NOTES

PART 1 Adolescent Suicide

Chapter II The Slot Machine

37 completed suicide: While most people speak of “committing” suicide, prevention groups encourage the use of the less judgmental word “completing” suicide.

38 third leading cause: Each year, about five children between the ages of five and nine kill themselves; for those aged ten to fourteen, the number grows to more than three hundred (a rate of 1.5 per 100,000—one-fifth that of the fifteen-to-nineteen-year-old age group). Suicidal intent is especially difficult to determine in children, however. Each year some twelve thousand children are hospitalized for deliberate self-destructive acts: stabbing, scalding, burning, jumping from high places, running into traffic. Some suicidal children may be motivated by an attempt to escape an intolerable home life, others by self-punishment, others to rejoin a lost loved one—often recently dead—or to gain attention from a neglectful parent. Many have been physically abused by a family member. In a study of 662 preadolescent children treated at the Neuropsychiatric Institute over a five-year period, UCLA psychiatrists found that 5 percent were suicidal or “seriously self-destructive.” Many came from families in which the concept of guilt was used to control the child’s behavior. Suicide became not only a way of escaping family problems but a form of self-punishment. The child often blamed himself for family problems and came to believe that he deserved to die.

38 Kay Jamison compared: Jamison, Night Falls Fast, 22–23.

39 19 percent of high school students: J. A Grunbaum et al., “Youth Risk Behavior Surveillance—United States, 2001,” Morbidity and Mortality Weekly Report, CDC Surveillance Summary 51 (SS4) (2002): 1–64.

39 No one knows: For a masterful review of recent adolescent suicide research, see Gould et al., “Youth Suicide Risk and Preventive Interventions.”

41 more than 90 percent: Y. Conwell et al., “Relationships of Age and Axis I Diagnosis in Victims of Completed Suicide: A Psychological Autopsy Study,” American Journal of Psychiatry 153 (8) (1996): 1001–8.

42 fifty-six hundred adolescents: Giffin and Felsenthal, Cry for Help, 218.

43 not the only answer: After a suicide one often hears family members say, “I don’t understand it. He had problems, but he was getting over them. Lately, he seemed so happy.” People commonly kill themselves just when they appear to be coming out of a depression. It may be because they have made their decision to kill themselves, and their problems finally seem solved. Ironically, making the decision may help lift the depression—and give them the energy needed to carry out the act. If they have recently been prescribed antidepressant medication, the suicide may be made possible because the medication has taken effect and reduced their depression sufficiently that they are able to act on their self-destructive thoughts.

43 twenty-six depressed patients: Hendin et al., “Desperation and Other Affective States.”

43 “This is probably the most primordial”: G. Zilboorg, “Some Aspects of Suicide,” Suicide 5 (3) (1975): 135.

43 a “death trend”: Moss and Hamilton, “Psychotherapy of the Suicidal Patient.”

44 A University of Washington study: T. L. Dorpat et al., “Broken Homes and Attempted and Completed Suicide,” Archives of General Psychiatry 12 (1965): 213–16.

44 “Loss in all of its manifestations”: Styron, Darkness Visible, 56.

44 Comparing 505 children: Garfinkel et al., “Suicide Attempts in Children and Adolescents.”

44 120 young suicide victims: Gould et al., “Psychosocial Risk Factors.”

44 intense mood shifts: Pfeffer’s work is described in C. R. Pfeffer, The Suicidal Child (New York: Guilford Press, 1986).

45 one of mutual involvement: J. L. Rubenstein et al., “Suicidal Behavior in Adolescents: Stress and Protection in Different Family Contexts,” American Journal of Orthopsychiatry 68 (1998): 274–84; J. L. Rubenstein et al., “Suicidal Behavior in ‘Normal’ Adolescents: Risk and Protective Factors,” American Journal of Orthopsychiatry 59 (1989): 59–71.

45 childhood trauma: For an overview of the link between childhood trauma and suicidal behavior, see “Childhood Trauma” in Goldsmith et al., Reducing Suicide, 157–91.

45 at least two disorders: A. B. Silverman et al., “The Long-Term Sequelae of Child and Adolescent Abuse: A Longitudinal Community Study,” Child Abuse and Neglect 20 (8) (1996): 709–23.

45 9 to 20 percent: Goldsmith et al., Reducing Suicide, 183.

45 A review of twenty studies: E. E. Santa Mina and R. M. Gallop, “Childhood Sexual and Physical Abuse and Adult Self-Harm and Suicidal Behaviour: A Literature Review,” Canadian Journal of Psychiatry 43 (8) (1998): 793–800.

45 study of 159 adolescents: E. Y. Deykin et al., “A Pilot Study of the Effect of Exposure to Child Abuse or Neglect on Adolescent Suicidal Behavior,” American Journal of Psychiatry 142 (1985): 1299–1303.

46 five times more likely: D. A. Brent et al., “Alcohol, Firearms, and Suicide Among Youth: Temporal Trends in Allegheny County, Pennsylvania, 1960 to 1983,” Journal of the American Medical Association 257 (24) (1987): 3369–72.

46 drinking within three hours: Powell, “Alcohol Consumption.”

47 “A baby repeatedly left”: Giffin and Felsenthal, Cry for Help, 195.

47 “Nearly every suicidal child”: Ibid., 185, 215.

48 had physical fights: M. Peck, “Suicide in Late Adolescence and Young Adulthood,” in Hatton and Valente, Suicide: Assessment and Intervention, 222.

48 nearly four times more likely: “Suicide Attempts and Physical Fighting Among High School Students—United States, 2001,” Morbidity and Mortality Weekly Report 53 (22) (2004): 474.

48 psychiatrist David Shaffer found: D. Shaffer and M. Gould, “Study of Completed and Attempted Suicides in Adolescents,” Progress Report: National Institute of Mental Health (1987).

48 a recent disciplinary crisis: Gould et al., “Psychosocial Risk Factors.”

49 fewer than five minutes: T. R. Simon et al., “Characteristics of Impulsive Suicide Attempts and Attempters,” Suicide and Life-Threatening Behavior 32 (Supplement) (2001): 49–59.

49 “They are like a trivial border incident”: Alvarez, Savage God, 97.

49 “If youth is the season of hope”: G. Eliot, Middlemarch (Cambridge: Riverside Press, 1956), 398.

49 permanence of death: In a study of two hundred adolescents, one in five answered yes when asked if they could come back to life following a suicide. Such magical thinking is not limited to young people; some suicidal adults, too, describe death as a temporary state or believe that they will be able to observe the effect of their suicide on family and friends.

50 “I thought death would be”: Newsweek, August 15, 1983, 74.

50 “I wandered the streets”: K. Menninger, The Vital Balance (Harmondsworth, England: Penguin, 1977), 267.

52 frequency of moving: Potter et al., “Influence of Geographic Mobility.” Each year more than 14 percent of Americans relocate, compared with 8 percent of Britons and 4 percent of Germans.

52 A sixteen-year-old: Giffin and Felsenthal, Cry for Help, 125–27.

53 family had recently moved: San Mateo Times, February 11, 1983, 10.

54 “Television has brought”: J. Anderson, “An Extraordinary People,” New Yorker, November 12, 1984, 126.

54 more than a thousand studies: Senate Committee on the Judiciary, September 14, 1999, “Children, Violence, and the Media: A Report for Parents and Policy Makers,” http://judiciary.senate.gov/mediavio.

54 in video games: In 2005, the American Psychological Association called for a reduction in video game violence. Noting that 73 percent of violent acts in video games go unpunished, APA spokesperson Elizabeth Carll warned that “showing acts of violence without consequences teaches youth that violence is an effective means of resolving conflict.” (“APA Calls for Reduction of Violence in Interactive Media Used by Children and Adolescents,” www.apa.org/releases/videoviolence05.)

54 six prominent medical groups: Congressional Public Health Summit, July 26, 2000, www.aap.org/advocacy/releases/jstmtevc.htm.

57 therapists attribute the decrease: Columbia University researchers examined teenage suicide rates and use of antidepressants from 1990 to 2000 in 588 regions of the country and found an increase in antidepressant use was associated with a decrease in suicides. (M. Olfson et al., “Relationship Between Antidepressant Medication Treatment and Suicide in Adolescents,” Archives of General Psychiatry 60 (10) (2003): 978–82.)

Chapter III Brian

64 settled on a diagnosis: At the time, Brian was thought to be too young for manic depression, which was believed to manifest itself most commonly in the mid- to late twenties. It is now believed that the average age of onset is eighteen.

Chapter IV Something in the Air

79 “a contagious illness”: D. Bushman, “Cluster Suicides,” Reporter Dispatch (Gannett Westchester Newspapers), December 2, 1984, 1.

79 “sort of like punk rock”: Ibid., 16.

80 studied sixty-two patients: B. J. Rounsaville and M. M. Weissman, “A Note on Suicidal Behaviors Among Intimates,” Suicide and Life-Threatening Behavior 10 (1) (1980): 24–28.

81 columnist Ann Landers: Reporter Dispatch (Gannett Westchester Newspapers), April 2, 1985.

83 an article appeared: J. E. Brody, “‘Autoerotic Death’ of Youths Causes Widening Concern,” New York Times, March 27, 1984, C1.

83 “The most singular feature”: Winslow, Anatomy of Suicide, 108.

84 “In the year of Grace”: Coleman, Suicide Clusters, 17.

84 “Some threw themselves”: Fedden, Suicide, 150.

84 “Very few of those”: Cavan, Suicide, 69.

85 “A strange and terrible”: Fedden, Suicide, 299.

85 “vanity, if not sanity”: Alvarez, Savage God, 104.

85 “to abandon oneself”: A. Wynter, The Borderlands of Insanity (London: Henry Renshaw, 1877), 244–45.

85 “The East African societies”: Bohannan, African Homicide and Suicide, 263.

85 “A child is more open”: Friedman, On Suicide, 57.

86 “To all this may be added”: Mathews, “Civilization and Suicide,” 484.

86 “The sensational fashion”: Friedman, On Suicide, 137.

87 “One ‘new Werther’”: R. Friedenthal, Goethe: His Life and Times (Cleveland and New York: World Publishing Company, 1965), 129–30.

87 “the mischievous influence”: Miller, Guilt, Folly, and Sources of Suicide.

87 “weakening the moral principles”: Winslow, Anatomy of Suicide, 87.

87 forty-three Russian roulette deaths: Coleman, Suicide Clusters, 126.

88 “When the mind is beginning”: Galt, Treatment of Insanity, 212.

88 “No fact is better established”: Phelps, “Neurotic Books and Newspapers.” This paper offers an extensive, if shrill, description of the controversy at the turn of the century.

88 “inducing morbid people”: J. A. Motto, “Suicide and Suggestibility: The Role of the Press,” American Journal of Psychiatry 124 (2) (1967): 157.

89 “literary chamber of horrors”: These examples are found in Phelps, “Neurotic Books,” 36.

89 found that suicides increase: Phillips, “Influence of Suggestion on Suicide.”

89 linking suggestion and suicide: Phillips has also investigated the effect of mass media on aggressive behavior. In a 1979 study of California motor vehicle deaths, he found that front-page suicide stories may provoke an increase in auto fatalities. Three days after a story, fatal car crashes increase by more than 30 percent. The rate of single-car crashes is most affected, suggesting that some of the drivers may have had self-destructive motives. Again, the greater the publicity, the greater the rise in the number of deaths. In addition, he found significant similarities between the dead driver and the person described in the suicide story. Phillips has also linked murder-suicide stories to a rise in U.S. plane crashes. (D. P. Phillips, “Suicide, Motor Vehicle Fatalities, and the Mass Media: Evidence Toward a Theory of Suggestion,” American Journal of Sociology 84 (5) (1979): 1150–74; D. P. Phillips, “Airplane Accident Fatalities Increase Just After Newspaper Stories About Murder and Suicide,” Science 201 (1978): 748–50.)

90 numerous other studies: For a review of the literature, see Gould, “Suicide and the Media.”

90 yearlong CDC survey: N. D. Brener et al., “Effect of the Incident at Columbine on Students’ Violence- and Suicide-Related Behaviors,” American Journal of Preventive Medicine 22 (3) (2002): 146–50.

90 extends to television news coverage: Examining the effect of thirty-eight nationally televised news or feature stories about suicide from 1973 to 1979, Phillips and a colleague found a significant increase (7 percent) in teenage suicides during the week following the broadcasts. The more networks carrying the story, the bigger the increase. Girls were more susceptible to the influence than boys. They did not find a significant increase in adult suicides following the programs. (D. P. Phillips and L. L. Carstensen, “Clustering of Teenage Suicides After Television News Stories About Suicide,” New England Journal of Medicine 315 (11) (1986): 685–89.)

90 fictional television suicides: In one study, Madelyn Gould and David Shaffer researched the effect of four made-for-TV movies about teenage suicide broadcast in late 1984 and early 1985. Teenage suicide rates in the metropolitan New York area rose in the two weeks after broadcast for three of the four movies; six more teenagers than would have been expected took their lives. Shaffer suggested that the fourth film, Silence of the Heart, did not trigger suicides because it portrayed suicide in a less sensational fashion. In addition, educational materials and training guides were distributed to schools beforehand, suicide prevention hotline numbers were displayed during the broadcast, and a panel discussion on suicide prevention was aired immediately following the movie. (Gould and Shaffer, “Impact of Suicide in Television Movies.”) The study was challenged by the television networks, which pointed out that there was no way of knowing whether the teenagers who killed themselves actually saw the movies. Phillips himself contradicted Gould and Shaffer’s findings. Looking at the effect of the same movies on teenage suicide in California and Pennsylvania, he found no rise in the rate. (D. P. Phillips and D. J. Paight, “The Impact of Televised Movies About Suicide: A Replicative Study,” New England Journal of Medicine 317 (13) (1987): 809–11.) Psychologist Alan Berman also questioned the results of the Gould-Shaffer study. Collecting data from 189 medical examiners across the country, representing 20 percent of the U.S. population, he found no increase in youth suicides in the two weeks following three of the TV movies; in some areas there was a decrease. (Berman examined two of the films used in the Gould-Shaffer study, and a third film broadcast after their study had been completed.) He did find evidence that one of the broadcasts may have influenced the choice of methods. (A. Berman, paper presented at a joint meeting of the American Association of Suicidology and the International Association for Suicide Prevention, San Francisco, May 25–30, 1987.)

90 A 1999 English survey: K. S. Hawton et al., “Effects of a Drug Overdose in a Television Drama on Presentations to Hospital for Self Poisoning: Times Series and Questionnaire Study,” British Medical Journal 318 (1999): 972–77.

90 films from 1917 to 1997: Gould et al., “Media Contagion and Suicide.”

91 asks whether cyberspace: K. Becker et al., “Parasuicide Online: Can Suicide Websites Trigger Suicidal Behaviour in Predisposed Adolescents?” Nordic Journal of Psychiatry 58 (2) (2004): 111–14.

91 he opposes censorship: From time to time newspapers have been persuaded or pressured into suppressing stories about suicide. In the 1930s, for instance, Mussolini prohibited all reports of suicide in the Italian press; his vision of the modern fascist state did not include the possibility of suicide.

91 fell more than 80 percent: E. Etzersdorfer et al., “Newspaper Reports and Suicide,” New England Journal of Medicine 327 (1992): 502–3; and E. Etzersdorfer and G. Sonneck, “Preventing Suicide by Influencing Mass-Media Reporting: The Viennese Experience, 1980–1996,” Archives of Suicide Research 4 (1998): 67–74.

91 issued recommendations: P. W. O’Carroll and L. B. Potter, “Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop,” Morbidity and Mortality Weekly Report 43, RR-6 (1994): 9–18. (See Web site at www.nimh.nih.gov/research/suicidemedia.) In 2001, the CDC and several other groups, including the American Foundation for Suicide Prevention and the American Association of Suicidology, issued media recommendations for reporting on suicide. These can be found in an appendix to Gould et al., “Media Contagion.”

91 Annenberg Public Policy Center: K. H. Jamieson, “Can Suicide Coverage Lead to Copycats?” American Editor, June 14, 2002. See Web site at www.asne.org.

92 Cobain’s death had no effect: D. A. Jobes et al., “The Kurt Cobain Suicide Crisis: Perspectives from Research, Public Health, and the News Media,” Suicide and Life-Threatening Behavior 26 (1996): 260–71.

Chapter V Dana

95 125,000 visits: “Suicide and Attempted Suicide,” Morbidity and Mortality Weekly Report 53 (22) (2004): 471.

95 “Although depression is more common”: Jamison, Night Falls Fast, 46.

96 “Most people who commit”: Stengel, Suicide and Attempted Sucide, 87.

96 “The man up there is saying”: Time, November 25, 1966, 49.

96 “a desperate version”: Giffin and Felsenthal, Cry for Help, 14.

96 thirteen-year-old Illinois girl: Ibid., 19.

96 Michigan youth hospitalized: A. Wrobleski, Afterwords, October 1984, 1. For more on attitudes of hospital staff toward attempters, see T. C. Welu, “Psychological Reactions of Emergency Room Staff to Suicide Attempters,” Omega 3 (2) (1972): 103–9. Completed suicide also provokes complex reactions in medical personnel. “Something about acute self-destruction is so puzzling to the vibrant mind of a man or woman whose life is devoted to fighting disease that it tends to diminish or even obliterate empathy,” writes the surgeon Sherwin Nuland. “Medical bystanders, whether bewildered and frustrated by such an act, or angered by its futility, seem not to be much grieved at the corpse of a suicide.” (Nuland, How We Die, 151.)

96 chronic psychiatric problems: A. J. Elliott et al., “A Profile of Medically Serious Suicide Attempts,” Journal of Clinical Psychiatry 57 (1996): 567–71.

97 slashed her wrists lightly: Klagsbrun, Too Young to Die, 33–34.

97 lonely sixteen-year-old: Giffin and Felsenthal, Cry for Help, 30–31.

Chapter VI “Use the Enclosed Order Form to Act Immediately. You Could Save a Life”

114 a 1969 article: Cited in C. P. Ross, “Teaching Children the Facts of Life and Death: Suicide Prevention in the Schools,” in Peck, Farberow, and Litman, Youth Suicide, 153.

116 “Our goal is to help”: D. Breskin, “Dear Mom and Dad,” 35.

116 “Children with a clearer understanding”: G. R. Bernhardt and S. G. Praeger, “Preventing Child Suicide: The Elementary School Death Education Puppet Show” (unpublished paper), 6.

117 “Any school administrator”: Quoted in a letter sent by Donna-Marie Buckley, whose son had hanged himself, to President Reagan, June 1984.

118 Shaffer studied the effects: Paper presented at the twenty-first annual meeting of the American Association of Sucidology, Washington, D.C., April 13–17, 1988. See Shaffer et al., “Adolescent Suicide Attempters.” See also Shaffer’s more general discussion of youth suicide prevention, Shaffer et al., “Preventing Teenage Suicide.”

119 115 school-based programs: A. Garland et al., “A National Survey of School-Based, Adolescent Suicide Prevention Programs,” Journal of the American Academy of Child and Adolescent Psychiatry 28 (1989): 931–34.

119 “By deemphasizing”: A. F. Garland and E. Zigler, “Adolescent Suicide Prevention: Current Research and Social Policy Implications,” American Psychologist 48 (1993): 169–82.

119 A 1994 CDC summary: P. W. O’Carroll et al., “Programs for the Prevention of Suicide Among Adolescents and Young Adults,” Morbidity and Mortality Weekly Report 43, RR-6 (1994), 1–7.

119 “no justification”: Metha et al., “Youth Suicide Prevention.”

119 study of twenty-one hundred students: R. H. Aseltine, “An Evaluation of a School Based Suicide Prevention Program,” Adolescent and Family Health 3 (2003): 81–88. See also R. H. Aseltine and R. DeMartino, “An Outcome Evaluation of the SOS Suicide Prevention Program,” American Journal of Public Health 94 (2004): 446–51.

120 significant reductions: J. Kalafat, “School Approaches to Youth Suicide Prevention,” American Behavioral Scientist 46 (9) (2003): 1211–23.

120 Yellow Ribbon Suicide Prevention Program: See Web site at www.yellowribbon.org.

PART 2 History

Chapter I Primitive Roots: The Rock of the Forefathers

129 Among the books that describe the history of suicide, from which many of the examples in my discussion are drawn, I owe a special debt to Biathanatos by John Donne; A Full Inquiry into the Subject of Suicide by Charles Moore; The Anatomy of Suicide by Forbes Winslow; Suicide by Émile Durkheim; Suicide by Henry Romilly Fedden; To Be or Not To Be by Louis Dublin and Betty Bunzel; and The Savage God by A. Alvarez.

129 “Lo, my name reeks”: J. H. Breasted, Development of Religion and Thought in Ancient Egypt (New York: Charles Scribner’s Sons, 1912), 163–69.

131 “The Baganda were very superstitious”: J. Roscoe, The Baganda: An Account of Their Native Customs and Beliefs (New York: Barnes & Noble, 1966), 20–21.

132 Primitive fear of the suicide’s ghost: Examples of primitive attitudes toward suicide are found in Westermarck, Origin and Development of the Moral Ideas, 229–64; Durkheim, Suicide, 217–25; Dublin and Bunzel, To Be or Not To Be, 137–53.

133 For many years India: For examples of revenge suicide in southern India, see Fedden, Suicide, 45–46.

134 “They are a nation lavish”: Durkheim, Suicide, 218.

134 “They dwell on the red blaze”: Dublin and Bunzel, To Be or Not To Be, 145.

135 “There is another world”: Alvarez, Savage God, 53.

135 a king was buried: Herodotus, The Histories, trans. A. de Selincourt. (Harmondsworth, England: Penguin, 1988), 294.

135 “keen competition”: Ibid., 342.

136 “Should he outrage”: A. B. Ellis, The Tshi-Speaking Peoples of the Gold Coast of West Africa (The Netherlands: Anthropological Publications, 1970), 287.

136 the village of Deorala: Los Angeles Times, October 10, 1987, part I, p. 1.

136 “The government of Madhya Pradesh”: “Indian Police Arrest Sons After Woman Commits Suttee,” Sydney Morning Herald, August 8, 2002, www.smh.com.au/articles/2002/08/07.

137 Yet in Japan: My discussion of suicide in Japan owes much to Iga, Thorn in the Chrysanthemum; M. Iga and K. Tatai, “Characteristics of Suicides and Attitudes Toward Suicide in Japan,” in Farberow, Suicide in Different Cultures, 255–80; J. Seward, Hara-Kiri: Japanese Ritual Suicide (Rutland, Vt., and Tokyo: Charles E. Tuttle, 1968).

137 “The Japanese calendar”: W. E. Griffis, The Religions of Japan (New York: Charles Scribner’s Sons, 1895), 112.

138 variety of circumstances: Durkheim noted that “a strange sort of duel is even reported there, in which the effort is not to attack one another but to excel in dexterity in opening one’s own stomach.” Durkheim, Suicide, 222.

138 “The Japanese are an obstinate”: Moore, Full Inquiry, 140. In 1932, Henry Morton Robinson observed, “If the Samurai code existed in America today, Tammany Hall would be a catacomb of self-slain heroes.” (North American Review 234 [4] [1932]: 304.)

138 “the very shrine”: G. Kennan, “The Death of General Nogi,” Outlook, October 5, 1912, 258.

139 almost 250 recorded cases: O. D. Russell, “Suicide in Japan,” American Mercury, July 1930, 341–44.

139 “He mingles with the gods”: Newsweek, September 24, 1945, 58.

140 “My daughters and myself”: Time, March 1, 1976, 31. In The Thorn in the Chrysanthemum, Mamoru Iga wrote, “The mother who commits suicide without taking her child with her is blamed as an oni no y na hito (demonlike person)” (p. 18). In the United States the opposite is true. In 1985 in Los Angeles, a thirty-two-year-old Japanese immigrant whose husband had been unfaithful walked into the Pacific Ocean carrying her infant daughter and four-year-old son. Although passersby managed to pull her from the surf, her children drowned. Charged with voluntary manslaughter, the woman told police that she had killed her children because she loved them dearly. She was sentenced to eleven years in prison, but after intervention by local Japanese groups, her sentence was reduced to three years’ probation. She eventually returned to her husband.

140 the suicide of Yukio Mishima: My description of Mishima’s suicide is drawn from newspaper accounts and from Iga and Tatai, “Characteristics of Suicides.” For further discussion of Mishima’s suicide see Lifton, Broken Connection, 262–80.

141 “a sadomasochistic homosexual”: New York Times, November 9, 1974.

142 “the readiness of the Japanese”: Durkheim, Suicide, 222.

143 “People didn’t know they were suffering”: Most of the details in this paragraph are taken from a fascinating article by Kathryn Shulz, “Did Depressants Depress Japan?” (New York Times Magazine, August 22, 2004, 39–41.)

143 blend of traditional and contemporary: The historical gulf between primitive and Eastern acceptance of suicide and its condemnation by the West are illustrated in a perhaps apocryphal story told by psychiatrist Joost Meerloo. A sociologist and a psychiatrist who flew to the Orient to attend a conference on alienation and self-destruction were out for a stroll one night when they saw a man hanging from a tree. They rushed to the spot, quickly cut him down, and tried to restore him to consciousness. As they worked feverishly over his prostrate body, a crowd gathered and began to murmur ominously. The air grew thick with tension. Although they had saved the life of the stranger, the sociologist and the psychiatrist were starting to fear for their own lives when a policeman appeared just in time to rescue them from a probable lynching. Relieved at being saved from the mob, these Good Samaritans were shocked when the policeman hauled them off to court, where the judge informed them that they had committed an outrageous offense—they had interfered with the plans of a holy man who wished to join his ancestors. They were ordered to pay a stiff fine, and since the holy man had given away all his earthly possessions in preparation for his suicide, the sociologist and psychiatrist were ordered to assume full responsibility for his material needs for the rest of his life. Meerloo, Suicide and Mass Suicide, 93–94.

143 “One single suicide”: K. Huus, “Japan’s Chilling Internet Suicide Pacts,” MSNBC News, www.msnbc.msn.com.

Chapter II The Classical World: “He Is at Liberty to Die Who Does Not Wish to Live”

144 “steep down from a high rafter”: Homer, The Odyssey, trans. R. Fitzgerald (Garden City, N.Y.: Anchor/Doubleday, 1963), 194.

145 “thrusting into their throats”: Thucydides, The History of the Peloponnesian War, in R. M. Hutchins, ed., Great Books of the Western World (Chicago: Encyclopaedia Britannica, 1952), 6: 459.

145 “went quite mad”: Herodotus, Histories, 414.

145 “to depart from their guard”: Dublin and Bunzel, To Be or Not To Be, 184.

146 “If one of your own possessions”: Plato, Dialogues of Plato, trans. B. Jowett, ed. J. D. Kaplan (New York: Washington Square Press/Pocket Books, 1951), 74.

146 “in a spirit of slothful”: Plato, The Laws, trans. T. J. Saunders (Harmondsworth, England: Penguin, 1975), 391.

146 “To kill oneself to escape”: Aristotle, Ethics, rev. ed. trans. J. A. K. Thompson (Harmondsworth, England: Penguin, 1976), 130.

146 “The many at one moment”: Epicurus, “Letter to Menoeceus,” in W. J. Oates, ed., The Stoic and Epicurean Philosophers (New York: Random House, 1940), 31.

147 “to weigh carefully”: Lecky, History of European Morals, 1: 226.

147 “If one day”: Fedden, Suicide, 81.

147 “as he had advanced”: Ibid., 80.

147 “Such a discussion”: Moore, Full Inquiry, 1: 238.

148 the death of Marcus Porcius Cato: For the story of Cato and his suicide, see Plutarch, The Lives of the Noble Grecians and Romans, trans. J. Dryden (New York: Modern Library, 1932), 918–60.

149 “when God himself” and “a noble lesson”: Dublin and Bunzel, To Be or Not To Be, 186–87.

149 “Jupiter himself”: Choron, Suicide, 22.

149 “A resolution this”: Pliny, Letters, trans. W. Melmoth (London: William Heinemann, 1915), 1: 81–82.

149 “Foolish man”: Fedden, Suicide, 79.

149 “Where had their philosophy gone”: For the description of Seneca’s death, see Tacitus, The Annals of Imperial Rome, trans. M. Grant (London: Penguin, 1989), 376.

151 sheer exhibitionism: The suicide of Peregrinus is described in Fedden, Suicide, 66–67. For a more cynical account see The Works of Lucian of Samosata, trans. H. W. Fowler and F. G. Fowler (Oxford: Clarendon Press, 1905), 4: 79–95.

151 Frazer reported that in Rome: Fedden, Suicide, 84.

151 six suicides in the Old Testament: Quotations from the Bible are from The Revised Standard Version (New York: Thomas Nelson & Sons, 1946, 1952).

152 “In the same manner”: Sprott, English Debate, 147.

153 “the splendid martyrs”: Eusebius, The History of the Church from Christ to Constantine, trans. G. A. Williamson (New York: New York University Press, 1966), 344.

153 “No City escaped punishment”: Donne, Biathanatos, 60.

153 “rejoicing and exulting”: Eusebius, History of the Church, 202.

153 “Amachus, give orders”: Fedden, Suicide, 121.

153 “Let fire and cross”: Eusebius, History of the Church, 146.

153 fate of St. Simeon Stylites: For an extensive and graphic description of martyrdom, see Menninger, Man Against Himself. Wrote Menninger, “Upon examination, the components of the self-destructive urge in asceticism and martyrdom are apparently identical with those which we found to determine actual suicide—the self-punitive, the aggressive, and the erotic” (p. 125).

153 “Lo! For these thirty years”: Ibid., 119.

154 getting out of hand: Aspiring monks who despaired of winning the battle between celibacy and nature often chose suicide by more direct means. The biographer of Pachomius, a young monk who applied asps to himself in an unsuccessful suicide attempt, wrote that in this struggle with the devil “many have destroyed themselves; some, bereft of their senses, have cast themselves from precipices; others laid open their bowels; others killed themselves in divers ways” (Fedden, Suicide, 125). Still others, as Gibbon put it, “judged it the most prudent to disarm the tempter” (Ibid., 126). Castration, the church eventually realized, was a partial suicide. A church canon later declared, “He that gelds himselfe cannot be a Clerke, because he is an Homicide of himselfe, and an enemy to Gods creature.” (Quoted in Donne, Biathanatos, 133). Perhaps the most revered of all martyrs were the numerous Christian women who preferred death to defilement by heathens. Fifteen-year-old Pelagia, fearing for the loss of her chastity, jumped from a roof to escape a Roman soldier and was canonized for her suicide. “God cannot be offended with this, when we use it but for a remedy,” observed St. Ambrose (Ibid., 148).

154 “If it is base”: E. Westermarck, Christianity and Morals (London: Macmillan, 1939), 253.

154 “monstrous”: Quotations are taken from St. Augustine, City of God, trans. H. Bettenson (Harmondsworth, England: Penguin, 1984), 26–39.

156 “Let him who hath murdered himself”: Dublin and Bunzel, To Be or Not To Be, 245.

156 “The madman, or the idiot”: Fedden, Suicide, 138.

156 “life is a gift”: Aquinas’s arguments against suicide are found in T. Aquinas, Summa Theologiae (New York: McGraw-Hill; London: Eyre & Spottiswoode, 1975), 38: 30–37.

156 the start of the fourteenth century: Dublin and Bunzel pointed out that because of Church prohibitions, civil penalties, and the general stability of institutions and customs in the Middle Ages, individual suicide was practically unheard of during the eight hundred years between Augustine and Aquinas. Yet outside the tight framework of the Church there were sporadic bursts of self-destruction. In the Middle Ages demonic possession was the explanation for most mental disorder, and suicide was considered the ultimate evidence of the devil’s work. It has been estimated that in the 250 years prior to the end of the seventeenth century, at least one hundred thousand women were accused of witchcraft, tortured, and burned at the stake. Accused women often sought a less painful and humiliating end by taking their own life. Ironically, their suicides were usually interpreted as proof of their collusion with the devil.

Chapter III Renaissance and Enlightenment: “It Is His Case, It May Be Thine”

158 “Thou, constrained”: G. Pico della Mirandola, “Oration on the Dignity of Man,” in E. Cassirer, P. O. Kristeller, and J. H. Randall Jr., eds., The Renaissance Philosophy of Man (Chicago: University of Chicago Press, 1948), 225.

159 “Death is a remedy”: Unless indicated otherwise, quotes in this paragraph are from Montaigne, The Essays of Montaigne, trans. J. Florio (New York: Modern Library), 308–20.

159 “All the wisdom”: R. Noyes, “Montaigne on Death,” Omega 1 (4) (1970): 315.

159 “lest men far and wide”: D. Erasmus, The Colloquies of Erasmus, trans. C. R. Thompson (Chicago and London: University of Chicago Press, 1965), 360.

159 “people who lived next door”: D. Erasmus, The Praise of Folly, trans. H. H. Hudson (Princeton: Princeton University Press, 1941), 41.

160 “But yf the dysease”: T. More, Utopia. ed. J. C. Collins (Oxford: Clarendon Press, 1904), 100.

160 “his hand did quake”: E. Spenser, The Faerie Queene, ed. P. C. Bayley (Oxford: Oxford University Press, 1966), 1: 195–99.

160 M. D. Faber has pointed out: M. D. Faber, “Shakespeare’s Suicides: Some Historic, Dramatic and Psychological Reflections,” in Shneidman, Essays in Self-Destruction, 30–58.

161 “the disease of head-long dying”: This and the quotations in the following two paragraphs are from Donne, Biathanatos, 62, 50, 47, 17–18.

161 “thirst and inhiation” and “because I had the same desires”: C. M. Coffin, ed., The Complete Poetry and Selected Prose of John Donne (New York: Modern Library, 1952), 375–76.

162 “I wonder if Biathanatos”: Alvarez, Savage God, 155–56.

162 “because it is upon”: Coffin, Complete Poetry, 387.

162 “hevy, thoghtful, and wrawe”: G. Chaucer, The Canterbury Tales, ed. W. Skeat (New York: Modern Library, 1929), 581.

162 “If there be a hell”: For Burton quotations, see Burton, Anatomy of Melancholy, 281–88.

163 “There be two sorts”: Faber, “Shakespeare’s Suicides,” 31–32.

163 preached three sermons: A description of Neser’s work can be found in G. Rosen, “History,” in Perlin, Handbook for the Study of Suicide, 18.

163 an English country clergyman: Quotations in this paragraph are from Hunter and Macalpine, Three Hundred Years of Psychiatry, 1535–1860, 113–15, and Fedden, Suicide, 185.

164 “as cruelly as possible”: Fedden, Suicide, 142.

164 “brought through the town”: Dublin and Bunzel, To Be or Not To Be, 207.

164 “harled through the town”: Westermarck, Christianity and Morals, 255.

164 “until he be persuaded”: H. Silving, “Suicide and Law,” in Shneidman and Farberow, Clues to Suicide, 83.

165 “The body is drawn”: Moore, Full Inquiry, 1: 304.

165 “the worst kind of murder”: Kushner, Self-Destruction in the Promised Land, 15.

165 “felloniously and willfully”: The case of Abraham Harris can be found in Noble, “Glance at Suicide.”

165 “Wheresoever you finde”: Donne, Biathanatos, 93.

166 “is now growne so common”: Sprott, English Debate on Suicide, 32.

166 “Cato was not so much” and “What Cato did”: Fedden, Suicide, 240–41.

166 three hundred suicides: MacDonald, Mystical Bedlam, 278.

166 “These actions, considered”: Winslow, Anatomy of Suicide, 319–20.

167 “To be happy or not to be”: Gruman, “Historical Introduction to Ideas,” 99.

167 “When I am overcome”: For quotations in this paragraph, see Montesquieu, Persian Letters, trans. C. J. Betts (Harmondsworth, England: Penguin, 1987), letter 76, pp. 152–54.

167 “Every man has a right”: For Rousseau’s discussion of suicide, see letters 21 and 22 in Julie ou la Nouvelle Héloïse (Paris: Garnier-Flammarion, 1967), 278–91.

168 “his goods are given”: Fedden, Suicide, 224.

169 “Each one has his reasons”: Ibid., 204.

169 “We kill ourselves”: Ibid., 237.

169 “It is a decision”: Ibid., 205.

169 “If suicide be criminal”: For Hume quotations, see Hume, “On Suicide,” in Essays Moral, Political and Literary, 585–96.

171 “The carcass,” “sons of perdition,” and “contribute somewhat”: Sprott, English Debate on Suicide, 122.

171 “It might not only”: Moore, Full Inquiry, 1: 339.

171 “Many of those”: These and other quotes in this paragraph are found in Hey, Three Dissertations, 179–80, 208.

171 “Freedom, then”: Gruman, “An Historical Introduction,” 97.

172 “The rule of morality”: I. Kant, Lectures on Ethics, trans. L. Infield (Gloucester, Mass.: Peter Smith, 1978), 152.

172 “The causes of misery”: De Staël quotations are drawn from M. de Staël, The Influence of Literature Upon Society (Hartford: S. Andrus & Son, 1844), 99–112.

173 “The excuse of not being”: Moore, Full Inquiry, 1: 324.

173 “A penniless poor dog”: Ibid., 1: 323–24.

173 the result of its reputation: For material in these two paragraphs, see Bartel, “Suicide in Eighteenth-Century England.”

173 “We do not find”: Montesquieu, The Spirit of Laws, rev. ed. trans. T. Nugent (New York: Colonial Press, 1899) 1: 231 (bk. 14, chap. 12).

173 a letter to a friend: A. A. Lipscomb, ed., The Writings of Thomas Jefferson (Washington, D.C.: Thomas Jefferson Memorial Association, 1904), 11: 64. In a letter dated February 8, 1805, Jefferson observed, “I prefer much the climate of the United States to that of Europe. I think it is a more cheerful one. It is our cloudless sky which has eradicated from our constitutions all disposition to hang ourselves, which we might otherwise have inherited from our English ancestors.”

174 “No urgent motive”: Moore, Full Inquiry, 1: 343.

174 “in order to avoid”: Winslow, Anatomy of Suicide, 79.

174 “With the greatest pleasure”: Ibid., 133.

174 “There are little domestic news”: W. S. Lewis, ed., Horace Walpole’s Correspondence (New Haven: Yale University Press, 1941), 35: 236.

175 “By this conviction”: Winslow, Anatomy of Suicide, 86.

176 “practised it as one”: Alvarez, Savage God, 204. My description of the Romantics owes much to Alvarez’s chapter “The Romantic Agony,” 194–205.

176 “We swung between madness”: Ibid., 204.

Chapter IV Science: Moral Medicine and Vital Statistics

177 “hypertrophy of the poetic organ”: Choron, Death and Western Thought, 159.

178 “Whatever may be the cause”: R. Hunter and I. Macalpine. eds., A Treatise on Madness and Remarks on Dr. Battie’s Treatise on Madness (London: Dawsons, 1962), 36–37.

178 “Few, perhaps, are aware”: Winslow, Anatomy of Suicide, 136–37. Of course, it is likely that many young suicides were caused not by masturbation but by guilt over the act.

178 “Suicide presents” and “the treatment of suicide”: Choron, Suicide, 63.

179 “A lady, shortly after”: For this and the following two quotations see Winslow, Anatomy of Suicide, 174–75, 203.

179 “A pint every hour”: Galt, Treatment of Insanity, 212.

179 “Once in a while”: M. Fuller, “Suicide Past and Present: A Note on Jean-Pierre Falret,” Life-Threatening Behavior 3 (1) (1973): 62.

179 holding the patient under: Bucknill and Tuke, Manual of Psychological Medicine, 465. Referring to this treatment, Bucknill and Tuke quote Pinel approvingly: “One must blush at this medical delirium, worse, perhaps, than that of the madman whose reason it was to restore.”

180 “travelling, agreeable society”: Winslow, Anatomy of Suicide, 166.

180 “I should as soon”: Bucknill and Tuke, Manual of Psychological Medicine, 473.

180 “How many females”: Galt, Treatment of Insanity, 341.

181 “As no rational being”: Winslow, Anatomy of Suicide, 222. In the debate over whether suicides were insane, many nineteenth-century writers complained that suicides in their day lacked the heroism and cool rationality of the ancient Greeks and Romans. One physician asserted that 10 percent of classical suicides were insane and 90 percent were rational, while 10 percent of nineteenth-century suicides were rational and 90 percent were insane.

181 “I am far from from supposing”: T. Chevalier, Remarks on Suicide (London: 1824), 4.

181 “Two cases have occurred”: Mathews, “Civilization and Suicide,” 474.

181 “We know, as a fact”: This and the following quotes in this paragraph are from Strahan, Suicide and Insanity, 188, 30, 75, 78.

181 “All the superstitious fear”: Fedden, Suicide, 260.

182 “Agnis Miller wieff”: Shneidman, Deaths of Man, 115–16.

182 “I dare ensure”: Quote and information in this paragraph may be found in J. Graunt, Natural and Political Observations made upon the Bills of Mortality (Baltimore: Johns Hopkins University Press, 1939), 31–36.

183 “The evil frequently appears”: Masaryk, Suicide, 48.

183 “On this area”: Morselli, Suicide, 37.

184 “extremes of heat and cold”: Strahan, Suicide and Insanity, 154.

184 “Suicide and madness”: Morselli, Suicide, 72.

184 “Nationality has a noticeable effect”: Masaryk, Suicide, 121.

184 “A very low suicide frequency”: Ibid., 42.

184 “The frequency of suicide”: Morselli, Suicide, 102.

184 “From whence this fact proceeds”: Ibid., 76.

185 a German priest calculated: S. Gargas, “Suicide in the Netherlands,” American Journal of Sociology 37 (5) (1932): 698.

185 “The certainty of the figures”: Morselli, Suicide, 16. At the time it was believed that suicide was virtually unknown in “primitive” societies except in cases of “economic” suicide. Then in 1984, Alfred Vierkandt, a German sociologist, reported mass suicides among tribes in New Zealand and in Madagascar, and since then studies have found suicide in primitive societies throughout the world.

187 an entire society may experience anomie: Prior to the fall of the Berlin Wall in 1989, West Berlin had one of the highest suicide rates in the world, more than twice that of West Germany as a whole. Alienated not only geographically but spiritually, culturally, and politically, it was the embodiment of anomie.

187 “Lack of power”: Durkheim, Suicide, 254.

187 “suicide varies inversely”: Ibid., 209.

187 “are very often combined”: Ibid., 287.

187 “social facts must be studied”: Ibid., 37–38.

188 “When we learn”: Friedman, On Suicide, 110.

188 “Thus the unconscious”: Ibid., 119.

188 “the decisive factor”: Ibid., 71, 76.

188 “No one kills himself”: Ibid., 87.

188 “Let us suspend”: Ibid., 141.

188 Robert Litman has pointed out: Much of my discussion of Freud is drawn from Litman, “Sigmund Freud on Suicide.”

188 “I have long since resolved”: E. Jones, The Life and Work of Sigmund Freud (New York: Basic Books, 1953), 1: 132.

189 “In the two opposed situations”: S. Freud, Mourning and Melancholia (1917), in J. Strachey, ed., Standard Edition of the Complete Psychological Works (London: Hogarth Press, 1953–65), 14: 252.

189 “A patient over whom”: S. Freud, The Psychopathology of Everyday Life (1901), in Strachey, ed., Works, 6: 3.

189 “We find that impulses”: S. Freud, Totem and Taboo (1913), in Strachey, ed., Works, 13: 154.

189 a kind of inverted murder: Freud might also have agreed with the English comedy troupe Monty Python, who observed that “a murder is nothing but an extroverted suicide.”

189 “After long hesitancies”: S. Freud, An Outline of Psycho-Analysis (1940), in Strachey, ed., Works, 23: 148.

190 “We find that”: S. Freud, The Ego and the Id (1923), in Strachey, ed., Works, 19: 53.

Chapter V Faith, Hopelessness, and 5HIAA

193 the NYSPI researchers: The work of NYSPI on serotonin can be found in J. J. Mann et al., “Evidence for the 5-HT Hypothesis of Suicide: A Review of Post-Mortem Studies,” British Journal of Psychiatry (Supplement) (8) (1989): 7–14; Underwood et al., “Morphometry of the Dorsal Raphe Nucleus”; Mann et al., “Serotonin Transporter Gene Promoter”; Arango et al., “Genetics of the Serotonergic System”; Underwood et al., “Serotonergic and Noradrenergic Neurobiology”; Arango et al., “Serotonin 1A Receptors”; and Boldrini et al., “More Tryptophan Hydroxylase.” For a concise overview of the field, see J. J. Mann and V. Arango, “The Neurobiology of Suicidal Behavior,” in Jacobs, Harvard Medical School Guide, 98–114. See also J. J. Mann and V. Arango, “Neurobiology of Suicide and Attempted Suicide,” in Wasserman, Suicide, 29–34. And V. Arango and M. Underwood, “Serotonin Chemistry in the Brain of Suicide Victims,” in R. W. Maris, M. M. Silverman, and S. S. Canetto, Review of Suicidology, 1997 (New York: Guilford Press), 237–50. A few of the details in my description of NYSPI’s work have been taken from media accounts, in particular Ezzell, “Why?” For an extensive and extraordinarily lucid discussion of chemical and biological factors in suicide, I recommend K. R. Jamison’s Night Falls Fast, 163–212.

193 “the emotional seat belt”: J. Mann, Psychiatric News, April 7, 2000, www.psych.org/pnews/00–04–07/serotonin.html.

194 “sadness, anxiety, moral dejection”: Solomon, Noonday Demon, 286.

194 “surgery of the soul”: New York Times, June 7, 1937, in Whitaker, Mad in America, 116.

194 Robert Whitaker cites: Ibid., 73–138.

195 suicide and serotonin: Much of my description of Åsberg’s work is drawn from Pines, “Suicide Signals.” See also Åsberg et al., “5-HIAA in the Cerebrospinal Fluid.” And Åsberg, “Neurotransmitters and Suicidal Behavior.” For an interview with Åsberg, see the American Foundation for Suicide Prevention Web site at www.afsp.org/about-us/asberg.htm.

196 “the more lethal”: Ezzell, “Why?” For the study, see Oquendo et al., “Positron Emission Tomography.”

196 Mice with low serotonin: The information on serotonin and animal studies can be found in Jamison, Night Falls Fast, 185–89, and Solomon, Noonday Demon, 254.

197 four to six times higher: Psychiatric News, www.psych.org/pnews/98–01–19/suicide.html.

197 massive Danish study: P. Qin et al., “Suicide Risk in Relation to Family History of Completed Suicide and Psychiatric Disorders: A Nested Case-Control Study Based on Longitudinal Registers,” Lancet 360 (9340) (2002): 1126–30.

198 2002 study by psychiatrist David Brent: D. A. Brent et al., “Familial Pathways to Early-Onset Suicide Attempts: A High-Risk Study,” Archives of General Psychiatry 59 (2002): 801–7.

198 1985 study of the Old Order Amish: J. A. Egeland and J. N. Sussex, “Suicide and Family Loading for Affective Disorders,” Journal of the American Medical Association 254 (7) (1985): 915–18.

198 “racing one’s horse” and “excessive use of the public telephone”: Jamison, Night Falls Fast, 170.

198 psychiatrist Alex Roy found: Roy et al., “Suicide in Twins.”

199 Looking at attempted suicide: Roy et al., “Attempted Suicide.”

199 adoptions in Copenhagen: R. Schulsinger et al., “A Family Study of Suicide,” in M. Schou and E. Stromgren, eds., Origins, Prevention and Treatment of Affective Disorder (New York: Academic Press, 1979), 277–87.

199 “Reducing suicide”: New York Times, October 8, 1985, C8.

200 “what is being measured:” Shneidman, Comprehending Suicide, 72, 73.

200 “French runs in families”: “High-Suicide Families Eyed by Genetic Scientists,” Boston Globe, www.healthyplace.com/communities/depression/related/suicide.

201 “Taking all evidence”: V. Arango and M. Underwood, “Serotonin Chemistry in the Brain of Suicide Victims,” in Maris et al., Review of Suicidology, 1997, 238.

201 1895 address: Quotations in this paragraph are from “Is Life Worth Living?” in James, Essays on Faith and Morals, 1–31.

202 “Have we a right”: Zilboorg, “Considerations on Suicide,” 15.

202 “The contemporary physician”: Szasz, Theology of Medicine, 68.

202 “Perhaps the greatest contribution”: Hastings, Encyclopaedia of Religion and Ethics, 12: 24.

203 product of psychological disturbance: A few pundits, however, felt that increasing attention to psychological factors created too much sympathy toward suicide. “It is high time for the pulpit and religious press to emphasize strongly the wickedness of suicide,” wrote Bishop Oldham in 1932. “. . . The warranted revolt from the barbarous practice of former centuries, whereby those who took their own lives were buried at a crossroads at midnight, and a stake driven through their bodies, has resulted in a weak sentimentality, and we have ceased to express and, perhaps, to feel the horror we ought.” Literary Digest, July 16, 1932, 20.

203 In England: For a discussion of twentieth-century English suicide law, see Williams, Sanctity of Life, 278–83.

203 “unless there is some outstanding feature”: Ibid., 279.

203 “Intentionally causing”: Larue, Euthanasia and Religion, 37.

204 “There is but one”: A. Camus, The Myth of Sisyphus and Other Essays, trans. J. O’Brien (New York: Vintage Books, 1955), 3.

204 examined fluctuations: Henry and Short, Suicide and Homicide.

204 Jack Gibbs and Walter Martin refined: Gibbs and Martin, Status Integration and Suicide.

204 Departing from Durkheim: Douglas, Social Meanings of Suicide.

204 “A wealthy man”: Menninger, Man Against Himself, 19.

205 “To say that the death instinct”: Zilboorg, “Considerations on Suicide,” 17.

205 a mathematical formula: M. L. Farber, Theory of Suicide (New York: Funk & Wagnalls, 1968), 75.

PART 3 The Range of Self-Destructive Behavior

Chapter I Winner and Loser

209 “one calm summer night”: E. A. Robinson, “Richard Cory,” in F. O. Matthiessen, ed., The Oxford Book of American Verse (New York: Oxford University Press, 1950), 469–70.

Chapter II Under the Shadow

221 “No one ever lacks”: Pavese, Burning Brand, 99.

222 reported rarity of suicides: Several death-camp survivors have pointed out that there were ways of killing oneself other than active suicide; one had only to approach the barbed-wire fences to be shot by guards, or to relax one’s struggle for survival to succumb. “We all had to fight constantly against the wish to go passively into death,” a survivor told psychiatrist Joost Meerloo. “There is always a moment when a man surrenders, with his soul, with his will, and with his dreams. If that happened in the camps he was lost. Suicide was not even needed.” Meerloo, Suicide and Mass Suicide, 130.

222 “The day was dense”: P. Levi, The Drowned and the Saved (New York: Summit, 1988), 76.

222 “It is impossible”: D. J. Enright, ed., The Oxford Book of Death (Oxford: Oxford University Press, 1983), 106.

222 “There is no refuge”: J. Bartlett, Familiar Quotations (Boston: Little, Brown, 1980), 450.

223 Manes pulled a knife: Suicide was not an unfamiliar option for Manes; his father, despondent after his wife’s death, killed himself, reportedly by stabbing, when Manes was a young man. Three years after Donald Manes’s death, his twin brother, who had been in treatment for depression, attempted suicide, also by stabbing himself in the chest.

223 he shot himself: Kammerer’s story is told in A. Koestler, The Case of the Midwife Toad (New York: Random House, 1972).

223 David Kelly, a fifty-nine-year-old: The circumstances leading to Kelly’s suicide are detailed in J. Cassidy, “The David Kelly Affair,” New Yorker, December 8, 2003, www.newyorker.com/fact/content.

223 “I have only myself”: Time, November 17, 1980, 94.

224 “Dearest, I feel certain”: L. Woolf, The Journey Not the Arrival Matters: An Autobiography of the Years 1939 to 1969 (New York: Harcourt Brace Jovanovich, 1969), 93–94.

224 “Paradoxical and tragic”: L. S. Kubie, “Multiple Determinants of Suicide,” in Shneidman, Essays in Self-Destruction, 458.

225 “To whom concerned”: P. Friedman, “Suicide Among Police: A Study of Ninety-three Suicides Among New York City Policemen, 1934–1940,” in Shneidman, Essays in Self-Destruction, 438.

225 a few general types: Many of the details in my discussion of murder followed by suicide have been taken from the excellent overview of the subject provided in M. K. Nock and P. M. Marzuk, “Murder-Suicide: Phenomenology and Clinical Implications,” in Jacobs, Harvard Medical School Guide, 188–209.

225 eighty-eight women who had murdered a child: Hendin, Suicide in America, 100–101.

225 “Although such events”: Nock and Marzuk, “Murder-Suicide,” 199.

225 “One central theme”: Ibid.

226 “Good creatures”: A. E. Housman, Complete Poems (New York: Henry Holt, 1959), 185.

226 “If I commit suicide”: Alvarez, Savage God, 125.

226 “Suicide always seeks”: Lifton’s discussion of suicide is found in Lifton, Broken Connection, 239–61.

227 “The impulse to death” and “for some, organic death”: Hillman, Suicide and the Soul, 63, 83.

227 “The suicidal attempt”: Kubie, “Multiple Determinants of Suicide,” 455.

228 “Is it conceivable”: Quotations in this paragraph are found in Pavese, Burning Brand, 89, 48, 365, 366.

229 “being imprisoned”: Styron, Darkness Visible, 50.

229 “as if I were being stuffed”: Plath quotations are from Plath, Bell Jar, 105, 152, 193.

229 “an experience of harassment”: E. Ringel, “The Presuicidal Syndrome,” Suicide and Life-Threatening Behavior 6 (3) (1976): 131.

229 “Everything was like”: Shneidman, Voices of Death, 15–16.

230 “The logic of suicide”: Alvarez, Savage God, 116.

230 “some standard domestic squabble”: The description of Alvarez’s attempt and the quotes in this paragraph are from Savage God, 257–72.

Chapter III The Manner of Dying

233 “Take a look at them”: J. M. Cain, Double Idemnity (New York: Vintage Books, 1978), 67.

233 was considered “unseemly”: Jamison, Night Falls Fast, 136.

234 “What a low-minded wretch”: Moore, Full Inquiry, 1: 357.

234 “Hanging is a type of death”: Fedden, Suicide, 231.

234 “Not only have they”: Alvarez, Savage God, 131–32.

234 “Since many Norwegians”: Hendin, Suicide in America, 144.

235 “Sexual experience”: Ibid., 145.

235 a rash of ninety-three suicides: P. Friedman, “Suicide Among Police,” in Shneidman, Essays in Self-Destruction, 414–49.

235 people have completed suicide by: About half of this list is taken from a similar list compiled by George Kennan in an article for McClure’s and quoted in Menninger, Man Against Himself, 55. The other, more recent, examples are drawn from a variety of books and news clippings.

236 Yet on closer inspection: The nineteenth-century Parisienne who applied one hundred leeches to her body may well have been attempting to cure rather than kill herself, in an era when leeches were a common remedy for suicidal depression.

236 “That the various methods”: S. Freud, “The Psychogenesis of a Case of Homosexuality in a Woman” (1920), in Strachey, Works, 18: 162.

236 “The choice of the manner”: Ellis and Allen, Traitor Within, 125–26.

237 “jumping out”: Meerloo, Suicide and Mass Suicide, 74.

237 stab or shoot themselves: Hendin, Suicide in America, 147–48.

237 “Some suicides use their control”: Ibid., 149.

237 “the multiplicity of methods”: Ibid.

238 “Suicides have a special language”: A. Sexton, The Complete Poems (Boston: Houghton Mifflin, 1981), 142–43.

238 go to great lengths: And they will go to great lengths to insist on suicide. Wrote Pavese: “There is nothing ridiculous or absurd about a man who is thinking of killing himself being afraid of falling under a car or catching a fatal disease. Quite apart from the question of the degree of suffering involved, the fact remains that to want to kill oneself is to want one’s death to be significant, a supreme choice, a deed that cannot be misunderstood. So it is natural that no would-be suicide can endure the thought of anything so meaningless as being run over or dying of pneumonia. So beware of draughts and street corners.” (Pavese, Burning Brand, 87.) Pity, then, poor Heliogabalus, a Roman emperor renowned for his eccentricity. Told by Syrian priests that he’d take his own life, he obtained a golden sword, a rope of imperial purple and gold, and a priceless ring filled with poison. And in case he decided on jumping, he ordered a pavement of jewels to be laid beneath one of his towers to receive his body. Unfortunately, before he had a chance to take advantage of his elaborate preparations, he was murdered by his guards.

238 “A man who has attempted”: Winslow, Anatomy of Suicide, 210.

238 six people who survived leaps: D. H. Rosen, “Suicide Survivors: Psychotherapeutic Implications of Egocide,” Suicide and Life-Threatening Behavior 6 (4) (1976): 209–15.

239 Thomas Lynch describes: T. Lynch, The Undertaking: Life Studies from the Dismal Trade (New York: Penguin, 1998), 153. I first read of the story in Jamison, Night Falls Fast, 134–35.

239 In one early project: For a brief summary of research on suicide notes, see C. J. Frederick, “Suicide Notes: A Survey and Evaluation,” Bulletin of Suicidology, March 1969, 17–26.

239 psychiatrist Calvin Frederick: C. J. Frederick, “An Investigation of Handwriting of Suicide Persons Through Suicide Notes,” Journal of Abnormal Psychology 73 (3) (1968): 263–67.

240 “Suicide notes often seem like parodies”: Shneidman, Voices of Death, 58. Collections of suicide notes can be found in Shneidman, Voices of Death, 41–76; Shneidman and Farberow, Clues to Suicide, 197–215; Ellis and Allen, Traitor Within, 170–85; H. Wolf, “Suicide Notes,” American Mercury, November 1931, 264–72; and M. Etkind, . . . Or Not to Be: A Collection of Suicide Notes (New York: Riverhead Books, 1997).

240 “Whether the writers”: Stengel, Suicide and Attempted Suicide, 44.

240 “‘You are not to blame’”: Hendin, Suicide in America, 155.

Chapter IV The Numbers Game

245 A six-year study: Paper presented at a joint meeting of the American Association of Suicidology and the International Association for Suicide Prevention, San Francisco, May 25–30, 1987.

245 studying suicide in Scandinavia: Material in this and the following two paragraphs is from Hendin, Suicide and Scandinavia.

247 at least twenty: D. Baum, “The Price of Valor,” New Yorker, July 12 and 19, 2004, 49.

247 sociologist M. Harvey Brenner: New York Times, April 6, 1982, C1.

248 “The suicide rate seems to mirror”: Kushner, Self-Destruction in the Promised Land, 150–51.

248 “the struggle for existence”: “Suicide in Cities,” American Journal of Sociology 10 (4) (1905): 562.

249 Minneapolis suicides: C. F. Schmid, “Suicide in Minneapolis, Minnesota: 1928–32,” American Journal of Sociology 39 (1) (1933): 30–48.

249 district-by-district survey: P. Sainsbury, Suicide in London: An Ecological Study (London: Chapman and Hall, 1955).

249 studies by psychiatrist Alex Pokorny: A. D. Pokorny, “Suicide and Weather,” Archives of Environmental Health 13 (1966): 255–56; and Pokorny et al., “Suicide, Suicide Attempts.”

250 “A suicidal depression”: Alvarez, Savage God, 79.

250 “It was a spring day”: Kaysen, Girl, Interrupted, 52.

250 “If a person works”: Ellis and Allen, Traitor Within, 21.

250 Steven Stack points out: Stack, “Occupation and Suicide.”

251 “Dentists suffer”: The Straight Dope, www.straightdope.com.

251 one in three psychiatrists: C. L. Rich and F. N. Pitts Jr., “Suicide by Psychiatrists: A Study of Medical Specialists Among 18,730 Consecutive Physician Deaths During a Five-Year Period, 1967–72,” Journal of Clinical Psychiatry 41 (8) (1980): 261–63.

251 “a vocational hazard”: Beam, Gracefully Insane, 217.

251 “It draws workaholics”: Time, February 16, 1981.

252 “You can’t kill yourself by jumping”: R. H. Seiden, “We’re Driving Young Blacks to Suicide,” Psychology Today, August 1970, 24.

253 “Many of these subjects” and “It does not seem surprising”: Hendin, Black Suicide, 139, 145.

253 “To be a Negro”: Seiden, “We’re Driving Young Blacks,” 28.

253 “They believe they have”: Time, September 16, 1985, 33.

254 “You ache with the need”: Ibid.

254 analyzed 437 shootings: Hutson et al., “Suicide by Cop.”

254 “The problem with such speculations”: A. F. Poussaint, “Black Suicide” (paper presented at “The Enigma of Suicide,” a conference sponsored by the Samaritans in Boston, March 24, 1984), 11–12.

255 posttraumatic slavery syndrome: Poussaint and Alexander, Lay My Burden Down, 15. This book offers a comprehensive overview of African-American suicide, and my discussion owes much to it.

255 “There is a type of suicide”: Durkheim, Suicide, 276.

255 “Their expectations of life”: Poussaint, “Black Suicide,” 12.

255 “Black Poets should live”: Poussaint and Alexander, Lay My Burden Down, 110.

256 a study of marital status and suicide: S. Stack, “The Effect of Marital Integration in African American Suicide,” Suicide and Life-Threatening Behavior 26 (4) (1996): 405–14.

256 Charles Prudhomme predicted: C. Prudhomme, “The Problem of Suicide in the American Negro,” Psychoanalytic Review 25 (1938): 187–204, 372–91.

256 Harlem’s suicide rate: K. B. Clark, Dark Ghetto: Dilemmas of Social Power (New York: Harper and Row, 1965).

256 A 1998 study traced the rise: J. Neeleman et al., “Suicide Acceptability in African and White Americans: The Role of Religion,” Journal of Nervous and Mental Disease 186 (1) (1998): 16.

257 “Perhaps these unifying”: Seiden, “Why Are Suicides,” 5. Also see R. H. Seiden, “Mellowing with Age: Factors Influencing the Nonwhite Suicide Rate,” International Journal of Aging and Human Development 13 (4) (1981): 265–84. And Seiden, “Current Development in Minority Group Suicidology.”

257 a study by Alton Kirk: A. R. Kirk, “Socio-Psychological Factors in Attempted Suicide Among Urban Black Males” (Ph.D. diss., Michigan State University, 1976).

257 “try to become more assimilated”: A. R. Kirk, “Psycho-Social Modes of Adaptation and Suicide Among Blacks” (unpublished paper, Michigan State University), 10.

257 Part is historical: The medical community’s patronizing attitudes toward African-Americans date back at least as far as 1851, when one prominent Southern physician identified a type of insanity peculiar to slaves: “drapetomania”—the desire to run away. The cure? Light beatings and hard labor. (These attitudes have persisted. In a 1988 experiment, 290 psychiatrists reviewed case studies in which the patients were alternately described as white male, white female, black male, and black female; their diagnoses diverged in two directions: more severe for black males, less severe for white males.) (See Whitaker, Mad in America, 173.) Minorities in general may avoid seeking help from the mental health care system, which is hardly surprising given that, in a system predominately run by and geared toward whites, they have less access. And, according to recent government-sponsored reports, “When they utilize care, minorities are more likely than whites to be misdiagnosed or to receive inferior quality of care.” (Goldsmith, Reducing Suicide, 355.)

257 considered depression: National Mental Health Association, “Depression and African-Americans Fact Sheet” (Alexandria, Va.: National Mental Health Association, 2000).

257 “The internal strength”: Poussaint and Alexander, Lay My Burden Down, 26.

258 Things have changed: After her twenty-year-old son killed himself in 1990, Donna Holland Barnes sought out support groups to help her cope with her grief. She was surprised not to see any other African-Americans. In 1998, Holland, a professor of sociology, cofounded the National Organization for People of Color Against Suicide (NOPCAS), a nonprofit organization devoted to suicide prevention and awareness in the African-American community.

258 “Blacks view suicide”: Kirk, “Psycho-Social Modes,” 11.

258 One of the few large-scale studies: J. C. Smith et al., “Comparison of Suicides Among Anglos and Hispanics in Five Southwestern States,” Suicide and Life-Threatening Behavior 15 (1) (1985): 14–26.

259 nearly twice as likely: “Youth Risk Behavior Surveillance—United States, 2000,” Morbidity and Mortality Weekly Report, CDC Surveillance Summary 49 (SS05) (2000): 1–96.

259 “After they were confined”: L. H. Dizmang, “Suicide Among the Cheyenne Indians,” Bulletin of Suicidology, July 1967, 9.

260 new ways to vent aggression: The Native American death rate from cirrhosis of the liver is far higher than for any other race, especially among the young. The rates of homicide and violent accidents are also high, although there is evidence that they have decreased somewhat over the past few decades.

260 the causes were numerous: “Suicide Among Aboriginal People,” Royal Commission Report, February 23, 1995, prepared by Nancy Miller Chenier, Political and Social Affairs Division, Canadian Parliament.

261 “Inuit culture is rooted”: “Tragedy of Inuit Suicides Must End: New Measures Needed on World Suicide Prevention Day,” press release issued September 7, 2004, by Stephen Hendrie, director of communications, Inuit Tapiriit Kanatami.

261 “Prior to the development”: Rofes, “I Thought People,” 25. My discussion of gay and lesbian suicide owes much to this pioneering work.

261 “Homosexuality used to be”: Ibid., 11.

262 “The homosexual act in itself”: Meerloo, Suicide and Mass Suicide, 72. Among the eminent psychiatrists who believed homosexuality to be inherently suicidal were Karl Menninger and Gregory Zilboorg. Zilboorg, in fact, suggested that male suicide was invariably connected to homosexuality. Pointing out that far more men than women kill themselves, Zilboorg suggested that “man’s suicide has more to do with the inner struggles created by passivity and feminine strivings, i.e., by homosexuality. This would perhaps explain why more men shoot themselves than women, shooting having obviously something to do (symbolically) with passive homosexual wishes.” Zilboorg, “Considerations on Suicide,” 25.

262 “Have lesbians and gay men”: Rofes, “I Thought People,” 14.

262 survey of 3,648 men: Cochran and Mays, “Lifetime Prevalence of Suicide Symptoms.”

262 1986 study concluded: C. L. Rich et al., “San Diego Study I: Young vs. Old Subjects,” Archives of General Psychiatry, 43 (6) (1986): 577–82.

262 A study of male twins: Herrel et al., “Sexual Orientation and Suicidality.”

262 A 1978 Kinsey report, for instance: A. P. Bell, and M. S. Weinberg, Homosexualities: A Study of Diversity Among Men and Women (New York: Simon and Schuster, 1978).

262 A gay suicidologist likened this: www.virtualcity.com/youthsuicide/sltb.

263 One frequently cited paper: D. Shaffer et al., “Sexual Orientation in Adolescents Who Commit Suicide,” Suicide and Life-Threatening Behavior 25 (Supplement 4) (1995): 64–71.

263 “Less than two months ago”: J. Nelson, “Documentation Regarding Some Relationships Between Adolescent Suicide and Homosexuality” (unpublished paper, March 1987).

263 one of the first systematic studies: New York Times, March 4, 1988. See P. Marzuk et al., “Increased Risk of Suicide in Persons with AIDS,” Journal of the American Medical Association 259 (1988): 1333–37.

264 has been linked to increased anxiety: “You and AIDS: The HIV/AIDS Portal for Asia Pacific,” www.youandaids.org.

264 “exchange formulas for suicide”: R. Shilts, “Talking AIDS to Death,” in J. Kaplan, ed., The Best American Essays 1990 (New York: Ticknor & Fields, 1990), 243.

264 survey of 113 men: S. C. Kalichman et al., “Depression and Thoughts of Suicide Among Middle-Aged and Older Persons Living with HIV-AIDS,” Psychiatric Services 51 (7) (2000): 903–7.

264 survey of 3,365 students: Garofolo et al., “Sexual Orientation and Risk.”

264 survey of nearly forty thousand: Remafedi et al., “Relationship Between Suicide Risk.”

264 “All of the problems”: This and other Gibson quotes are from P. Gibson, “Gay Male and Lesbian Youth Suicide” (paper presented at a joint meeting of the American Association of Suicidology and the International Association for Suicide Prevention, San Francisco, May 25–30, 1987). For a critique of this paper, see P. LaBarbera, “The Gay Youth Suicide Myth,” www.leaderu.com/jhs/labarbera.

265 study by the Los Angeles Suicide Prevention Center: S. Schneider et al., “Suicidal Behavior in Adolescent and Young Adult Gay Men” (paper presented at a joint meeting of the American Association of Suicidology and the International Association for Suicide Prevention, San Francisco, May 25–30, 1987).

266 “He wanted to be normal”: The material on Jim Wheeler was taken from several Web sites, including www.jimwheeler.org.

Chapter V Backing into the Grave

267 survey of the etymology: Daube, “Linguistics of Suicide.” For much of the material in these first three paragraphs I am indebted to this fascinating paper.

268 Alvarez cites an earlier usage: Alvarez, Savage God, 48.

268 “One barbarous word”: Fedden, Suicide, 29.

269 “eating to gluttony”: Ibid., 184.

269 “the daredevil”: Durkheim, Suicide, 45–46.

269 “I have now learnt” and “When a member of my family”: S. Freud, The Psychopathology of Everyday Life (1901), in Strachey, Works, 6: 178–82.

270 “in the end each man”: Menninger, Man Against Himself, vii.

270 two armies at war: Meerloo, Suicide and Mass Suicide, 92.

270 “The development of symptoms”: K. Menninger, “Expression and Punishment,” in Shneidman, On the Nature of Suicide, 71.

271 self-mutilation: In Man Against Himself, Menninger offers an extensive analysis of self-mutilation. For a brief but comprehensive summary of the syndrome, see M. A. Simpson, “Self-Mutilation and Suicide,” in Shneidman, Suicidology, 281–315. See also A. R. Favazza, “Self-Mutilation,” in Jacobs, Harvard Medical School Guide, 125–45.

272 about 3 percent: G. E. Murphy et al., “The Lifetime Risk of Suicide in Alcoholism,” Archives of General Psychiatry 47 (1990): 383–92.

272 115 times that: G. E. Murphy, Suicide in Alcoholism (New York: Oxford University Press, 1992). As cited in Goldsmith et al., Reducing Suicide, 84.

272 “a form of self-destruction”: Menninger, Man Against Himself, 161.

272 147 suicidal male alcoholics: Hendin, Suicide in America, 127.

272 one-third of alcoholic suicides: Murphy et al., “Suicide and Alcoholism.”

273 “I didn’t think I was worth anything”: Giffin and Felsenthal, Cry for Help, 53.

273 review of more than thirty studies: A. Gardner and C. Rich, “Eating Disorders and Suicide,” in R. Yufit, ed., Proceedings of the 21st Annual Meeting of the American Association of Suicidology (Denver: American Association of Suicidology, 1999), 171–72.

274 Melvin Selzer has demonstrated: Selzer and Payne, “Automobile Accidents.”

274 In a subsequent study: New York Times, April 1, 1968, 35.

274 “lifelong war against boredom”: Greene describes playing Russian roulette and making several adolescent suicide attempts in G. Greene, A Sort of Life (New York: Touchstone, 1971), 73–88, 128–33.

274 “They use risk-taking behavior”: The quote and a description of the study are taken from Washington Post, June 9, 1987, Health Section, 5.

275 “I would describe myself”: M. Begley, “Risky Business,” Backpacker, May 1986, 38. Yukio Mishima compared athletes who sought such extreme experience to kamikaze pilots. But most rock climbers, skydivers, and so on are not, of course, suicidal. “Generally speaking, all dangerous activities (for example, auto racing, mountain climbing, acrobatics, etc.) could reflect suicidal tendencies,” writes Jean Baechler. “There is no question of considering all race-car drivers as suicidal but simply of having available a form of suicidal behavior that is revealed in taking risks.” Baechler, Suicides, 19. Some, however, may be attracted to such risky endeavors partially because of their self-destructive possibilities. The British climber Menlove Edwards was famous for his risky expeditions and bold routes. The feats that in public won him medals had a pathetic parallel in his private life. A homosexual who never found lasting love, he was tormented by depression. When depressed, he liked to row far out into the open sea in a battered boat, then ride huge waves to shore, scrambling to safety as they crashed on the rocks. At age thirty-four he suffered a breakdown and made three suicide attempts. He lived the last fourteen years of his life as a recluse, cared for by his sister, although he continued to climb. In 1958 he completed suicide by swallowing potassium cyanide.

275 “Life is impoverished”: Alvarez, Savage God, 253.

275 “Many soldiers have the fantasy”: Meerloo, Suicide and Mass Suicide, 75.

275 In his 1950s study of murder: M. E. Wolfgang, “Suicide by Means of Victim-Precipitated Homicide,” in H. L. P. Resnik, ed., Suicidal Behaviors (Boston: Little, Brown, 1968), 90–104.

275 a forty-three-year-old German man: M. Landler, “German Court Convicts Internet Cannibal of Manslaughter,” New York Times, January 31, 2004.

276 A twenty-two-year-old babysitter: Quite the opposite of people who use murder as a means of suicide are those political prisoners who are murdered and are called “suicides.” During the 1930s when the National Socialists imprisoned and killed many of their opponents and insisted they were suicides, the French revived the caustic phrase être suicidé—“to be suicided.” In the 1980s and early 1990s, this occurred among antiapartheid prisoners in South Africa who were said to have killed themselves while in detention.

276 creativity: On the other hand, some artists make art of self-destruction, an aesthetic of asceticism. Like a contemporary St. Simeon Stylites, one New York performance artist spent five days and nights in a two-by-three-foot locker without food. Another sat on a shelf in an art gallery for twenty-two days. Then there was the man who lived in a cage for a year.

276 “Most people are no longer alive”: Meerloo, Suicide and Mass Suicide, 19.

277 “backing into the grave”: Pretzel, “Philosophical and Ethical Considerations,” 32.

277 examples of self-destruction: Steincrohn, How to Stop Killing Yourself.

277 “One must be careful”: Baechler, Suicides, 18.

277 “There is a little murder”: K. Menninger, Sparks, ed. L. Freeman (New York: Thomas Y. Crowell Company, 1973), 142.

277 “A thousand people”: J. Carroll, The Winter Name of God (Kansas City: Sheed and Ward, 1975), 87–88.

PART 4 Prevention

Chapter II Suicidology

291 until 1906: There were a few exceptions. During the Enlightenment, when there was great interest in using scientific advances to extend the human life span, societies were formed in which physicians, clergy, and laymen essentially acted as eighteenth-century paramedics. The members of one such group, London’s Royal Humane Society, founded in 1774, were trained to restore life “to the drowned, those suspended by the cord, or otherwise suffocated: likewise in cases of intense cold; the aweful and tremendous stroke of lightning; and other premature, accidental or sudden deaths.” Members were paid four guineas for each successful revival; unsuccessful attempts earned two. While preventing suicide was not its primary goal, the society came in contact with many attempted suicides. “By the Annual Reports of this society it appears, that since its first institution not fewer than five hundred cases of suicide have fallen under its cognizance,” observed the Reverend G. Gregory in 1797, “in about three hundred and fifty of which its interposition has been providential enough to restore the despairing culprit to himself, to his friends, and to society; and to rescue the soul of the sinner from the overwhelming pressure of despondency, and, perhaps from the danger of everlasting condemnation.”

Although the society considered suicide a “horrid crime,” its members were among the first to realize that suicidal people can and should be helped. They also recognized a characteristic of suicidal people that would be crucial to subsequent prevention efforts: ambivalence. After describing the rescue and rehabilitation of a homeless woman who attempted suicide in 1778, one member wrote, “This happy issue must give pleasure to every reflecting mind. It proves that there is no life so miserable but it may be worthy of our endeavours to save it; and it is an additional argument, to the many others Our Society has afforded, against a prevailing sentiment, that all attempts to save a suicide are in vain; for, they will repeat the act. A sentiment this, neither founded in the knowledge of human nature, nor justified by experience.” In 1797, a year in which, according to society records, eleven would-be suicides were saved and “all of them were reconciled to life,” the RHS held an anniversary celebration. The evening’s highlight was “the Procession of the Persons restored to Life by the efforts of the Humane Society, and its Medical Assistants.” Odes “To Sympathy” and “To Science” were recited, which seems appropriate considering that the society’s good works were inspired as much by the spirit of scientific inquiry as by sympathy for the suicidal. (Material on the Royal Humane Society from G. Gregory, A Sermon on Suicide (London: J. Nichols, 1797).)

In the nineteenth century, there were a few organized prevention efforts. Like the Royal Humane Society, the Lemberg Volunteer Rescue Society (with a branch office in Budapest) was an emergency paramedical service whose cases included suicides and suicide attempts. According to a 1906 German newspaper article the society had attended to 720 suicides and suicide attempts since its founding in 1893. Fedden reports that toward the end of the century an association was formed in Foochow, China, to keep four boats patrolling the Foochow Bridge to save would-be suicides from drowning.

295 “Prior to the 1950s”: Frederick, “Current Trends,” 172.

296 broke the key: E. S. Shneidman and N. L. Farberow, “Some Comparisons Between Genuine and Simulated Suicide Notes,” Journal of General Psychology 56 (1957): 251–56.

300 “Both of those have given way”: A. B. Tulipan and S. Feldman, eds., Psychiatric Clinics in Transition (New York: Brunner-Mazel, 1969), 128.

304 “The goal of the NIMH Center”: E. S. Shneidman, “The NIMH Center for Studies of Suicide Prevention,” Bulletin of Suicidology, July 1967, 2.

304 coined by Shneidman: Shneidman subsequently learned that the word suicidologie had been used in 1929 by Dutch professor W. A. Bonger.

304 “massive public education”: E. S. Shneidman, “A Comprehensive NIMH Suicide Prevention Program” (1966) (a thirty-six-page memorandum to Stanley Yolles, then director of NIMH), 14.

304 “The ‘early signs’ of suicide”: Ibid., 2.

305 “Just as there are fire stations”: Ibid., 7.

305 The suicide prevention movement: Psychiatrist Erwin Ringel, who in 1947 founded Vienna’s Lebensmuedenfuersorge (Society for the Care of People Who Are Tired of Life), frequently expressed his belief in the efficacy of such centers by maintaining that “if Romeo had had a crisis intervention clinic handy, neither he nor Juliet would have died.” (Washington Post, January 21, 1973, C5.)

305 “How to Set Up a Suicide Prevention Center”: N. Allen, “How to Set Up a Suicide Prevention Center,” California’s Health, January 1970.

305 wide variations: Much of the information on prevention centers in these paragraphs is drawn from Fisher, Suicide Prevention and/or Crisis Services.

306 Shneidman even pointed out: Shneidman, “Comprehensive NIMH Suicide Prevention Program,” 29.

306 “One of the problems”: D. Lester, “Spiritualism and Suicide,” Omega 12 (1) (1981): 45–49.

306 A 1972 summary: D. Lester, Why People Kill Themselves (Springfield, Ill.: Charles C. Thomas, 1972).

306 psychologist Richard McGee: R. K. McGee et al., “A Survey of Telephone Answering Services in Suicide Prevention and Crisis Intervention Agencies,” Life-Threatening Behavior 2 (1) (1972): 42–47.

307 CSSP-sponsored task force: H. L. P. Resnik and B. C. Hathorne, eds., Suicide Prevention in the 70’s (Washington, D.C.: U.S. Government Printing Office, 1973), 3.

307 When a 1968 study: C. Bagley, “The Evaluation of a Suicide Prevention Scheme by an Ecological Method,” Social Science and Medicine 2 (1968): 1–14; and R. Fox, “The Recent Decline of Suicide in Britain: The Role of the Samaritan Suicide Prevention Movement,” in Shneidman, Sucidology, 499–524.

307 more carefully controlled study: C. Jennings et al., “Have the Samaritans Lowered the Suicide Rate? A Controlled Study,” Psychological Medicine 8 (1978): 413–22.

307 compared eight cities: D. Lester, “Effect of Suicide Prevention Centers on Suicide Rates in the United States,” Health Services Reports 89 (1974): 37–39.

307 institute’s top priority: At the same time, the federal government was at the height of its commitment to community mental health centers. Emphasis shifted from research to direct services. The government’s goal was to reach more people for less money. With the move toward crisis intervention and youth problems, suicide research received decreasing support, and the suicide prevention center per se was swallowed up in the extraordinary growth of hotlines of all varieties. By 1974 there were almost seven hundred hotlines in the United States; St. Louis alone was alleged to have ninety-three. There were hotline newsletters and hotline conventions. National magazines and TV melodramas offered histrionic accounts of tearful calls and heroic rescues. “At this very moment, thousands of hotlines are ringing,” began a book describing the hotline phenomenon. “People are calling for help about problems that deal with pregnancy, illegal drugs, boy-girl problems, family hassles, alcohol abuse, suicide, loneliness, child abuse, runaways, rape, and more.” The book, which included instructions on how to start a hotline, described the LASPC as “the grandfather of all hotlines.” Its progeny now included Rap Shop, Some Body Loves You Baby, Awakening Peace, Fort Help, Mother, Need, The Way Out, Listening Post, Pulse, Inc., Oz, Yell Inc., Sunshine Line, and Tele-Mom (M. O. Hyde, Hotline! [New York: McGraw-Hill, 1976]). In a 1972 issue of Romaine Edwards’s Hotline Newsletter, the author, who claimed to have founded fifteen hotlines, captured the hotline fever: “The word got around quickly: You didn’t need a battalion of degreed headshrinkers to start helping local folk with their big and little problems. . . . All you needed were a couple of phone numbers, a few friends, and a little publicity, and presto!”

308 study of ten centers: Hendin, Suicide in America, 183.

308 half of the four thousand calls: Lester and Lester, Suicide, 162.

308 psychiatrist Jerome Motto: J. A. Motto, “Evaluation of a Suicide Prevention Center by Sampling the Population at Risk,” Suicide and Life-Threatening Behavior 2 (1) (1971): 18–22.

308 eighteen-month follow-up: R. E. Litman and C. I. Wold, “Beyond Crisis Intervention,” in Shneidman, Suicidology, 525–46.

310 “The committee finds”: Goldsmith et al., Reducing Suicide, 9.

310 University of Alabama study: H. L. Miller et al., “An Analysis of the Effects of Suicide Prevention Facilities on Suicide Rates in the United States,” American Journal of Public Health 74 (4) (1984): 340–43.

Chapter III Treatment

313 “People say”: Giffin and Felsenthal, Cry for Help, 41.

314 A twenty-year follow-up study: Brown et al., “Risk Factors for Suicide.”

314 Reasons for Living scale: M. M. Linehan et al., paper presented at the Fourteenth Annual Meeting of the American Association of Suicidology, Albuquerque, N.M., 1981.

314 Risk-Rescue Rating: A. D. Weisman and J. W. Worden, “Risk-Rescue Rating in Suicide Assessment,” Archives of General Psychiatry 26 (1972): 553–60.

314 like the weather: Simon, “Suicide Prevention Contract.”

315 SAD PERSONS scale: W. M. Patterson et al., “Evaluation of Suicidal Patients: The SAD PERSONS Scale,” Psychosomatics 24 (4) (1983): 343–49.

315 “Patient Monitoring of Suicidal Risk”: R. C. Drye et al., “No-Suicide Decisions: Patient Monitoring of Suicidal Risk,” American Journal of Psychiatry 130 (2) (1973): 171–74.

315 whether they actually work: A recent study of seventy-six people who completed suicide either as hospital inpatients or immediately after discharge found that more than three-quarters denied suicidal thoughts or intent as their last communication to mental health professionals. “Many clinicians use a patient’s denial of suicide to relieve their anxiety,” warned psychiatrist Jan Fawcett, a coauthor of the study. “But this denial is not to be relied upon.” K. A. Busch et al., “Clinical Correlates of Inpatient Suicide,” Journal of Clinical Psychiatry 64 (1) (2003): 14–19. See also E. Bender, “Suicide Expert Calls for More Aggressive Screening,” Psychiatric News 38 (11) (2003): 28.

315 survey at Harvard Medical School: M. C. Miller et al., “Talisman or Taboo? The Controversy of the Suicide Prevention Contract,” Harvard Review of Psychiatry 6 (1998): 78–87. For an overview of the subject, see M. C. Miller, “Suicide-Prevention Contracts: Advantages, Disadvantages, and an Alternative Approach,” in Jacobs, Harvard Medical School Guide, 463–81.

315 “the use of such clinical contracts”: M. Goin, “The ‘Suicide-Prevention Contract’: A Dangerous Myth,” Psychiatric News 38 (14) (2003), pn.psychiatryonline.org.

315 “The contract against self-harm”: Simon, “Suicide Prevention Contract.”

316 proved unsuccessful: Pokorny, “Prediction of Suicide.”

316 computer was shown to be more accurate: J. H. Greist et al., “A Computer Interview for Suicide-Risk Prediction,” American Journal of Psychiatry 130 (12) (1973): 1327–32.

316 brought to emergency rooms: A. Spirito et al., “Attempted Suicide in Adolescence: A Review and Critique of the Literature,” Clinical Psychology Review 9 (3) (1989): 335–63.

316 getting the person: It has been estimated that only 12 percent of those who attempt suicide receive medical attention. Indeed, it is said that over 90 percent of people who complete suicide have a diagnosable mental disorder. Yet two-thirds of all people with diagnosable mental disorders do not receive treatment. (Of those who do receive treatment, only half see mental health professionals. And only about half of those who receive treatment—be it from a mental health professional or a physician—are diagnosed and treated appropriately.) There are a number of reasons for this. Suicidal people face stigma on two fronts, the diminishing but still considerable stigma of mental illness, and the stigma of suicide. Many face financial obstacles: 16 percent of Americans have no medical insurance (for minorities, the figure is even higher), and even those who are insured are unlikely to receive adequate coverage; carriers commonly have greater restrictions for coverage of mental illness than for other health conditions. Many of those who end up taking medications stop prematurely. Some are discouraged by unpleasant side effects, which usually start before the therapeutic benefit is felt. Others give up because they begin to feel better and want to see if they can do without the medications. (Patients must often try several different drugs or combinations of drugs at different dosage levels before one works. After each new medication is introduced, several weeks or more must pass before patient and clinician can determine whether it is effective.) Compliance rates for patients on antidepressants run about 65–80 percent; for lithium, about 60 percent; for anticonvulsants, about 55 percent. (The FDA stresses the importance of close monitoring, especially during the first few months of treatment—patients are most likely to become suicidal within the first nine days of starting antidepressant medication—or whenever dosages are altered or medications changed.) See “Barriers to Effective Treatment and Intervention,” in Goldsmith et al., Reducing Suicide, 331–73.

317 “The immediate goal” and “I did several things”: Shneidman, Definition of Suicide, 229.

318 “Suicidal behaviors”: J. A. Motto, “Recognition, Evaluation, and Management of Persons at Risk for Suicide,” Personnel and Guidance Journal 26 (1978): 537–43.

318 “Suicide proneness”: D. H. Buie and J. T. Maltsberger, “The Psychology and Assessment of Suicide” (unpublished paper), 18.

318 “In our age the triumph”: D. Merkin, “Psychoanalysis: Is It Science or Is It Toast?” New York Times Book Review, September 5, 2004, 9.

319 “immobile” and “waxlike”: Whitaker, Mad in America, 154.

319 Prozac Nation: E. Wurtzel, Prozac Nation (Boston: Houghton Mifflin, 1995).

319 thirteen times more likely: R. J. Baldessarini et al., “Treating the Suicidal Patient with Bipolar Disorder: Reducing Suicide Risk with Lithium,” Annals of the New York Academy of Sciences 932 (2001): 24–38.

319 a German study: K. Thies-Flechtner et al., “Effect of Prophylactic Treatment on Suicide Risk in Patients with Major Affective Disorders. Data from a Randomized Prospective Trial,” Pharmacopsychiatry 29 (3) (1996): 103–7.

320 suicidal acts rose sixteenfold: Baldessarini et al., “Effects of Lithium.”

320 only 8–17 percent: Goldsmith et al., Reducing Suicide, 237.

320 6–14 percent: Ibid., 237.

321 Those concerns resurfaced: Much of my discussion of the SSRI controversy is taken from articles in the New York Times in 2004.

322 only 20 percent: Mahler, “Antidepressant Dilemma,” 61.

322 “It is probably the case”: A. Solomon. “A Bitter Pill,” New York Times, March 29, 2004.

322 439 depressed teenagers: J. March, “Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination for Adolescents with Depression: Treatment for Adolescents with Depression Study (TADS) Randomized Controlled Trial,” Journal of the American Medical Association 292 (7) (2004): 807–20.

323 “Medicine alone is not sufficient”: Goldsmith et al., Reducing Suicide, 258.

323 modus operandi: Electroconvulsive therapy, for instance, is said by some clinicians to be the most effective treatment for severe suicidal depression, because when it works, it works so quickly. (As to why it works, doctors are still at a loss to explain.) Overused and abused in the days when it was known as shock treatment, ECT may now, in a kinder, gentler incarnation, be underutilized because of its lingering stigma. (ECT has not been subject to clinical studies, and there is no conclusive evidence that ECT has a long-term effect on suicide rate and suicidal behavior.)

324 “psychodynamic formulation”: Buie and Maltsberger, Practical Formulation of Suicide Risk. See also J. T. Maltsberger, “The Psychodynamic Understanding of Suicide,” in Jacobs, Harvard Medical School Guide, 72–82.

326 no better than radiologists: A. L. Berman, “Notes on Turning 18 (and 75): A Critical Look at Our Adolescence” (paper presented at the Eighteenth Annual Meeting of the American Association of Suicidology, Toronto, Canada, April 18–21, 1985).

326 A 1983 survey: Study by A. L. Berman, ibid.

326 “relatively superficial in nature”: Ellis et al., “Patient Suicide.”

326 “Residents are trained”: See Light, Becoming Psychiatrists; Light, “Psychiatrists and Suicide”; Light, “Professional Problems”; and Light, “Treating Suicide.”

327 “During the course”: Stone, “Suicide Precipitated by Psychotherapy.”

327 a series of papers: A. A. Stone and H. M. Shein, “Psychotherapy of the Hospitalized Suicidal Patient,” American Journal of Psychotherapy 22 (1) (1968): 15–25; H. M. Shein and A. A. Stone, “Psychotherapy Designed to Detect and Treat Suicidal Potential,” American Journal of Psychiatry 125 (9) (1969): 141–45; and Shein and Stone, “Monitoring and Treatment.” The story of Shein’s suicide is told in Beam, Gracefully Insane, 222–32. Sociologist Rose Coser’s nuanced examination of the rash of suicides about which Shein and Stone wrote can be found in Coser, Training in Ambiguity.

327 “Some patients almost ready”: J. T. Maltsberger, and D. H. Buie Jr., “Common Errors in the Management of Suicidal Patients” (unpublished paper, 1980), 14.

328 Impressed with the jocular: Stone, “Suicide Precipitated by Psychotherapy,” 5.

328 In one of the few papers: Maltsberger and Buie, “Countertransference Hate.”

328 William Wheat isolated: Hendin, Suicide in America, 169. In 2001, the authors of a study in which data were collected from twenty-six therapists who had had a patient complete suicide came to a similar conclusion. “The 26 suicide cases we studied suggest that therapists working with suicidal patients frequently fail to recognize the severity of the emotional crises they experience,” they wrote. “Our data indicate that only a small percentage of persons who are intent on killing themselves while in treatment give the therapist little or no indication of their crisis.” Hendin et al., “Recognizing and Responding.”

329 more than two hundred therapists: Litman, “When Patients Commit Suicide.”

330 describe a man: N. L. Farberow et al., “Suicide Among Schizophrenic Mental Hospital Patients,” in Farberow and Shneidman, Cry for Help, 90.

331 ascendancy of HMOs: In 1999, 72 percent of Americans with health insurance were covered by managed care, which promotes treatment of mental health in primary care, limits access to mental health specialists, and has severely reduced coverage of inpatient and outpatient care (between 1988 and 1998, managed care plans cut their spending on psychiatric treatment by 55 percent). Although the influence of managed care on suicide itself is largely unexamined, a 1999 study of 1,204 outpatients with depression in seven different HMOs, which found that only 48–60 percent received some sort of mental health care, concluded that patients with suicidal ideation were at particular risk for receiving inappropriate treatment. (K. B. Wells et al., “Quality of Care for Primary Care Patients with Depression in Managed Care,” Archives of Family Medicine 8 [6] [1999]: 529–36.) People who complete suicide have substantially more difficulty getting health care at all. A study of 22,957 deceased people of all ages found that, compared with people who died of illnesses or injuries, those who complete suicide are three times more likely to have difficulty accessing health care (and twice as likely to refuse needed care)—because of trouble paying bills, difficulty being admitted to a treatment facility, problems finding a doctor, and so on. (C. L. Miller and B. Druss, “Datapoints: Suicide and Access to Care,” Psychiatric Services 52 [12] [2001]: 1566.)

331 perhaps least prepared: There is evidence that physician training might impact the suicide rate. In the 1980s, on the Swedish island of Gotland, where most treatment is provided by GPs, suicide prevention experts trained island physicians about recognition and treatment of depressed and suicidal people. Despite physician fears that they’d trigger suicides if they asked their patients about suicide, the island’s suicide rate was lower by 60 percent (almost entirely due to a decrease in suicide by females; the male rate was essentially unchanged), a decrease exceeding that of Sweden as a whole over that same time. Although the rate eventually rose back to pretraining levels, coinciding with the departure of about half the island’s physicians, the results were nevertheless promising. (W. Rutz et al., “Long-Term Effects of an Educational Program for General Practitioners Given by the Swedish Committee for the Prevention and Treatment of Depression,” Acta Psychiatrica Scandinavica 85 [1992]: 83–88; Z. Rihmer et al., “Depression and Suicide on Gotland: An Intensive Study of All Suicides Before and After a Depression-Training Programme for General Practitioners,” Journal of Affective Disorders 35 (1995): 147–52.)

331 “leaves them in the role”: From a speech to the APA’s annual Institute on Psychiatric Services, October, 1997, as reported in Psychiatric News, www.psych.org/pnews/97–12–05/primary.

331 widespread lack of knowledge: J. W. J. Williams et al., “Primary Care Physicians’ Approach to Depressive Disorders: Effects of Physician Speciality and Practice Structure,” Archives of Family Medicine 8 (1) (1999): 58–67.

331 more than half of patients with depression: E. S. Higgins, “A Review of Unrecognized Mental Illness in Primary Care: Prevalence, Natural History, and Efforts to Change the Course,” Archives of Family Medicine 3 (10) (1994): 908–17.

331 72 percent had prescribed SSRIs: Voelker, “SSRI Use Common,” 1882.

331 Philadelphia medical schools: Light, Becoming Psychiatrists, 30.

332 91 percent of physicians: Giffin and Felsenthal, Cry for Help, 28.

332 believe the old canard: K. Michel, “Suicide Prevention and Primary Care,” in K. Hawton and K. van Heeringen, eds., International Handbook of Suicide and Attempted Suicide (Chichester, UK: John Wiley and Sons, 2000), 661–74.

332 primary care physicians: Williams et al., “Primary Care Physicians’ Approach.”

333 “hundreds of ways”: Reynolds and Farberow, Suicide.

333 a study of hospitalized patients: Jamison, Night Falls Fast, 152.

333 suicides at Metropolitan State Hospital: A. R. Beisser and J. E. Blanchette, “A Study of Suicides in a Mental Hospital,” Diseases of the Nervous System 22 (1961): 365–69.

333 a study attributing a decline: L. F. Woolley and A. H. Eichert, “Notes on the Problem of Suicide and Escape,” American Journal of Psychiatry 98 (1941): 110–18.

333 “rather hesitantly”: Styron’s account of his hospitalization can be found in Darkness Visible, 67–75.

334 “begin planning for discharge”: American Psychiatric Association, “Psychiatric Hospitalization,” www.psych.org/public_info/hospital.

334 “extremely difficult”: Okin, “Future of State Hospitals,” 579.

335 “Often caught in the dilemma”: Jamison, Night Falls Fast, 153.

336 A study by San Francisco psychiatrist: Motto and Bostrom, “Randomized Controlled Trial.”

337 “one of the ways that the Lord”: The story of the lawsuit is told in M. A. Weitz, Clergy Malpractice in America: Nally v. Grace Community Church of the Valley (Lawrence: University Press of Kansas, 2001).

338 “Suicide can best be understood”: Shneidman, Definition of Suicide, 226.

338 appeared on the television news show: Giffin and Felsenthal, Cry for Help, 162–63.

Chapter IV Social Studies

340 One August day: For historical material on the Golden Gate Bridge, see A. Brown, Golden Gate: Biography of a Bridge (Garden City, N.Y.: Doubleday, 1965).

341 “almost any place in Japan”: O. D. Russell, “Suicide in Japan,” American Mercury, July 1930, 342.

341 On January 7, 1933: The description of the suicides at Mihara-Yama is drawn from newspaper and magazine accounts of the time, and from Ellis and Allen, Traitor Within, 94–99.

342 A study of 116 people: Y. Takahashi, “Aokigahara-Jukai: Suicide and Amnesia in Mt. Fuji’s Black Forest” (paper presented at a joint meeting of the American Association of Suicidology and the International Association for Suicide Prevention, San Francisco, May 25–30, 1987). In today’s industrialized Japan, several Tokyo skyscrapers have taken their places as suicide landmarks. The Takashimadaira public housing complex, sixty-four apartment buildings on the edge of Tokyo, opened in April 1972. Within eight years, more than seventy people leaped from its rooftops—some journeying from as many as 120 miles away—earning it the nickname Mecca for Suicide.

342 “At one time there seemed”: W. Sweetser, Mental Hygiene: or, an Examination of the Intellect and Passions (New York: George P. Putnam, 1850), 292.

344 the names of 515 people: Seiden, “Where Are They Now?”

344 David Rosen interviewed: D. H. Rosen, “Suicide Survivors: Psychotherapeutic Implications of Egocide,” Suicide and Life-Threatening Behavior 6 (4) (1976): 209–15.

344 second study by Seiden: Seiden and Spence, “Tale of Two Bridges.”

345 moot political issue: In 1977, the bridge’s fortieth anniversary year, pro-barrier activists held a Memorial Day rally on the bridge to commemorate the more than six hundred bridge suicides. Ironically, one of the speakers was the Reverend Jim Jones, who arrived with three busloads of his People’s Temple followers. “It is entirely fitting that on Memorial Day we are here on account of the hundreds of people who are not casualties of war, but casualties of society,” he said. “For, in the final analysis, we have to bear collective responsibility for those individuals who could not find a place to go with their burdens, who came to that place of total helplessness, total despondency, where they took their own lives here on this beautiful bridge, this Golden Gate Bridge, a symbol of human ingenuity, technological genius but social failure.” Eighteen months later he would lead 912 of his followers into mass suicide in the jungles of Guyana. The text of Jones’s speech is reprinted in R. H. Seiden, “Reverend Jones on Suicide,” Suicide and Life-Threatening Behavior 9 (2) (1979): 116–19.

345 “grandeur”: A. Blum, “Suicide Watch,” New York Times, March 20, 2005.

347 “Much could be gained”: Friedman, On Suicide, 52–53. The opposite prevention strategy was proposed in the seventeenth century by Richard Capel. He suggested that instead of avoiding bridges that might tempt one to jump, one should march firmly across with a constant heart, and the urge would be conquered. “A false meanes is for a man to yeeld to much to feares, so as to thinke to avoid tentation, by declining, and not by resisting, as some dare not carry a knife about them, or when their knife is out, cast it from them, this is to yeeld too much to Satan: neither doth it helpe the matter, but rather keepe the tentation in. . . . The way to drive away our tentation is to keepe our knives about us . . . to fight it out against Satan, by setting the Word and Christ against him.” Sprott, English Debate, 46.

347 a landmark 1983 study: J. H. Boyd, “The Increasing Rate of Suicide by Firearms,” New England Journal of Medicine 308 (15) (1983): 872–74.

347 the strictness of state gun-control laws: D. Lester and M. E. Murrell, “The Influence of Gun Control Laws on Suicidal Behavior,” American Journal of Psychiatry 137 (1) (1980): 121–22.

348 “Where there are more guns”: A. Marcus, “Study: Handgun Ownership Raises Risk of Suicide,” Health on the Net News, www.hon.ch/News. See Hemenway and Miller, “Association of Rates.” See also Miller and Hemenway, “Relationship Between Firearms and Suicide.”

348 eighty-two consecutive suicides: Seiden, “Suicide Prevention,” 271.

348 King County, Washington, firearms study: A. L. Kellerman and D. T. Reay, “Protection or Peril? An Analysis of Firearm-Related Deaths in the Home,” New England Journal of Medicine 314 (24) (1986): 1557–60.

348 “If some persons”: Seiden, “Suicide Prevention,” 271.

348 “get the guns out of the house”: Apparently, few people heed such advice. In a study of depressed adolescents who entered psychotherapy, only 27 percent of parents who, at intake, reported having guns in their home removed them after being urged to do so by the therapist. (D. A. Brent et al., “Compliance with Recommendations to Remove Firearms in Families Participating in a Clinical Trial for Adolescent Depression,” Journal of the American Academy of Child and Adolescent Psychiatry 39 [10] [2000]: 1220–26.)

348 study of 238,000 people: Wintemute et al., “Mortality Among Recent Purchasers.”

349 “It is unlikely”: R. W. Hudgens, “Preventing Suicide,” New England Journal of Medicine 308 (15) (1983): 897–98.

349 “The NRA is not for gearing”: A. Parachini, “Gun Deaths: Suicides Versus Murders,” Los Angeles Times, April 19, 1983, pt. V, p. 5.

349 twenty-year-old manager: This and subsequent examples are taken from newspaper and magazine accounts.

350 As a term project: L. Moss, “Help Wanted: A Limited Study of Responses to One Person’s Cry for Help,” Life-Threatening Behavior 1 (1) (1971): 55–66.

Chapter V Life or Liberty

352 “Suicide is a fundamental”: T. Szasz, The Second Sin (Garden City, N.Y.: Anchor/Doubleday, 1973), 67.

352 “If the psychiatrist is to prevent”: T. Szasz, in a speech given at the conference “Suicide: What Is the Clinician’s Responsibility?” Boston, February 1, 1985.

352 “In fact, I firmly believe”: T. Szasz, in a debate with Edwin Shneidman in 1972 at the University of California, Berkeley. Taped by Audio-Digest Foundation, Suite 700, 1930 Wilshire Blvd., Los Angeles, CA 90057.

353 a lawsuit filed by the widow: The lawsuit against Szasz is described in Jamison, Night Falls Fast, 254.

353 Abraham Lincoln: Psychiatrist Ronald Fieve has written that if Lincoln had been his patient today, he would insist on immediate “hospitalization, observation for suicidal intent, anti-depression drugs, and later, lithium as the treatment of choice.” Lincoln survived his depression without such help; gun control seems to have been the form of suicide prevention he could most have benefited from.

353 “The ‘right’ to suicide”: Murphy, “Suicide and the Right to Die.”

353 survived six-story jumps: Hendin, Suicide in America, 210.

353 “The right to kill oneself”: Ibid., 225.

353 “Suicide is not a ‘right’”: Shneidman, “Aphorisms of Suicide,” 322.

354 “Although such cases”: S. E. Wallace, “The Survivor’s Rights,” in Wallace and Eser, Suicide and Euthanasia, 67.

354 “Suicidal persons are succumbing”: M. Boldt, “The Right to Suicide,” Suicide Information and Education Centre Current Awareness Bulletin 1 (2) (1985): 1.

354 “the act [of suicide] clearly represents an illness”: Szasz, Theology of Medicine, 68.

354 “If a sociologist predicted”: A. Brandt, Reality Police: The Experience of Insanity in America (New York: William Morrow, 1975), 146.

355 “If a middle-aged lady”: Debate between Szasz and Shneidman in 1972, University of California, Berkeley.

355 “If everyone who evinces”: Friedman, On Suicide, 84–85. The difficulty of drawing the line between sickness and health was described by Melville: “Who in the rainbow can draw the line where the violet tint ends and the orange tint begins? Distinctly we see the difference of the colors, but where exactly does the one first blendingly enter into the other? So with sanity and insanity. In pronounced cases there is no question about them. But in some supposed cases, in various degrees supposedly less pronounced, to draw the exact line of demarcation few will undertake, though for a fee becoming considerate some professional experts will. There is nothing namable but that some men will, or undertake to, do it for pay.” (H. Melville, Billy Budd, Sailor and Other Stories [New York: Bantam, 1981], 52–53.)

355 “The argument connecting”: Green and Irish, Death Education, 120.

356 A Harvard University study: Hendin, Suicide in America, 189–90.

356 “Suicide is pre-judged”: Quotes in this paragraph can be found in Hillman, Suicide and the Soul, 36, 37, 87, 93, 92.

356 review of Hillman’s book: R. E. Litman, “Concern for Suicide: Before and After,” in Shneidman, Farberow, and Litman, Psychology of Suicide, 637–40.

356 “In regarding the desire”: Szasz, Theology of Medicine, 81.

357 “Some of the things”: Green and Irish, Death Education, 120.

357 “If the person says”: Ibid., 121.

PART 5 The Right to Die

In updating this part, I relied heavily on two indispensable essay collections, The Case Against Assisted Suicide, edited by Kathleen Foley and Herbert Hendin, and Physician-Assisted Dying, edited by Timothy E. Quill and Margaret P. Battin, as well as on Marilyn Webb’s exploration of end-of-life issues, The Good Death.

Chapter I A Fate Worse Than Death

364 “Among the Karens”: Westermarck, Origin and Development of the Moral Ideas, 231.

365 “Thus was he blessed”: Suetonius, The Lives of the Twelve Caesars, ed. J. Gavorse (New York: Modern Library, 1931), 115.

365 “if any man labour”: Fedden, Suicide, 72.

365 “Just as a landlord”: Lecky, History of European Morals, 1: 232–33.

365 “I will not relinquish”: Ibid., 232.

365 “do away with the sufferings”: Humphry and Wickett, Right to Die, 4.

366 “the most excusable cause”: Moore, Full Inquiry, 270.

366 “I esteem it the office”: F. Bacon, Selected Writings, ed. H. G. Dick (New York: Modern Library, 1955), 277. For pointing the way to this quote and to numerous other tidbits of helpful information, and for helping me clarify my thinking on right-to-die issues, I am indebted to Anne Fadiman and to her essay “The Liberation of Lolly and Gronky.”

366 “We have very great pity”: Mannes, Last Rights, 64.

366 “should not torment his patient”: Hendin, Death as a Fact of Life, 82–83.

366 “in cases of incurable”: Russell, Freedom to Die, 57–58.

366 “practices of savages”: Ibid., 62.

366 “Vast numbers of human beings”: R. G. Twycross, “Voluntary Euthanasia,” in Wallace and Eser, Suicide and Euthanasia, 88.

367 “Some are proposing”: Y. Kamisar, “Euthanasia Legislation: Some Non-Religious Objections,” in Downing, Euthanasia, 115.

367 only the beginning: “Of the five identifiable steps by which the Nazis carried out the principle of ‘life unworthy of life,’ coercive sterilization was the first,” writes Lifton. “There followed the killing of ‘impaired’ children in hospitals; and then the killing of ‘impaired’ adults, mostly collected from mental hospitals, in centers especially equipped with carbon monoxide gas. This project was extended (in the same killing centers) to ‘impaired’ inmates of concentration and extermination camps and, finally, to mass killings, mostly of Jews, in the extermination camps themselves.” (R. J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide [New York: Basic Books, 1986].) Lifton’s book offers a comprehensive description of the Nazi “euthanasia” program.

368 “For every illness”: New York Times, January 18, 1985, B1.

368 “The classical deathbed scene” and “Where can we draw the line”: J. Fletcher, “The Patient’s Right to Die,” in Downing, Euthanasia, 65–66.

368 “I do not remember”: M. Angell, “The Quality of Mercy,” in Quill and Battin, Physician-Assisted Dying, 16

368 dedication to life: It has been suggested that what one skeptical doctor calls “their crusade to slay the dragon of death” may be a function of doctors’ neuroses as much as of their concern for patients; on psychological tests, doctors score high on death anxiety.

368 “The dignity starts with”: Clark, Whose Life Is It Anyway?, 143.

369 “We are discovering”: Hendin, Death as a Fact of Life, 79.

369 terminally ill seventy-eight-year-old: This story is told in Barnard, Good Life, 88.

369 growing acceptance of passive euthanasia: In active and passive euthanasia, the patient has requested to die; in “mercy killing,” the “killer” takes matters into his or her own hands because the patient is no longer able to express his or her wishes, as in the case of a coma victim or someone suffering from Alzheimer’s disease.

369 “Thou shalt not kill”: H. Gardner, ed., The New Oxford Book of English Verse (New York and Oxford: Oxford University Press, 1972), 682.

370 “Basic to our considerations” and “It is morally justifiable”: Wanzer et al., “Physician’s Responsibility,” 955, 958.

370 According to a study reported: USA Today, January 4, 1985, 1.

370 “When inevitable death is imminent”: “The Vatican’s Declaration on Euthanasia, 1980,” in Larue, Euthanasia and Religion, 42.

371 Doctors have been sued: In 1981, at the request of the patient’s family, two California doctors disconnected the respirator of a comatose patient named Clarence Herbert. (In the past he had told his wife he did not want to become “another Karen Ann Quinlan.”) When he did not die, they disconnected his feeding tube as well. When Herbert died six days later, the Los Angeles district attorney charged the doctors with murder. Although the case was eventually dismissed, it was the first time doctors had ever been charged for removing life-support equipment, and it sent shock waves through the medical community. But doctors can also be sued for not following a request to cease life-sustaining measures. William Bartling was a seventy-year-old retired dental-supply salesman suffering from emphysema, arteriosclerosis, chronic respiratory failure, an abdominal aneurysm, and a malignant lung tumor. In 1984, kept alive by a respirator, feeding and drainage tubes, and a device that vacuumed his throat every two hours, he requested to be disconnected from life-support systems and allowed to die. His doctors refused—and, for a time, tied his hands down so he could not pull out the tubes himself. After the state superior court ruled in favor of the doctors, a California appellate court overturned the decision, ruling that the hospital had violated Bartling’s right to “self-determination as to his own medical treatment.” Bartling, however, died twenty-three hours before the appellate court could hear his plea and two months before the courts affirmed his right to die.

371 estimates that 70 percent: Webb, Good Death, 189. Ironically, in the last decade, physicians working with dying patients have noticed that in an increasing number of cases, it is the family members and not the doctors who are insisting on keeping suffering loved ones alive at any cost.

372 66 percent of physicians: Humphry and Clement, Freedom to Die, 188.

372 nine thousand terminally ill patients: W. A. Knaus et al., “A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients,” Journal of the American Medical Association 274 (1995): 1591–98.

372 the case of Terri Schiavo: My account is drawn largely from articles in the New York Times published during March and April 2005, as well as from D. Eisenberg, “Lessons of the Schiavo Battle,” Time, April 4, 2005, 23–30.

374 “I have learned from my life”: Barnard, Good Life, 15. Barnard would later stir controversy in the right-to-die movement by insisting that the decision of when to perform euthanasia was best made by the doctor—not by the the patient or the patient’s family.

375 “Can doctors who remove”: P. Singer, Rethinking Life and Death (New York: St. Martin’s Press, 1994), 221.

375 “the morphine drip is undeniably euthanasia”: T. A. Preston, “Killing Pain, Ending Life,” New York Times, November 1, 1994, A27.

375 “What, morally, is the difference”: Fletcher, “Patient’s Right to Die,” 68.

375 described her mother’s death: Rollin, Last Wish.

375 In one recent case: The story of Huntington Williams and John Welles is from W. Yardley, “For Role in Suicide, a Friend to the End is Now Facing Jail,” New York Times, March 4, 2005, A1, and W. Yardley, “Probation for Connecticut Man, 74, Who Aided Suicide,” New York Times, April 8, 2005, A24.

376 have come to public attention: In a particularly poignant example, in 1985, John Kraai, a seventy-six-year-old general practitioner in a small town near Rochester, New York, injected a lethal dose of insulin into his patient and friend of more than forty years, an eighty-one-year-old nursing-home resident suffering from Alzheimer’s disease and gangrene of the feet. Shortly after he was charged with second-degree murder, Kraai killed himself by lethal injection.

376 Michigan pathologist: My account of Dr. Kevorkian’s activities is taken largely from Michael Betzold’s Appointment with Doctor Death and Jack Kevorkian’s Prescription: Medicide, as well as from numerous newspaper accounts, and from my interviews with Geoffrey Fieger and Janet Good. See also J. Lessenberry, “Death Becomes Him,” Vanity Fair, July 1994. Information about Kevorkian in prison is from T. Ward, “Dr. K: I Expect to Die in Prison,” Daily Oakland Press, April 11, 2004.

380 the man she called “the doctor”: Kevorkian called Janet Good his “associate” and to show his appreciation gave her a signed print of one of his paintings, The Gourmet (War). In it, a Roman centurion stands behind a decapitated man who, his neck dripping with blood, holds a plate on which his severed head reposes, an apple in its mouth. Good was proud of the gift but kept it behind her computer desk, and showed it only to a few friends. “I don’t think any sane person would hang that on the wall,” she told me.

383 Gallup poll in 1947: E. D. Stutsman, “Political Strategy and Legal Change,” in Quill and Battin, Physician-Assisted Dying, 247.

383 1995 study: Doukas et al., “Attitudes and Behaviors on Physician-Assisted Death: A Study of Michigan Oncologists,” Journal of Clinical Oncologists 13 (5) (1995): 1055–61.

383 1996 study of physicians: A. L. Back et al., “Physician-Assisted Suicide and Euthanasia in Washington State: Patient Requests and Physician Responses,” Journal of the American Medical Association 275 (1996): 919–25.

384 1997 New England Journal of Medicine report: L. R. Slome et al., “Physician-Assisted Suicide and Patients with Human Immunodeficiency Virus Disease,” New England Journal of Medicine 336 (6) (1997): 417–21.

384 the same journal reported: D. E. Meier et al., “A National Survey of Physician-Assisted Suicide and Euthanasia in the United States,” New England Journal of Medicine 338 (17) (1998): 1193–1201.

384 1996 survey of 852: D. A. Asch, “The Role of Critical Care Nurses in Euthanasia and Assisted Suicide,” New England Journal of Medicine 334 (1996): 1374–79.

384 “I feared the effects”: T. Quill, “Death and Dignity: A Case of Individualized Decision Making,” New England Journal of Medicine 324 (10) (1991): 691–94. For a discussion of “nonabandonment,” see T. E. Quill and C. K. Cassel, “Nonabandonment,” in Quill and Battin, Physician-Assisted Dying, 24–38.

384 seemed quite civilized: Comparing Quill and Kevorkian, bioethicist Arthur Caplan wrote, “I am convinced that what Kevorkian did in helping Janet Adkins die is completely immoral. Yet I do not believe that Quill acted unethically. . . .

“Kevorkian did not know Adkins prior to attaching her to his homemade suicide device; Quill had known Diane as a patient and as a friend for many years before her death. Kevorkian scoured the country looking for someone upon whom he could use his machine. Quill did all that he could to get his patient to choose life, not death.

“Kevorkian helped to her death a woman who was questionably competent, was in no pain and who was not terminally ill; Quill wrote a prescription for sleeping pills for a terminally ill, competent woman who was in a great deal of pain. Kevorkian personally hitched Janet Adkins to a machine that he himself had built, promoted and fervently hoped someone would use; Quill fervently hoped he could help manage Diane’s suffering so that she never would choose to end her life.” (Betzold, Appointment with Doctor Death, 146.)

385 Ballot initiatives: After the bills including provisions for both physician-assisted suicide and voluntary euthanasia had been defeated in California and Washington, Oregon dropped voluntary euthanasia from its proposed bill to maximize the chances of its passage.

386 “For many people”: D. Colburn, “Fewer Turn to Assisted Suicide,” Oregonian, March 11, 2005. The Oregonian has provided the most detailed coverage of the Death with Dignity Act.

386 “I don’t know if I’d ever take it”: D. Colburn, “Assisted Suicide Advocate Dies at 79,” Oregonian, October 28, 2003.

386 deaths have been gentle: The stories of Oregonians who have used the Death with Dignity Act are taken mostly from Lee, Compassion in Dying. An exception is the story of the fifty-four-year-old former health care worker, which was taken from J. Estrin, “In Oregon, Choosing Death Over Suffering,” New York Times, June 1, 2004, F4. The story of Peggy Sutherland is taken both from Lee, Compassion in Dying, and from a lovely piece by Todd Schwartz, “A Death of Her Choosing,” Oberlin Alumni Magazine,Summer 2003, www.oberlin.edu/alummag/summer2003.

388 not always foolproof: In some 18 percent of physician-assisted suicides in the Netherlands, patients lived more than three hours after taking the lethal dose; doctors usually intervened with a lethal injection—a practice that would, of course, be illegal in Oregon.

389 “To confine legalized”: Humphry and Clement, Freedom to Die, 336.

389 one country: In 2002, Belgium became the second country to legalize physician-assisted suicide and voluntary euthanasia. In 1996–97, voluntary euthanasia was legal for nine months in Australia’s Northern Territory, a rural area where little palliative care is available; four people were given lethal doses of medications before the territorial law was overturned by Australia’s national parliament. In Switzerland, assisted suicide (but not euthanasia) has long been permitted, by doctors and laypeople alike, if done for “altruistic purposes.” There is evidence that more than a few people have traveled to Switzerland for the express purpose of receiving assisted suicide.

Chapter II “Your Good End in Life Is Our Concern!”

392 “There is only one prospect worse”: A. Koestler, in Exit: A Guide to Self-Deliverance, preface, 3.

395 the formation of the Hemlock Society: Hemlock is one of forty-six right-to-die societies in twenty-three countries from Australia to Israel to Zimbabwe. Although most societies share a common goal—to guarantee people the right to choice in their own death—the groups disagree on the lengths to which they will go. The groups range from those that favor only passive euthanasia to those that wish to legalize assisted suicide and voluntary euthanasia.

399 by writing Final Exit: Quotes from this and the following two paragraphs are from Humphry, Final Exit.

400 deaths by plastic bag: P. M. Marzuk et al., “Increase in Suicide by Asphyxiation in New York City After the Publication of Final Exit,” New England Journal of Medicine 329 (20) (1993): 1508–10; and P. M. Marzuk et al., “Increase in Fatal Suicidal Poisonings and Suffocations in the Year Final Exit Was Published: A National Study,” American Journal of Psychiatry 151 (1994): 1813–14.

400 “This misuse I regret”: D. Humphry, Final Exit, 3rd ed. (New York: Dell, 2002), xv.

401 no one had ever written: A few books and pamphlets have tackled the subject in a darkly comic mode, most notably 21 Delightful Ways of Committing Suicide, written and illustrated by Jean Bruller and published in the United States in 1930.

401 “It is the sovereign right”: Guide to Self-Deliverance, 31.

402 “I feel no remorse”: Boston Globe, September 20, 1982.

404 a fatal overdose: The story of Wickett’s death is told in Deadly Compassion by Rita Marker, an antieuthanasia activist who had debated Humphry over the years. Surprisingly, after Humphry left her, a distressed Wickett turned to Marker, and they became friends. According to Marker, Wickett came to believe that legalizing physician-assisted suicide or voluntary euthanasia would be a mistake, because it might coerce vulnerable, elderly people to seek a premature death. Wickett believed her mother had not, in fact, wanted to die, but had felt subtle pressure from her father to go along with him. Marker, Deadly Compassion, 213.

406 “Compassion is not an advocacy”: Michaele Houston in Coombs Lee, Compassion in Dying, 50. For my description of Compassion in Dying’s work I have relied heavily on this book, and on B. C. Lee, “A Model That Integrates Assisted Dying with Excellent End-of-Life Care,” in Quill and Battin, Physician-Assisted Dying, 190–201.

407 launched Caring Friends: The description of the Caring Friends program comes from several Web sites, including www.endoflifechoices.org; from R. Marker, “Patience and Plastic Bags,” Human Life Review, Spring 2003; and from a speech by Dr. Richard MacDonald, “The Caring Friends Program—Five Years of Peaceful Dying,” delivered at a picnic in Milwaukee, as reported in an End-of-Life Choices chapter newsletter, vol. 14, no. 3, http://communities.madison.com/endoflifechoiceswis.

408 “This isn’t rocket science:” Marker, “Patience and Plastic Bags.” The description of the Exit Bag is also taken from this article.

408 “the helium makes the voice”: “Helium,” Hemlock Timelines 83 (Spring 2000): 12.

408 “I’m sort of a midwife”: Marker, “Patience and Plastic Bags.”

410 “If you can’t get your sulfuric acid”: Age, May 31, 2003, www.theage.com.au/articles/2003/05/31.

412 “Then—the highlight of the weekend”: “Network Trains 15 Exit Guides in St. Louis!” Final Exit Network Newsletter, vol. 1., no. 1, www.finalexitnetwork.org/newsletter.

412 “We have 33 cases”: “We Are ‘Transparent,’ “ Final Exit Network Newsletter, vol. 1, no. 2, www.finalexitnetwork.org/newsletter.

Chapter III “The Limits Are Obscure . . . and Every Errour Deadly”

415 “whether it was logical”: Mannes, Last Rights, 62–63.

415 “It seems unimaginable”: Fletcher, Morals and Medicine, 193.

415 “Their argument turns”: Battin, Ethical Issues in Suicide, 179.

415 interferes with God’s will: In 1847, when ether was first used in the delivery room, many people protested that labor pains were divinely ordained and to use anesthetics went against God’s will.

415 “If it is for God alone”: J. Rachels, The End of Life: Euthanasia and Morality (Oxford: Oxford University Press, 1986), 163.

415 “Human life consists”: Mannes, Last Rights, 141.

416 “When life is more terrible”: Choron, Suicide, 78.

416 “The final stage”: Maguire, Death by Choice, 151.

416 “Even if this is true”: Seneca, “Letter to Lucilius, No. 70,” in The Stoic Philosophy of Seneca, trans. M. Hadas (Gloucester, Mass.: Peter Smith, 1965), 203.

416 forty-four-year-old Maryland woman: People, October 13, 1986, 43–44.

417 “People say they want”: T. Schwartz, “A Death of Her Choosing,” Oberlin Alumni Magazine, Summer 2003, www.oberlin.edu/alumnimag/summer2003.

417 In 1919, German psychiatrist: A year later, Hoche coauthored The Permission to Destroy Life Unworthy of Life.

417 Richard Brandt compared: R. Brandt, “The Rationality of Suicide,” in Battin and Mayo, Suicide, 117–32.

418 described six cases: Jackson and Youngner, “Patient Autonomy.”

418 “How free or informed”: L. R. Kass, “ ‘I Will Give No Deadly Drug’: Why Doctors Must Not Kill,” in Foley and Hendin, Case Against Assisted Suicide, 24.

418 uncompleted suicide pacts: M. Rosenbaum, “Crime and Punishment: The Suicide Pact,” Archives of General Psychiatry 40 (1983): 979–82. See also Fishbain et al., “A Controlled Study.”

418 emotionally coerced: If Koestler is to be blamed, however, the blame must be not for his wife’s death but for her life. “A good man would have weaned her,” wrote Barbara Grizzuti Harrison. “. . . I think it’s fair to say he killed her.” But to call Koestler a murderer seems as patronizing and demeaning to Cynthia as her husband may have been, denying her any volition of her own. “For a man in grave and failing health, self-deliverance was the final right,” wrote Hemlock Society cofounder Ann Wickett. “For Cynthia, it was the final act of devotion. That too was her right. One regrets, however, less the nature of her death, than the nature of her life. She deserved more.”

419 “She was his appendix”: A. Wickett, “Why Cynthia Koestler Joined Arthur,” Hemlock Quarterly, January 1985, 4–5.

419 “It is hardly an exaggeration”: Ibid.

419 “Some writers opposed”: M. P. Battin, “Suicide: A Fundamental Human Right?” in Battin and Mayo, Suicide, 279.

419 “Activists draw”: A. Solomon, Noonday Demon, 268.

419 suicide prevention experts are sympathetic: Some may describe it as something other than suicide. “We need not argue the issue of whether it is rational for an individual with a painful terminal illness to refuse extraordinary life-saving measures or to arrange more actively to end his life,” writes Herbert Hendin (Suicide in America, 214–15). “. . . The person facing imminent death who is in intractable pain and arranges to end his life may be a suicide in the dictionary definition of the term, but not in the psychological sense.” Many others in the field object to the right-to-die movement, while reserving the right to an assisted death for themselves. “I believe in suicide prevention, but I have Alzheimer’s in my family, and I’m fearful of death without dignity,” a leader in suicide prevention told me. “If you’re incompetent, they keep you from killing yourself. Well, the point at which I want out is when I lose competence. I have made a suicide pact with two of my sisters.” Edwin Shneidman participated in the initial Hemlock think tank and delivered the keynote address at Hemlock’s 1985 national conference. “I like Derek Humphry and I approve of what he does,” he told the audience. “But I’m not a card-carrying Hemlock member, and I maintain some substantial differences with the goals of the organization.” A friend of Shneidman’s interprets: “Ed doesn’t believe in rational suicide—except for himself.”

420 “From an intellectual standpoint”: Seiden, “Self-Deliverance or Self-Destruction?”

420 “Physician-assisted suicide is mistakenly understood”: D. Callahan, “Reason, Self-determination, and Physician-Assisted Suicide,” in Foley and Hendin, Case Against Assisted Suicide, 60.

420 “the limits are obscure”: Donne, Biathanatos, 216.

421 oft-quoted 1949 essay: L. Alexander, “Medical Science Under Dictatorship,” New England Journal of Medicine 241 (2) (1949): 39–47.

421 “I think there is no way”: Quoted on “Rational Suicide?” produced by Barry Lando for 60 Minutes, CBS-TV, October 12, 1980.

422 “Once any group”: Humphry and Wickett, Right to Die, 164.

422 “Miss Voluntary Euthanasia”: Y. Kamisar, “Euthanasia Legislation: Some Non-Religious Objections,” in Downing, Euthanasia, 115.

422 “I have seen the true wish”: Wallace and Eser, Suicide and Euthanasia, 102.

422 “Where is the sense”: Humphry and Wickett, Right to Die, 313.

422 government-sponsored study: The studies were summarized in P. J. van der Maas et al., “Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990–1995,” New England Journal of Medicine 335 (1996): 1699–1705.

422 a slippery crevasse: Criticism of the Dutch program can be found in Hendin, Seduced by Death; H. Hendin, “The Dutch Experience,” in Foley and Hendin, Case Against Assisted Suicide, 97–121; Jochemsen and Keown, “Voluntary Euthanasia Under Control?”; J. Keown, “Some Reflections on Euthanasia in the Netherlands,” in J. C. Willke et al., Assisted Suicide and Euthanasia, Past and Present (Cincinnati: Hayes Publishing Company, 1998). See also H. Hendin, “Suicide, Assisted Suicide, and Euthanasia,” in Jacobs, Harvard Medical School Guide, 540–60.

424 “Virtually every guideline”: H. Hendin, “Summary for Congressional Subcommittee on the Constitution. Suicide, Assisted Suicide and Euthanasia: Lessons From the Dutch Experience,” http://www.house.gov/judiciary/2169.htm.

424 “The man, afraid of being left”: Hendin, “Dutch Experience,” 109.

426 “Given legal sanction”: Ibid., 117.

426 “It may be more than ironic”: Hendin, “Summary for Congressional Subcommittee.”

427 “I am concerned”: B. Steinbock, “The Case for Physician Assisted Suicide: Not (Yet) Proven,” Journal of Medical Ethics 31 (2005): 235–41.

427 a woman in her mideighties: The case of the first patient is described in E. Hoover and G. H. Hill, “Two Die Using Oregon Suicide Law,” Oregonian, March 26, 1998, A1. Criticism of the case can be found in, among others, K. Foley and H. Hendin, “The Oregon Experiment,” in Foley and Hendin, Case Against Assisted Suicide, 144–74. Also in Steinbock, “Case for Physician Assisted Suicide.” Compassion in Dying’s senior medical adviser offers a spirited rebuttal in P. Goodwin, “The Distortion of Cases in Oregon,” in Quill and Battin, Physician-Assisted Dying, 184–89.

428 “If I get rebuffed”: W. Claiborne, “An Oregon Statute Is Blunting Death’s Sting,” Washington Post, April 29, 1998, A1, as quoted in Foley and Hendin, “Oregon Experiment,” 148.

429 “Under these conditions”: Ibid., 146.

429 “The fears that we had”: M. Vitez, “Oregon Is the Laboratory in Assisted-Suicide Debate,” Philadelphia Inquirer, March 13, 2005.

429 25 percent of cancer patients: Webb, Good Death, 114.

430 only 6 percent felt confident: L. Ganzini et al., “Attitudes of Oregon Psychiatrists toward Physician-Assisted Suicide,” American Journal of Psychiatry 157 (2000): 595–600.

430 an eighty-five-year-old widow: E. H. Barnett, “Is Mom Capable of Choosing to Die?” Oregonian, October 16, 1999. See also Lee, Compassion in Dying, 72–83.

431 no Kevorkianesque abuses: Which is no guarantee that they will never happen. Surgeon and author Sherwin Nuland, while generally supportive of physician-assisted suicide in some form, would like to see the Oregon Death with Dignity requirements strengthened to include repeated requests made to a physician with whom the patient has had a long-standing relationship; mandatory consultation with a physician whose specialty is in the area of the patient’s disease; evidence that all therapeutic options have been exhausted; mandatory consultation with a palliative-care expert—“not just the local anesthesiologist but a true palliative care expert”; mandatory evaluation by a psychiatrist experienced with end-of-life care; mandatory pastoral consultation of some sort; and mandatory notification of next of kin (“I’m not talking about veto power but about a frank discussion with people important in your life. When one takes one’s own life, it has a profound and permanent influence on the lives of other people, and they should be involved”). Nuland’s final recommendation? That a council of wise, civic-minded individuals should be convened to discuss the case and grant final consent. “I believe that by permitting physician-assisted suicide, a society is commenting on its values,” he says. “And therefore, I believe it’s the responsibility of society to validate these decisions.”

431 “They have one way only”: Herodotus, The Histories (London: Penguin, 1972), 128.

431 The Tschuktschi of northern Siberia: Some of this list is drawn from Humphry and Wickett, Right to Die, 2.

431 The perhaps apocryphal story: Maguire, Death by Choice, 86.

431 “Like leaves which fall”: Time, April 9, 1984, 68.

432 “The time is not far off”: Lamm, “Long Time Dying,” 21.

432 “our technological sophistication”: J. Hardwig, “Is There a Duty to Die?” Hastings Center Report 27 (2) (1997): 39–42.

433 “the postponement of an individual’s death”: New York Times, September 5, 1984.

433 “creatively and honorably accepting”: Callahan quotes are from Time, November 2, 1987, 76.

433 “Any sophisticated doctor”: Los Angeles Times, May 25, 1984, pt. 5, p. 27.

434 “The report entirely ignored”: N. G. Hamilton, “Oregon’s Culture of Silence,” in Foley and Hendin, Case Against Assisted Suicide, 180.

434 “One must look at”: Humphry and Clement, Freedom to Die, 313.

434 “Today, the needs of the individual”: Portwood, Common-Sense Suicide, 46–47.

434 “Assisted suicide and euthanasia”: New York State Task Force on Life and the Law, “When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context” (Albany, N.Y.: May, 1994), 43.

435 “When asked to describe” and “The primary issue”: D. Coleman, “Not Dead Yet,” in Foley and Hendin, Case Against Assisted Suicide, 220, 225. (Not Dead Yet was particularly incensed when Dr. Kevorkian’s assistant Janet Good remarked, “People can endure pain. But once children have to wipe their butts, that’s the end. When that dignity is gone, no one wants to live.”) Historian Paul Longmore has observed, “If a non-handicapped person expressed a desire to commit suicide, that person would immediately get crisis intervention therapy. Let a disabled person express such despair, and he or she is assumed to be ‘rational.’ “ (Marker, Deadly Compassion, 301.)

435 “We argue” and “conclude in support”: A. I. Batavia, “Disability and Physician-Assisted Dying,” in Quill and Battin, Physician-Assisted Dying, 63, 70.

436 “creatures born defective”: Humphry and Wickett, Right to Die, 14. The notion that the “incurably mentally ill” should be euthanized cropped up throughout the first several decades of the twentieth century, in part as an outgrowth of the eugenics movement, which held that many mentally and physically disabled people should be sterilized (see Whitaker, Mad in America, 65–66). Decrying the money spent to warehouse “gangsters and lunatics,” Nobel Prize–winning physician Alexis Carrel, in 1935, suggested they be “humanely and economically disposed of in small euthanasic institutions supplied with proper gases.” (Ibid., 66.) The discussion was silenced by the advent of World War II and the eventual knowledge of the horrors of the Third Reich.

436 “Sentimental prejudice”: Humphry and Wickett, Right to Die, 14–15.

436 “If a chronically sick man”: E. Slater, “Choosing the Time to Die,” in Battin and Mayo, Suicide, 202.

436 “a slobbering wreck”: Marker, Deadly Compassion, 97.

436 her sixteen-year-old cat: K. L. Lyle, Newsweek, March 2, 1992, as described in E. Newman, “Ethical Issues in Terminal Health Care, Part Three: Local Perspectives on the Right-to-Die Debate,” www.cp.duluth.mn.us.

436 “there can be no possibility”: M. R. Barrington, “Apologia for Suicide,” in Downing, Euthanasia, 159.

436 “These type of statistics”: Humphry, Good Euthanasia Guide 2005, 27.

437 “including the depressed”: National Review Online, www.nationalreview.com/interrogatory.

437 “It is realistic”: Seiden, “Self-Deliverance or Self-Destruction?” 10.

437 “At best, the living old”: Butler, Why Survive?, xi.

437 “Many elders suffer”: J. Levin and A. Arluke, “Our Elderly’s Fate?” New York Times, September 29, 1983, 27.

437 the suicide rate of elderly Americans: For an excellent overview of elderly suicide, see Conwell, “Suicide in Later Life.”

438 50 percent of elderly suicides: Barraclough, “Suicide in the Elderly.”

438 “In general, where the ‘geriatric case’”: Wrobleski, Afterwords, January 1985, 2.

439 “Since the elderly depressed”: Los Angeles Times, November 13, 1984.

439 elderly nursing home patients: New York Times, July 16, 1982.

440 “The discovery and cure”: Humphry and Clement, Freedom to Die, 58.

440 1,177 physicians: Foley and Hendin, Case Against Assisted Suicide, 298.

440 40 to 80 percent: Humphry and Clement, Freedom to Die, 55.

440 9,000 terminally ill patients: W. A. Knaus et al., “A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients,” Journal of the American Medical Association 274 (1995): 1591–98.

440 897 physicians: J. H. Von Roenn et al., “Physician Attitudes and Practice in Cancer Pain Management: A Survey from the Eastern Cooperative Oncology Group,” Annals of Internal Medicine 119 (1993): 121–26.

440 90 patients: Webb, Good Death, 120–22.

441 survey of oncologists: E. J. Emanuel, “Report of the ASCO Membership Survey on End of Life Care,” Proceedings of the American Society of Clinical Oncology 17 (Alexandria, Va.: 1998). Cited in K. Foley and H. Hendin, “Changing the Culture,” in Foley and Hendin, Case Against Assisted Suicide, 315.

441 “Physicians who unwisely prolong”: Ibid.

441 the less physicians know: R. K. Portenoy et al., “Determinants of the Willingness to Endorse Assisted Suicide: A Survey of Physicians, Nurses, and Social Workers,” Psychosomatics 38 (1997): 277–87.

441 “You don’t have to kill”: Quoted on “Rational Suicide?” 60 Minutes.

441 change their mind: Z. Zylicz, “Palliative Care and Euthanasia in the Netherlands: Observations of a Dutch Physician,” in Foley and Hendin, Case Against Assisted Suicide, 122–43.

441 “If all the care”: C. Saunders, “Dying They Live: St. Christopher’s Hospice,” in H. Feifel New Meanings of Death (New York: McGraw-Hill, 1977), 159.

442 “are no more mutually exclusive”: M. Angell, “The Quality of Mercy,” in Quill and Battin, Physician-Assisted Dying, 23.

442 “not only compatible” and “the highest rate”: T. E. Quill and M. P. Battin, “Excellent Palliative Care as the Standard, Physician-Assisted Dying as a Last Resort,” in Quill and Battin, Physician-Assisted Dying, 329.

442 “Where we proponents”: M. P. Battin and T. E. Quill, “False Dichotomy versus Genuine Choice: The Argument over Physician-Assisted Dying,” in Quill and Battin, Physician-Assisted Dying, 2.

442 “Often people ask”: N. Speijer, “The Attitude of Dutch Society Toward the Phenomenon of Suicide,” in Farberow, Suicide in Different Cultures, 164.

443 “When an older woman leaves”: Portwood, Common-Sense Suicide, 17–18.

443 for the Holy Stone: R. Gillon, “Suicide and Voluntary Euthanasia: Historical Perspective,” in Downing, Euthanasia, 182

444 “What we want”: G. B. Rolfe, “The Right to Die,” North American Review 157 (6) (1893): 758.

445 “In a rational state”: Ibid.

445 “Robert Lowell once remarked”: Alvarez, Savage God, 130.

445 “People are going to help”: USA Today, May 15, 1985, 8A.

445 “I believe that the classical”: New York Times, April 25, 1983, B8.

445 “I myself believe”: M. P. Battin, “Manipulated Suicide,” in Battin and Mayo, Suicide, 179.

PART 6 Survivors

Chapter I Merryl and Carl

455 “There are always two parties”: A. Toynbee, Man’s Concern with Death (New York: McGraw-Hill, 1969), 267, 271.

Chapter II The Mark of Cain

466 French engraving: Reproduced in J. B. C. I. Delisle de Sales, De la Philosophie de la Nature (London: 1789).

467 “decapitated”: This list is taken partially from a similar list in Cain, Survivors of Suicide, 29.

467 In 1289, it is recorded: Fedden, Suicide, 138.

468 “What punishment”: J. W. Ehrlich, ed., Ehrlich’s Blackstone (Westport, Conn.: Greenwood Press, 1973), 838.

468 the case of Lancelot Johnson: MacDonald, Mystical Bedlam, 137–38.

468 The jury’s verdict: The colonies were more lenient. In 1700, for instance, in his charter to Pennsylvania, William Penn recommended “that if any person, through temptation or melancholy, shall destroy himself, his estate, real and personal, shall, notwithstanding, descend to his wife, children, or relations, as if he had died a natural death.” (S. Yorke, “Is Suicide a Sin?” North American Review, February 1890, 277.)

468 Marc-Antoine Calas: Fedden, Suicide, 231–32.

469 “He plants a dagger”: Gregory, Sermon on Suicide, 12–13.

469 “Stay then, guilty man!”: Miller, Guilt, Folly, and Sources of Suicide, 24–25.

469 “The Sorrow which arises”: Hey, Three Dissertations, 202–3.

470 “With reference to suicide”: Winslow, Anatomy of Suicide, 152.

470 at the Annual Meeting: J. M. S. Wood and A. R. Urquhart, “A Family Tree Illustrative of Insanity and Suicide,” in Cain, Survivors of Suicide, 40–43.

470 George P. Mudge constructed: G. P. Mudge, “The Mendelian Collection of Human Pedigrees: Inheritance of Suicidal Mania,” in Cain, Survivors of Suicide, 44–51.

470 “Many are induced”: Winslow, Anatomy of Suicide, 96–97.

471 “The suicide by his last act”: Strahan, Suicide and Insanity, 90.

471 “in the hope”: Ibid., vi.

471 “But the worst of all”: J. Joyce, Ulysses (New York: Random House, 1961), 96.

471 “Nothing lowered”: Fedden, Suicide, 248.

472 “he placed the mark”: E. Lindemann and I. M. Greer, “A Study of Grief: Emotional Responses to Suicide,” in Cain, Survivors of Suicide, 67.

473 “I believe that the person”: E. S. Shneidman, “Foreword,” in Cain, Survivors of Suicide, x.

473 A 1967 study: Bergson, “Suicide’s Other Victims,” 104.

473 “Given the present stage”: H. L. P. Resnik, “Psychological Resynthesis: A Clinical Approach to the Survivors of a Death by Suicide,” in Cain, Survivors of Suicide, 177.

473 A bibliography of publications: J. L. McIntosh, “Survivors of Suicide: A Comprehensive Bibliography,” Omega 16 (4) (1986): 355–70. Also J. L. McIntosh, “Survivors of Suicide: A Comprehensive Bibliography Update, 1986–1995,” Omega 33 (2) (1996): 147–75.

473 A 2003 conference: “AFSP Releases Report on Survivors of Suicide Research Workshop,” www.afsp.org/survivor/sosworkshop903.

473 “Historically, one of the most”: McIntosh, “Suicide Survivors,” 339.

474 “To the tragic legion”: Styron, Darkness Visible, 33.

475 One study compared: L. G. Calhoun et al., “Reactions to the Parents of the Child Suicide: A Study of Social Impressions,” Journal of Consulting and Clinical Psychology 48 (1980): 535–36.

475 “Even in the numbness”: Wechsler, In a Darkness, 13.

Chapter III Merryl: The Torture Chamber

483 Carl had left no suicide note: In 1989, nearly seven years after his death, Merryl learned that Carl had left a suicide note. Believing it would do Merryl more harm than good, her parents and in-laws had withheld it from her. Merryl wrote to Carl’s parents, who sent her a photocopy. In the four-line note, which began, “She will get over it.” Carl weighed the “misery” of staying alive against the “control” and “freedom” he would gain by killing himself. “I wish the note had not been kept from me for so long,” says Merryl. “Although reading the note gave me great pain—at seeing Carl’s handwriting, at feeling more acutely his torturous state—the overall feeling was one of relief at having the fuller knowledge and at knowing that I was in Carl’s thoughts at the end.”

Chapter IV The O’er-Fraught Heart

487 “Although mourning involves”: S. Freud, Mourning and Melancholia (1917), in Strachey, Works, 14: 243–44.

487 “Mourning has a quite specific”: S. Freud, Totem and Taboo (1913), in Strachey, Works, 13: 65.

487 A study by the National Academy of Sciences: Osterweis, Solomon, and Green, Bereavement.

488 “There’s a tendency”: Worden, Grief Counseling, 32.

489 “Sooner or later”: Ibid., 14.

489 10 to 15 percent: Ibid., 1.

489 “The first response”: K. Lorenz, On Aggression, trans. M. K. Wilson (New York: Harvest/Harcourt Brace Jovanovich, 1966), 208.

490 “psychic numbing”: R. J. Lifton, Death in Life (New York: Random House, 1967), 86–87.

491 Sheila Weller described: Weller, “Whose Death Was It, Anyway?”

492 “Guilt is a way:” E. Dunne and K. Dunne-Maxim, F. Walsh, and M. McGoldrick, Living Beyond Loss: Death in the Family (New York: W. W. Norton, 2004), 276.

492 “There is an especially”: E. Lindemann and I. M. Greer, “A Study of Grief: Emotional Responses to Suicide,” in Cain, Survivors of Suicide, 66.

492 one in ten: S. Wallace, After Suicide (New York: Wiley, 1973).

492 “Some feel guilty”: A. Pangrazzi, “Suicide: How Christians Can Respond Today,” Catholic Update, July 1984, 3.

494 In his poem “The Portrait”: S. Kunitz, The Poems of Stanley Kunitz, 1928–1978 (Boston and Toronto: Atlantic Monthly Press/Little, Brown, 1979), 86.

495 “I spit upon”: J. Berryman, The Dream Songs (New York: Farrar, Straus and Giroux, 1969), 406.

495 fatally stabbed herself: Giffin and Felsenthal, Cry for Help, 173.

496 “I see now”: Alvarez, Savage God, 258.

496 serve a preventive role: The thought of a suicide’s effect on survivors has long been a restraint on—and occasionally a spur to—potential suicides. Suffering from a bout of chronic catarrh, Seneca, who championed the idea of suicide as man’s ever-available freedom, wrote, “Reduced to a state of complete emaciation, I had arrived at a point were the catarrhal discharges were virtually carrying me away with them altogether. On many an occasion I felt an urge to cut my life short there and then, and was only held back by the thought of my father, who had been the kindest of fathers to me and was then in his old age. Having in mind not how bravely I was capable of dying but how far from bravely he was capable of bearing the loss, I commanded myself to live.” (Battin, Ethical Issues, 78.) On the other hand, many suicidal people are beyond the ability to consider the effect their death might have on friends and family. “Decisions about suicide are not fleeting thoughts that can be willed away in deference to the best interests of others,” writes Kay Jamison, who attempted suicide as a young woman. “Suicide wells up from cumulative anguish or is hastened by impulse; however much it may be set in or set off by the outer world, the suicidal mind tends not to mull on the well-being and future of others. If it does, it conceives for them a brighter future due to the fact that their lives are rid of an ill, depressed, violent, or psychotic presence.” Night Falls Fast, 292.

497 “For children”: Osterweis, Solomon, and Green, Bereavement, 125.

497 Children are even more apt: Many parents mistakenly believe that a child is too young to grieve. “They think, ‘She’s only three—she won’t feel it,’” says Sandra Fox. Until recently, in fact, it was believed that because they cannot comprehend the permanence of death until about age nine, children are unable to mourn. Today, experts say that children begin to sense separation and loss at six months and may be able to grieve by age three. Children of any age express their grief differently from adults, through physical symptoms such as restlessness, colds, and upset stomachs, or through misbehavior, academic problems, and delinquency.

498 forty-five children: A. C. Cain and I. Fast, “Children’s Disturbed Reactions to Parent Suicide: Distortions of Guilt, Communication, and Identification,” in Cain, Survivors of Suicide, 93–111.

498 seventeen patients: T. L. Dorpat, “Psychological Effects of Parental Suicide on Surviving Children,” in Cain, Survivors of Suicide, 121–42.

Chapter VI A Safe Place

523 One survivor organization runs: See Web site at www.1000deaths.com.

524 “I feel so safe”: S. Slepicka, “The Role of Support Groups in the Healing Process of Suicide Survivors” (unpublished paper).

Chapter VIII A Place for What We Lose

531 “We find a place”: Worden, Grief Counseling, 17.

531 “Ah well, slowly but surely”: D. J. Enright, The Oxford Book of Death (Oxford: Oxford University Press, 1983), 113–14.

533 “I want Dick’s death not to be bigger”: Kenyon, “Survivor’s Notes.”