Morality, Mental Illness and the Prevention of Suicide

ABSTRACT

Since the middle of the 20^th century, suicidology, as a group of disciplines working to understand and prevent suicide, has reinforced the long-held view that suicide is caused first and foremost by mental illness. Yet, the record of the last two centuries demonstrates the difficulty in identifying the risks and in reducing the incidence of suicide despite persistent reliance on psychosocial means. In order to understand the reasons for this outcome it is crucial, we will argue, to expose the moral values on which the medicalised assumptions about causes of suicide was based. Our aim here will be to demonstrate how moral arguments against suicide, which existed for centuries, have shaped psychiatric theories and discourse on suicide since the turn of the 19^th century, and how this has persisted in present suicidology. These arguments, which had once justified legal and religious sanctions, were progressively naturalised and appropriated by medicine. Latent, implicit, even denied in contemporary suicidology, these moral arguments remain nonetheless at the heart of the medicalised conception of suicide, as it is through these moral values that medicine was able to ‘appropriate’ this act.

KEYWORDS:

• Suicidology
• statistics
• mental illness
• culture

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. Indeed, in the West, suicide was for centuries considered as a crime and a sin, imposing significant sanctions against the suicide and their family. These sanctions resulted in stigmatisation of the individual surviving a suicide attempt and of his or her family. While suicide is no longer illegal in most Western countries, the question of stigmatisation remains prevalent in suicide prevention, as a major obstacle to addressing the reality of this social and public health problem (Lederer 2006; MacDonald 1992).

2. Official journal of the World Psychiatry Association (WPA).

3. An overview of these results is available on the CDC website: https://www.cdc.gov/vitalsigns/suicide/index.html. In addition, they were widely reported by the media immediately following their publication. See, for instance: https://www.npr.org/sections/health-shots/2018/06/07/617897261/cdc-u-s-suicide-rates-have-climbed-dramatically, https://www.cnn.com/2018/06/07/health/suicide-report-cdc/index.html. This increase in media attention to suicide is also due, in part, to the suicide of two major U.S. celebrities, leading to open discussions of this issue on most major print and TV media outlets.

4. On the process of medicalisation of suicide before its decriminalisation in Europe and the United States, see Giraud (2000); Godineau (2012); Kushner (1991), see esp. Chapter 1 ‘From crime to disease, 1630–1843,’ 13–34; lederer (2006), see esp. Chapter 6 ‘Confinement and its vicissitudes,’ 242–282, and Chapter 7 ‘The legacy of spiritual physic,’ 283–320; MacDonald (1992), 85–103; Midelfort (1996), 41–56; Tinková (2013); Lind (2004); Siena (2009); Merrick (2009); Houston (2009).

5. An earlier version of this article was published in the Dictionnaire des sciences médicales, t. LIII, Paris, Panckoucke, 1821, art. ‘suicide’.

6. Brigham asserted that ‘as many [suicides] have been committed some years in the city of New York alone, as are assigned to the whole State’ (Brigham 1845, 232–234).

7. On the relation between civilisation and pathological phenomena, such as suicide and mental illness, see Chevalier (1958, 331–359); Brancaccio (2013, 700–715). Civilisation and its dangers are prioritised as a major cause of suicide by numerous alienists, namely by Alexandre Brierre de Boismont (1855).

8. See, for instance, Lederer (2013).

9. For 19^th-century French studies on social phenomena and behaviours considered as being immoral or deviant, see for instance Parent-Duchâtelet (1836); Villermé (1830; 2008). As he states in the first pages of the text, Villermé bases his study on the Parisian statistics (Recherches statistiques sur la ville de Paris et le département de la Seine). On Villermé, and his work on mortality statistics and hygiene movement in France, see Jorland (2010), especially Chapter 4 (‘La loi de villermé’), 87–115; Coleman (1982). On the development of moral statistics and their influence on the psychiatric theories of suicide, see Hacking (1990), especially Chapter 8 (‘Suicide is a kind of madness’), 64–72, and Chapter 9 (‘The experimental basis of the philosophy of legislation’), 73–80. On the development of the public health movement in France during the first half of the 19th century, and more specifically on the key figures of this branch of medicine and their publications, see Ackerknecht (1949, 117–155); La Berge (1992). Finally, on the specific role of the Annales d’hygiène publique et de médecine légale in the public health movement, see Lécuyer (1977, 215–245).

10. French alienist Etoc-Demazy (1844), for instance, identifies mental illness as the cause in one-third of suicides. In his review of Etoc-Demazy’s study published the same year, Brierre de Boismont’s (1844) data shows that two-thirds of cases are caused by mental illness. Brierre de Boismont (1849) then publishes his own statistical study on suicide and madness. In this study, he shows that 22% of suicides were caused ‘directly or indirectly by madness,’ (1849, 88), and that 14% were caused by ‘madness in the strict sense’ (ibid., 89–90). Devergie (1851) publishes a statistical study of the Morgue for the decade between 1836 and 1846, according to which mental illness accounted for 25% of suicides. However, Devergie excludes from this category certain causes pertaining to mental illness, namely suicidal monomania. Finally, even at the end of the 19^th century, mental illness remains but one cause of suicide among others. See, for instance, Foley (1880).

11. On the founding text of this theory, see Morel (1857). On the theory of degeneration, see Coffin (2003); Renneville (1996, 546–577); Carbonel (2010).

12. See for instance, Mandon (1862); Voisin (1872); Moreau de Tours ([1899] 1890); Corre (1891); Proal (1900). See also Renneville (2003); Guignard (2010); Dupouy (2011).

13. Several recent studies have claimed that suicide terrorists are in fact suicidal. However, these studies rely on little evidence of systematic and rigorous evaluations of the suicide-bombers whose acts were prevented (Sheehan 2014; Lankford 2011). On the moral implication of suicide bombing and its relation to other forms of suicide, see Pabst Battin (2005, especially Chapter 11, ‘The Ethics of Self-Sacrifice: What’s Wrong with Suicide Bombing?’, 240–247).

14. ‘Il existe donc une gradation passant de la pensée à l’acte, tout d’abord raté puis réussi. […] le désir de mourir avec son corollaire “ne plus exister,” ou l’anéantissement, le “non-être” sont pour la plupart du temps assez étrangers aux suicidants. On ne se tue pas pour ne plus exister, mais bien pour exister autrement’ (Schneider 1954, 9). See also Debout (2005, 12).

Additional information

Notes on contributors

Eva Yampolsky

Eva Yampolsky has a PhD in French literature (Emory University, 2011) and a PhD in the History of Medicine (University of Lausanne, 2019). She specialises in the history of psychiatry and suicide. She is currently a senior researcher at Institute for Humanities in Medicine (CHUV/University of Lausanne) on a project examining the Convulsionaries of Saint-Médard and the birth of neurology.

Howard I. Kushner

Howard I. Kushner is the Nat C. Robertson Distinguished Professor of Science & Society Emeritus at Emory University and the John R. Adams Professor of History Emeritus at San Diego State University. He is author of five books, numerous articles on the history of suicide, mental illness, and addiction.