International Review of Psychiatry, June 2010; 22(3): 288–293 ‘The one truly serious philosophical problem’: Ethical aspects of suicide MURAD M. KHAN 1 & AYESHA I. MIAN 2 1 Department of Psychiatry, Aga Khan University, Karachi, Pakistan and 2 Menninger Department of Psychiatry, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA Abstract Suicide is a major global public health problem with an estimated one million deaths every year. It is one of the most personal yet one of the most complex acts anyone can perform, as it goes to the very core of the concept of human existence and the meaning of life. The philosophical debate on suicide has spanned centuries with no clear answers. Juxtaposed within the various perspectives that suicide can be studied from is the ethical perspective that brings into sharp focus the conflict between personal autonomy and societal responsibility towards suicidal individuals. Mental health professionals find themselves in the midst of this conflict as they are assumed to have the responsibility to prevent suicide in their patients, while patients’ responsibility towards themselves is frequently overlooked. Mental health professionals need to be aware of the ethical concerns that arise in the care of suicidal patients. There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philo- sophy. (Camus, 1942). Introduction Suicide is a puzzling and disconcerting phenomenon. It is one of the most personal acts that one can perform, and often eludes easy explanation. It not only affects the suicidal individual, but leaves a mark on immediate family and friends as well as the community at large. According to the World Health Organization, over the last decade, globally, almost one million people die by suicide each year (WHO, 2001). There are more deaths by suicide annually than in all wars, conflicts, terrorist acts and homicides combined. Since it signifies a complex public health crisis, suicide is a subject of study across various disciplines including psychology, psychiatry, sociology and anthropology and philosophy. It is difficult to achieve a neutral definition of suicide, because it is a deeply moral question and as such its definition also stands as a signifier of society’s judgement of suicide. (Oyebode, 1996). Over the past century, the study of suicides across populations and countries over the world has clearly established that suicide occurs in almost all societies and cultures, in a variety of circumstances and across different phases of the life cycle (Diekstra, 1989). Due to its complex nature, there has been a vast range of viewpoints and attitudes towards suicide throughout history. On one hand, suicide may be conceived as being morally unacceptable; a phenom- enon that must be prevented, if possible. This is evidenced by government and non-governmental programmes and groups that target suicide reduc- tions and preventions. Conversely, a US district judge ruled that ‘like the abortion decision, the right of the terminally ill person to end his or her life involves the most intimate and personal choices a person can make in a lifetime and constitutes a choice central to personal dignity and autonomy’ (Roberts, 1994, p. 1255). This article is addressed mainly to mental health professionals as they navigate through ethical con- cerns that arise during the care of a suicidal patient. It covers the following areas in relation to ethical aspects of suicide: evolution of ethical concepts from the historical point of view, personal autonomy versus societal responsibility towards others, the interface of clinical and ethical issues in management of suicidal patients and issues related to suicide prevention in diverse cultural settings. We have focused on intentional suicide and have not addressed euthanasia, (active or passive) or assisted suicide, which, though extremely important topics, would be outside the scope of this article. Correspondence: Murad M. Khan, Department of Psychiatry, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan. Tel: (þ92 21) 4930051. Fax: (þ92 21) 493 4294. E-mail: murad.khan@aku.edu ISSN 0954–0261 print/ISSN 1369–1627 online ß 2010 Institute of Psychiatry DOI: 10.3109/09540261.2010.484017 Int Rev Psychiatry Downloaded from informahealthcare.com by Kings College London on 06/16/10 For personal use only.