nine year old Dutch woman who suffered from multiple mental disorders. She received her first diagnoses of depression and Borderline Personality Disorder at the age of twelve. As she recounts: “Other diagnoses followed – attachment disorder, chronic depression, I’m chronically suicidal, I have anxiety, psychoses, and I hear voices.” After an estimated twenty failed suicide attempts, Brouwers thought she found the solution to her suffering via euthanasia or physician-assisted suicide (EAS). EAS has been legal in the Netherlands since 2002, but Brouwers faced obstruction as her request was refused by multiple doctors. She finally turned to The Hague’s End of Life clinic, which approved her request and set a date for January 26 of this year. Scenes from Brouwers’ last fortnight of life were recorded by RTL Nieuws journalist Sander Paulus, who noted the young woman’s ongoing mental distress as well as the conviction with which Brouwers anticipated her euthanasia date. Footage featured by the BBC shows Brouwers collectedly making plans for her cremation ceremony with a funeral consultant. On January 26, surrounded by loved ones and two doctors, Brouwers consumed a liquid poison and “went to sleep.”

Brouwers’ case stoked vigorous debate in the Netherlands and elsewhere regarding the intent of euthanasia legislation. Her youth is one point of contention. Another factor is the nature of her affliction. In the discourses following Brouwers’ life, we see evidence of an assumed distinction between physical and psychiatric disorders. Journalist Harriet Sherwood went so far as to note in the tagline for her Guardian article that ”there was nothing wrong with her [Brouwers] physically.”

While psychiatric disorders are still primarily diagnosed via mental and behavioral markers, it is not strictly correct to assume that mental health disorders lack physical foundations. Often, the ways in which we speak of mental disorders reveal our imperfect knowledge of the biological elements (as differentiated from the more traditionally observed psychosocial components) of mental disease. This relative ignorance exists in part because researching biomarkers for psychiatric disease is a complex undertaking. What is known is that mental illnesses can often be life-long conditions that require ongoing treatment, treatment that appears to have been provided in Aurelia Brouwers’ situation.

The 2002 Dutch act exempting physicians from prosecution in specific EAS cases requires ”due care” by the attending doctor. This includes ascertaining unbearable suffering on the part of the patient without hope of improvement. The Netherlands is joined in this relatively open model by other European nations, including Belgium, Luxembourg, and Switzerland. Several American states, the Australian state of Victoria, and Canada also allow EAS, but in much more restricted circumstances mirroring the “Oregon model,” which stipulates a terminal illness with established life expectancy.

Arguments in favor of euthanasia often rest on the basis of respect for individual autonomy and on compassionate grounds. Here, for the sake of simplicity, I assume ethical assent to these grounds in support of voluntary euthanasia or physician-assisted suicide which is at the informed, long-standing behest of the patient. This is the only form of active euthanasia currently legal anywhere (whereas what some call ”passive” euthanasia or the withdrawal of futile treatment is considered to be normal medical practice). These moral justifications – autonomy and compassion – are taken as reasonable in states in which EAS is legalized. In the Netherlands, however, where EAS has been legal for sixteen years, Brouwers was initially refused by several doctors, and garnered national attention. Why?

Brouwers’ example seems to challenge notions of what constitutes “unbearable suffering,” impossibility of improvement, and “terminal” conditions. Popular conceptions of mental illness present it as something that one can “overcome” through patience or willpower, although the same perceptions do not apply to a broken bone or a cancer diagnosis. Dutch psychiatrist Dr. Frank Koerselman, speaking to the BBC, notes that Borderline Personality Disorder, from which Brouwers suffered, is known to decline in severity after the age of 40. But BPD was only one of Brouwers’ multiple diagnoses, which taken together, caused her immense suffering. Along these lines, some argue that her mental disease was itself terminal, as does Kit Vanmechelen in the BBC article. Brouwers had already engaged in numerous, though incomplete, suicide attempts.

What happens, though, when we allow EAS for psychiatric suffering as well as physical suffering (the more traditionally accepted justification)? As a society, our understanding of mental suffering does not seem to be as advanced as that of physical suffering (only recently was it discovered that emotional pain activates neural correlates similar to physical pain).

Many believe that it is a mistake to open this door. Dr. Koerselman opposes EAS for psychiatric disorders, in part because he posits it is not possible to distinguish a rationalized decision to die from a symptom of mental disease itself. On the other hand, a recent study of Belgian mental health nurses’ attitudes toward euthanasia for unbearable mental suffering found a widely positive response. Nurses were the subjects for this study because of their closeness to patients’ lives and frequent role as intermediate and advocate between patients and doctors.

Ethics is about individual cases, as well as the general principles that they reveal or elicit along the way. The case of Aurelia Brouwers is undeniably a tragic one, although Brouwers herself appeared to find some peace in her capacity to make an informed choice, supported by medical care. But what her life surely reveals is that we need to invest more in exploring the genesis and maintenance of mental disorders within our societies. One in four people world-wide will suffer from some form of mental illness. We need to invest more in understanding the biological bases of mental illness, as well as the social structures that are implicated in psychiatric disorders’ psycho-social components.  In the words of Brouwers, “I think it’s really important to do this documentary [of Brouwers’ life] to show people that mental suffering can be so awful that death, in the end, is the lesser of two evils.” As a society, we need to do better by those who experience mental pain.

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Manslaughter by Text Message

In 2014, Conrad Roy III, an eighteen-year-old resident of Fairhaven, Massachusetts, committed suicide. Roy placed a generator inside the cab of his pickup truck to facilitate the production and inhalation of a lethal amount of carbon monoxide.

In recent months, Roy had expressed to friends and family that he was in a low place mentally.  He shared details about his psychological state with his girlfriend, Michelle Carter.  In a series of text messages and Facebook correspondence over the course of a few weeks, Carter encouraged Roy to end his own life. “I thought you wanted to do this,” she told him, “The time is right and you’re ready, you just need to do it! You can’t keep living this way. You just need to do it like you did last time and not think about it and just do it babe. You can’t keep doing this every day.” When he expressed reservations about going through with it, Carter insisted, “You’re just making it harder on yourself by pushing it off, you just have to do it.”  

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Moral Panic and the “Blue Whale Game”

Over the last few months, there have been reports of a deadly internet game, “The Blue Whale.” Allegedly, teenage gamers participate by following the instructions provided by the designers of the game. These instructions include watching horror films and waking up in the middle of the night. The challenge goes on for 50 days, and then, the final instruction is to commit suicide.

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