This post isn’t about saying that suicide is something people should choose, or that it’s a good choice, or that it’s a choice that they want to have on the menu. I’m writing this because, while it’s much more complicated to get into the element of choice, I believe that it’s inaccurate to say that it’s not a choice, full stop. So let’s talk about it.
Note: The Straight Talk on Suicide page has links to crisis and other suicide prevention resources.
As a quick background about me, I have major depressive disorder and have a history of multiple suicide attempts. This post is not written because of any current suicidal ideation.
To be clear on what we’re talking about, we first need to be clear on what the words mean. Let’s consider some definitions (from Google Dictionary unless otherwise noted):
- suicide: (this comes from the Merriam-Webster Dictionary, as Google Dictionary doesn’t provide a definition)
- “Suicide is death caused by injuring oneself with the intent to die. A suicide attempt is when someone harms themselves with any intent to end their life, but they do not die as a result of their actions” (CDC Fast Facts)
- Wikipedia‘s definition, “the act of intentionally causing one’s own” cites Stedman’s Medical Dictionary
- choice: “an act of selecting or making a decision when faced with two or more possibilities”
- intentional: “done on purpose; deliberate”
- involuntary: “done without will or conscious control”
- selfish: “lacking consideration for others; concerned chiefly with one’s own personal profit or pleasure”
- selfless: “concerned more with the needs and wishes of others than with one’s own; unselfish”
- Google defines unselfish as “willing to put the needs or wishes of others before one’s own”
- “having no concern for self” (Merriam-Webster)
Choice does not mean that the options are good. It also doesn’t mean that you have control over what the options are, or how many of them are available. To be a choice only requires two options: A or B (in the case of suicide, living or dying). A choice is not inherently the result of a clear, unimpaired decision-making process; it’s simply picking A or B (or possibly C, D, E, or F) and having the mental capacity to know what the consequences are.
Relating these terms to suicide
In the case of suicide, a thought process known as cognitive deconstruction may be at play, but that narrows focus on choices and consequences rather than removing them altogether. It doesn’t remove awareness that dying is the consequence, but it temporally restricts the view of consequences so that nothing beyond the immediate consequence (as in lights out) is relevant.
Suicide is done with the intention to die (if the intent is not to die, that would be a suicidal gesture). It’s not the same thing as an accident, which involves neither intention nor choice. It is active, not passive or involuntary. The act of suicide is not the same thing as symptoms of illness that require no action whatsoever on the part of the ill person.
Suicide is neither selfish nor selfless/unselfish; for that matter, most choices don’t come down to selfishness or selflessness. It would be very difficult to argue, based on the dictionary definition, that suicide is selfish. So why does understanding of the English language fly out the window when it comes to suicide and selfishness? Stigma. Stigma encompasses attitudes that have nothing to do with dictionary definitions; after all, no one is going to spontaneously stop thinking suicide is selfish because it’s pointed out to them what the word doesn’t actually mean what they want it to mean.
Availability and acceptability of choices
The options that are and are not acceptable to an individual may not appear the same way to others. I could choose to be hospitalized for my illness, where I would have access to a more effective form of treatment than I can access in the community. However, there are very strong negatives to hospitalization, so in very few circumstances would that be an unacceptable choice for me. Deeming that option unacceptable is, in itself, a choice, even though it’s not ideal.
Happiness, on the other hand, is deemed by many to be a choice, but while it may be desirable, it’s not always on the menu of options. If my options are A or B, I can’t choose H.
Suicide vs suicidal
The StatPearls medical reference describes suicidal ideation as a “broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide.” Suicide is an action, and suicidal ideation is a thought process.
A 2014 article by the CEO of the American Foundation for Suicide Prevention was titled “Suicide Is Not Cowardly.” He wrote:
“Suicide is not a choice. Suicide is a health issue. Suicide can result if a mental illness—like major depression or bipolar disorder—goes untreated, in the same way that a patient can die from pneumonia if they go untreated.”
Later in the article, he wrote: “It’s important to understand that people who are feeling suicidal do not choose to feel that way; their feelings are a symptom of their mental illness.”
There is a very important distinction that absolutely needs to be made between suicide as an action and suicidal thinking. Suicidal ideation as a symptom of mental illness is not a matter of choice; it’s a symptom, and it may be entirely involuntary. Cognitive behavioural therapy tells us that thoughts and actions are not the same thing, and sometimes you need to do something about the actions before you can start to budge the thoughts.
Symptoms and resulting behaviours
Suicide is absolutely a health issue. Suicidal ideation can be a symptom of depression and other mental illnesses. However, if you have pneumonia and you do nothing, the pneumonia might kill you involuntarily. If you have suicidal ideation and you do nothing, you will remain alive. To go from suicidal ideation to dead takes an action (or long-term deliberate inaction that leads to death by failure to attend to the basic needs of life).
In an article on Suicide.org. titled Suicide Is Not A Choice, the author compared suicide to obsessions in OCD, arguing it’s not a choice, it’s a disorder that requires treatment. However, obsessive thoughts are a closer match to suicidal ideation, i.e. suicidal thoughts. Comparing suicide to compulsions makes for a far looser analogy, but a fundamental part of OCD treatment is not acting out compulsions. If a choice can be made not to perform compulsions, that is only possible if there was some element of choice in performing them—not a good choice, not a desirable choice, not a choice that would be made if better options could be identified, but not an involuntary action.
Is addiction a choice? Absolutely not. Is cracking open a bottle right now a choice? Yes. Are the alternatives that are available right now (withdrawal, emotional suffering, going to an AA meeting, etc.) any better? For that person, in that moment, probably not, or that bottle would remain unopened. Choice doesn’t mean having options that are good or what you would prefer. Effective treatment allows better alternatives to exist and be available.
Suicide behaves like a verb, not a noun
Sometimes suicide is used as a verb, i.e. “he suicided.” It gets rid of any spare bells and whistles and sticks to the point. What got me started on this post was reading an article from the Canadian Mental Health Association that says you’re not supposed to say “suicided.” They didn’t give a reason, but my guess is that they were probably averse to the idea that there’s any choice in suicide, perhaps because that seems too easy to link to blame, which can then link to stigma.
Yet suicide is not involuntary, nor is it passive. It requires conscious action; it behaves more like a verb than a noun. When suicidal people come up with detailed plans, gather lethal means, and possibly write suicide notes, those are active steps. Those steps are likely taken because mental illness or some other form of desperation has taken away (or at least appears to have taken away) other acceptable options.
The people who died by actively jumping, rather than falling, from the Twin Towers on 9/11 faced two choices, to burn to a crisp in the fire or jump; both were horrible options, but there were no apparent alternatives (like living), and those people chose what seemed like the least painful option. Being intensely suicidal can be like that. There appears to be one option, out of the shitty options of living or dying, that’s perceived as being associated with the least pain. Intense pain drowns out thinking about long-term consequences, but it doesn’t erase the ability to make choices from what appears to be available.
A lack of acceptable options
At those times when I tried to take my own life, I was committed to dying (there’s that word, commit). I had made plans, and I was committed to following through on them. I could absolutely have chosen in those moments not to try to die. However, living was not an option that I considered to be acceptable at those times. Option A was living and option B was dying, and my choice was dying.
Was I ill? Absolutely, very much so. Did the suicidal thinking originate in a choice? Nope. Would option B even have been on the table if I was well? Nope. Would I have made a different decision if other options were available and acceptable? Quite possibly, but that doesn’t negate the fact that I chose option B, dying. There was no impulsivity; the planning, procuring of means, and acting were all intentional. To say there was no choice leaves out a significant part of the overall picture of my personal experiences.
Obviously, not everyone has the same experiences, nor am I by any means trying to suggest that everyone perceives an element of choice in their own personal experiences. However, it only takes one purple people eater to demonstrate that the assertion that purple people eaters don’t exist isn’t accurate.
Does it matter if suicide is a choice?
Where am I seeing a link between the notion of choice and stigma? If suicide is not a choice, there’s no room for blame, and therefore, how could there be any basis for stigma? Easy-peasy lemon squeezy. Yet stigma can exist even if something is passive (like having a certain skin colour), and stigma can be absent when something is an active choice (like choosing takeout rather than delivery).
In a way, this reminds me of the tabula rasa (blank slate) concept and the belief that in order to be equal, we must be the same. From that comes the belief that it’s unacceptable to talk about being different, because that would open the door for inequality based on those differences. You see this in some arguments about sex differences being fully socially constructed, with no biological basis for difference.
Choice. Rational. Selfish. Cowardly. Blame. Shame. Stigma. These are all different things that don’t automatically go together. Treating them as though they do ends up oversimplifying the issue in a way that avoids getting at the meat of it. That meat of it is the stigma that forges those linkages, regardless of what’s in the dictionary. Looking for new words with acceptable dictionary definitions just fuels the euphemism treadmill, because stigma doesn’t operate based on dictionaries.
What this means for suicide prevention
In terms of suicide prevention, if we’re busy talking about suicide not being a choice, we’re not talking about providing better options. As long as mentally ill people can’t access treatment, perhaps because the emergency department is telling them they’re just “attention-seeking” and”not suicidal enough”, or the NHS’s SIM program has deemed them too much of a pain in the ass to be helped, or they can’t afford therapy, or their illness is treatment-resistant and the meds only do so much but there isn’t anything better available, it’s going to be hard for people to come up with better options. Why are those barriers in place? That probably has a lot to do with stigma too.
Maybe we need to talk more about the consequences of the shitty options that are made available because of both the existence of stigma and the difficulty of getting effective treatment for mental illness, and less about whether or not there’s an element of choice in suicide. Because bigger changes need to happen to stop suicide from ever being the most acceptable of the available options for anyone, and oversimplification probably isn’t going to get us there.
The Straight Talk on Suicide page has crisis and safety planning resources, along with info on suicide-related topics from the perspective of someone who’s been there.