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DOES DURKHEIM'S SOCIAL THEORY OF SUICIDE APPLY MORE TO ASSISTED SUICIDE THAN SUICIDE?
Dirk M. Dhossche, M.D.
Department of Psychiatry and Human Behavior
University of Mississippi Medical Center
2500 North State Street, Jackson, Mississippi 39216
Tel. 601 984 5866
Fax 601 984 5885
Emile Durkheim has argued in his 1897 book "Le Suicide" that collective social forces are more important determinants for suicide than extra-social or individual factors. Durkheim's theory does not take into account modern insights into risk factors for suicide, most importantly mental illness. The hypothesis that social and cultural forces are factors that are more important in assisted suicide and euthanasia than (unassisted) suicide awaits further study.
Keywords: Suicide, Assisted Suicide, Social Theory, and Psychiatric Disorders
Psychiatric illness, suicide, and their association remain subject to considerable bias and stigma. Some important obstacles toward public acceptance of suicide as a fatal outcome of psychiatric illness are discussed.
Stigma of suicide hangs together with stigma of psychiatric problems. Psychological barriers to seeking help for mental dysfunction or substance abuse are thought to be important determinants of undertreatment of psychiatric disorders. Negative preconceptions may result in non-compliance with beneficial psychiatric treatments, which may be perceived as a sign of weakness and inability to cope with life's vagaries. In other instances, psychiatric treatment is portrayed as cosmetic and indicative of a superficial life style, even by some health professionals. Other psychiatric practices such as electroconvulsive therapy, involuntary admission, stimulant treatment of children, and suicide prevention are also subject to stigma and, for some groups, constitute breaches of individual autonomy and freedom. However, these considerations are mostly alien to physicians' concerns about appropriate diagnosis of psychiatric suffering and effective treatments for these ailments.
Another impediment for acceptance of a medically oriented approach to suicide prevention is the sociological stance as exemplified by the theory of Emile Durkheim who has formulated an influential theory on social causes of suicide in his 1897 book "Le Suicide" (Durkheim, 1897). The theory argues that collective social forces are more important determinants for suicide than extra-social or individual factors. Psychiatric factors, race, heredity, climate, temperature, cosmic factors (i.e., seasonality), and imitation are dispatched as peripheral to suicide. Instead, the totality of suicides in a society is deemed the appropriate quantum of investigation.
In Durkheim's theory, disturbed regulation of the individual by the society is seen as the common denominator in all suicides. A U-shaped correlation between suicide rates and the degree of integration of individuals in society is hypothesized. Poor integration leads to increased suicides of the "egoistic" type; excessive integration increases suicide rates because of more "altruistic" suicides. "Anomic" suicide is caused by sudden changes in the social position of individual mainly due to economic upheavals. On average, subsequent studies have supported an association between suicide rates and indices of social fragmentation.
Others have criticized Durkheim for his undue emphasis on social factors at the expense of individual psychological and psychiatric causes, mainly because of two observations. First, as shown previously, suicide nearly always occurs in people with psychiatric illness across various cultures (Cheng, 1995; Rich et al., 1986; Robins et al., 1959). Although psychiatric impairment seems to be a necessary condition for suicide, it is not a sufficient one, as most psychiatrically ill people do not commit suicide. Social and interpersonal factors may be important on an individual level to explain why one person commits suicide and the other does not despite similar psychiatric impairments. Second, decreased social integration and functioning may be consequences rather than causes of psychiatric impairment. Berrios and Mohanna (Berrios et al., 1990) have emphasized the negative implications of this confusion of social factors as cause versus consequence: "... by playing down the psychiatric explanations, he (Durkheim) drew attention away from the sufferers themselves, and from the only practicable way of improving their predicament."
Another possible challenge for public acceptance of suicide prevention is legalization of assisted suicide and euthanasia in some countries. The goals of suicide and assisted suicide are diametrically opposed. Some people should be treated aggressively to prevent suicide, and others should be assisted in suicide or killed at their request. Physicians are asked to distinguish between the two groups based on the presence of terminal illness, great suffering, short life expectation, presence of psychiatric disorders, and other criteria. However, criteria are at times fallible due to the fugitive nature of estimated life expectancy, subjective nature of suffering, fuzzy boundaries between psychiatric disorders and normalcy, and ambivalence of some death wishes. It is well known that death wishes even in seriously ill patients fluctuate and may relate more to fear of the circumstances of their future death than of death itself. Some studies have shown that patients' interest in assisted suicide and euthanasia was associated with depressive symptoms, hopelessness, and other psychological factors (Emanuel et al., 2000).
In a 1996 study in the Netherlands (Groenewoud et al., 1997), it was estimated that psychiatrists received about 320 requests for assisted suicide per year. Only about 2-5 people (mostly with terminal comorbid medical illness) were assisted in suicide by their psychiatrists. Among those patients who requested physician-assisted suicide, 51% were diagnosed with mood disorders, 14% with psychosis, 12% with other mental disorders, and 23% with personality disorders. None was found without psychiatric disorder or personality disorder. Although requests for assisted suicide were expectedly common in psychiatric patients, very few were assisted in suicide by psychiatrists. It was also found that psychiatric consultation was rarely sought by non-psychiatric physicians about a patient's request for suicide. The authors ponder that in some of these cases depression or other psychiatric problems may have been missed.
There have been few systematic attempts to study the influence of social and cultural forces on the acceptance and/or practice of assisted suicide. Increasing pressures on society due to the rising elderly population, decreasing religious affiliation, decreasing community supports, and increasing individualism are factors worthy of further examination. Those are the same phenomena that Durkheim thought were related to suicide. It is easy to see that the elderly person who feels that he is a burden to his family and requests euthanasia would fall under Durkheim's category of altruistic suicide. Limited social supports and deteriorating health in AIDS patients may increase requests for death of the egoistic type in this group. Attitudes toward and rates of assisted suicide and euthanasia should be further examined against indices of social integration. The hypothesis that social forces are factors that are more important in assisted suicide and euthanasia than (unassisted) suicide may prove to be a fruitful avenue of sociological inquiry. The effects of assisted suicide and euthanasia on suicide should be scrutinized intensely in countries where euthanasia and assisted suicide are legally regulated.
The idea for this paper came during the organisation of a symposium "Suicide with and without medical help" (University of Antwerps, 2001) that was funded by the Joannes Juda Groen Foundation for Interdisciplinary Behavioral Research (Joannes Juda Groen Stichting voor Interdisciplinair Gedragswetenschappelijk Onderzoek, Sigo) (Amsterdam). There are no financial conflicts of interest.
Berrios, G, and Mohanna, M (1990). Durkheim and French psychiatric views on suicide during the 19th century. A conceptual history. British Journal of Psychiatry 156, 1-9.
Cheng, A T A (1995). Mental illness and suicide: A case-control study in east Taiwan. Archives of General Psychiatry 52, 594-603.
Durkheim, E (1897). Le suicide. Alcan. Paris.
Emanuel, E, Fairclough, D, and Emanuel, L (2000). Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. JAMA 15, 2460-2468.
Groenewoud, J, Van Der Maas, P, Van Der Wal, G, Hengeveld, M W, Tholen, A, Schudel, W, and Van Der Heide, A (1997). Physician-assisted death in psychiatric practice in the Netherlands. New England Journal of Medicine 336, 1795-1801.
Rich, C L, Young, D, and Fowler, R C (1986). San Diego suicide study: I. Young vs old subjects. Archives of General Psychiatry 43, 577-582.
Robins, E, Murphy, G E, Wilkinson, R H, Gassner, S, and Kayes, J (1959). Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. American Journal of Public Health 49, 888-899.
First Published: January 25th 2003