Suicide

Does everyone who attempts (or commits) suicide have a mental illness? This is a controversial and touchy topic, but it's been on my mind ever since medical school. I can tell you what happens. When someone attempts (or threatens) suicide, we put them on a "5150." This is a section of the California Welfare and Institutions Code that allows a 72 hour involuntary psychiatric hold for someone with a mental illness who poses a threat to themselves, a threat to others, or is gravely disabled. Much of the time, the patient has a documented psychiatric illness, but sometimes this is the first presentation to a hospital or old records are unavailable. Nevertheless, a 72 hour hold is placed, and to me, the reason is that the suicide attempt is sufficient evidence of mental illness. Of course, on further psychiatric evaluation, a hold can be lifted if in fact the patient does not meet all the criteria.

Let me put on my philosophy and logic hat. It seems to me now that we follow a pretty strict rule: if someone commits suicide, then they have a mental illness. The contrapositive states that if someone does not have a mental illness, they will not commit suicide. Is this an absolute truth? I'm not sure that it is. One could imagine (as philosophers do) morbid situations in which a perfectly sane person would choose not to live. A Japanese samurai of complete sound mind adheres to a bushido honor code and takes his own life rather than fall in the hands of the enemy. A prisoner in a Nazi concentration camp decides he would rather touch an electrified fence and die than continue to suffer. An elder Eskimo ends his life to leave greater amounts of food to the rest of the community. A 90 year old person who has lived a life of great satisfaction and fulfillment sustains a stroke requiring them to be on life-supporting machines; they choose not to live in that manner, and so pass away peacefully.

Of course, these examples are not the ones who show up to our emergency department. And I agree with placing a person on a 5150 if there is any worry that they are a threat to themselves as a default because the alternative - sending them home and having them complete their suicide - is unthinkable. But I write this post because we do a lot of things in medicine without thinking them through with a philosopher's lens, and we ought to step back and scrutinize what we do. Fleeting suicidal thoughts are normal and don't reflect mental illness. There may be a tiny subset of conditions in which someone may commit suicide rationally. Our laws and regulations are designed to aid this other majority with psychiatric disease, but we should recognize where they may not apply.