The phantasm of zero suicide
- Type :#article
- Date read: 2023-05-22
- Bibtex: @sjostrand2023
- Bibliography: Sjöstrand, M., & Eyal, N. (2023). The phantasm of zero suicide. The British Journal of Psychiatry, 222(6), 230–233. https://doi.org/10.1192/bjp.2023.3
- Having a focus on zero suicide risks societal responses that violate ethical principles
- Because we still have poor prediction tools for suicide, we risk harming some individuals by using intrusive prevention methods (worse access to medication, involuntary psychiatric care)
- Some efforts are a no-brainer though, like improved access to mental health care and better post-discharge follow-up
- A goal known to be unrealistic may undermine trust and exacerbate frustration and stigma
- What is their proposed middle path?
- Suicide prevention should normally only use benign methods that improve individual and population health. For example improving access to high-quality mental health services
- Coercive interventions when it makes the following decisions more autonomous. (I think an example would be a psychotic or manic episode). Soft group paternalism like restricting access to means for impulsive suicide (gun control)
- Increase lag-time from decision to possible suicide. You don’t have to completely remove means just increase the time required to act on impulses
- Reject a zero suicide goal that everyone already knows is unrealistic. It risks increasing guilt, blame and burnout among clinicians, patients and relatives.
On a societal level not all suicide-prevention efforts serve public health
Instead of a zero-suicide goal we propose a middle path for suicide prevention policy. Global and national public health should primarily aim at offering assistance and treatment to prevent the illnesses and social malaise that drive much suicide. Specific measures to prevent suicide are justified when they serve overall public health goals but may be unjustified when they have adverse results for many people.
Admittedly, many suicides are seemingly impulsive, non-deliberated acts, associated with mental disorders, substance misuse and poor problem-solving abilities, all factors that can undermine capacity for autonomous decision-making.24,25 However, the factors leading to a person’s suicide are too variegated for all to lack personal autonomy and rationality. Decision-making capacity may be retained even in severe psychiatric disorders.26 The global suicide rate is higher in later ages than in adolescence and correlated to physical ailments and functional impairments,1 and even when a death by suicide appears impulsive to external observers, it may well have been pre-meditated and considered for a long period of time.
If workers who are abused and exploited die by suicide because of, for example, terrible work conditions, the solution is not simply to ban suicide or restrict their access to means for suicide. The underlying causes are what must be altered. An obligation to reduce a cause of something (such as bad work conditions) is not the same thing as an obligation to reduce that thing (for example workers’ suicide rates) irrespective of the means to achieve it.
Governments and non-governmental organisations are increasingly adopting a ‘zero-suicide’ goal, but what such a goal precisely involves is unclear. Ostensibly it strongly prioritises the prevention and elimination of all suicide. We argue that, so understood, a societal goal of zero suicide risks contravening several ethical principles. In terms of beneficence and non-maleficence, a ‘zero-suicide’ goal risks being inefficient and may burden or harm many people. Autonomy-wise, a blanket ban on all suicide is excessive. As regards social justice, zero suicide risks focusing on the symptoms of social malaise instead of the structures causing it. With respect to transparency, a ‘zero’ goal that cannot be met makes these authorities look detached and risks frustration, distrust and, worse, stigmatisation of suicide and of mental health conditions. Instead, we propose a middle path for suicide prevention, founded on harm reduction, ‘soft group paternalism’ and efforts directed at increased quality of life for disadvantaged groups. Although soft group paternalism respects autonomy, this approach permits coercive interferences in certain circumstances. We hope that the justificatory framework tying together these largely familiar elements is novel and sensible. PDF: sjöstrand_2023_the_phantasm_of_zero_suicide.pdf