The Suicide Solution

Which is more compassionate: treating someone with prescriptions or procedures that kill the quality of live while maintaining a physical presence or supporting someone to live the remainder of life in a pos- itive, happy way?
Henry Marsh, author and one of Britain’s preeminent neurosur- geons, asks to what extent we should treat people with advanced can- cers in the hope of prolonging life. “Most of us would accept a great deal of suffering in hope of a cure. The issue is whether doctors should subject patients to unpleasant non-curative treatments. To my mind there is no question that we are overtreating at the moment.”113
I do not blame the medical profession for overtreating. We created this result. Doctors want to talk to their patients about healthy life choices, but we don’t want to hear it. We don’t want to change our habits or our life styles. We want to continue behaviors our medical profession tells us will create unhealthy results, but then we demand from them a pill or procedure that will wipe away the consequences.
I can only imagine what we, as patients, might say if a doctor rec- ommended preparing for death. We demand that they continue down any path toward not dying, no matter how small the chances. “Not dying” is more important in our culture than living, and most of us do not even see the two as different.

We take an umbrella in case it rains, we pack extra food and water on trips, and we buy stocks for capital gains yet cover them with options in case the price falls. In every area of our lives we plan for contingen- cies. But if a doctor says there is only a small chance of success, we refuse to even consider our death. Plan for death? Not in our culture.
Atul Gawande, American surgeon, author, and public health re- searcher, writes about our fixation for a solution to avoid death, even when we have a terminal illness.

What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail [of possibility]. We’ve created a multi-tril- lion dollar edifice for dispensing the medical equivalent of lottery tickets – and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan, but hope is our plan.114

We need a better plan. The perfection demanded of our medical system and inherent in the Strategy’s zero suicides goal, is part of the problem. The medical profession, those we consult to prevent suicide, has the highest rate of suicide of any professional group. Danielle Ofri, physician and writer, refers to the “tyranny of perfection” as a primary cause.115
Rather than decrease the vulture culture in medicine, whoever develops strategies for the medical profession initiated a Physician’s Help Program (PHP) to help them deal with stress. Physicians com- plain that members of their professional community who voluntarily disclose they have mental health problems can be forced into treatment without recourse; they can face expensive out-of-pocket costs and can be required to receive the prescribed therapy out of state. The PHP sys- tem itself makes doctors more reluctant to admit mental health issues.116

I find this is also true in the veteran community: the commendable Strategy goal of reducing the stigma associated with self-reporting is defeated by the system itself.
A study from the United Kingdom linked British regulatory process to both suicidal thoughts in physicians and defensive practice proce- dures such as overprescribing.117 I imagine the same is true for our system, although our tort liability system might add more anxiety here than in the UK.
Our next Strategy should look at ways to reduce tensions in our provider and reporting systems. I strongly believe we should also learn to deal with death as the 100 percent probable conclusion it is to living. What if we create a healthy way to discuss dying? We could engage suicidals in a conversation about what a salubrious ending looks like. The motivation is not to assist them in their suicide but help them walk through a process of creating the end they truly want. Most people want their deaths to end peacefully, not in a medicated or violent condition.
What can we do to help them create that? Perhaps cross suicide prevention with doula end-of-life training.118 Let us at least allow, if not promote, healthy discussions about death, dying, and what death by suicide looks like versus other choices one could make. Helping create the life they want is the same conversation as supporting them to create the death experience they truly desire.
A shift away from imposing on our citizens a duty to remain alive, no matter what the consequences to their quality of life, is simply re- flecting the reality that they owe no such duty to others in positions of authority. When interacting with suicidals, one of the most powerful gifts we can give them is to help them create their own reasons to live. “You must stay alive for the benefit of others” is not a strong reason and will often turn them away. By eliminating mandates on suicidals for our communal benefit we then need to rethink our own reasons why we engage suicidals at all.
If someone represented a state or national perspective when inter- acting with a suicidal, what do we want that person to say?
“We don’t want you to end your life.”

“Why do you care?”
“Think of the economic loss”
“Your nation / family / community need you.”
“Our stats look bad when stacked against other nations.” “It’s my job to stop you so I won’t let you k ill yourself.”
“I care because …”
When we have a national answer to the last question, let’s add it to the Strategy. The other answers don’t work. I don’t see a message of caring in the current Strategy, and I don’t always hear it implemented at the street level.
When we shift away from viewing suicide prevention as an obli- gation of suicidals to supporting them in creating the life they want because we care, we will indeed see a dramatic drop in suicide rates. Suicide notes frequently contain the theme of an uncaring world. Let’s create a caring ethos so strong that everyone in our country, no matter how isolated, can hear the message.
I don’t mean advertising a “We Care” tagline merely to increase public perception. How do we back it up, demonstrate it, walk the talk, show what we mean, and reinforce our intention with resources and action plans? Make it a central theme of our next Strategy. It might prove to be the only theme we need.