30 June:   Suicide, Literature and Philosophy – To be or not to be?  - Abhijit Pal

Evidence
• Literature and philosophy is littered with minds contemplating suicide, depicting suicide, defending suicide, arguing against suicide – it seems like a fundamental dimension of human existence, not a disease limited to a minority
• Philosophy and suicide are linked
• Philosophy asks the questions and literature explores the answers to them
o What makes life worth living?
o What’s the meaning of life?
o What are we living for?
• Suicide is intricately linked to these questions – statements “my life is not worth living”, “there’s no meaning to my life anymore”, “I have nothing to live for” surely play a role in the suicidal patient’s thought processes
• For truly effective suicide prevention, we need the idea that people must reject suicide instead of an ambivalence or ignorance of suicide – “I don’t want to kill myself because I want to do this/I believe in this/I need to do this” – an affirmation of life and living instead of a passive acceptance (None of us chose to be born, and I feel somewhere along the line people need to make the decision to live instead of just passively living to qualify for mental health)
• In the opening lines of the Myth of Sisyphus

“There is but one truly serious philosophical problem and that is suicide.  Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.” Camus

• Philosophy, as it is used here, refers to the process of self-reflection, examination and thought – not the body of work which falls under philosophy.  Philosophical inquiry asks the questions a suicidal patient answers irreversibly, but in a non suicidal state of mind, leading to the possibility of a satisfying answer

• Other examples of suicide in literature
o Shakespeare’s “To Be or Not to Be”

To be, or not to be: that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them?

Suicide features prominently in Shakespeare’s works (do they contribute to the appeal?), with Romeo and Juliet killing themselves, in Julius Caesar, Othello, Antony and Cleopatra and Hamlet.  These works are held up as the hallmark of Western literature, and suicide is such a prominent theme in all of them – why is this, and how can it be useful in psychiatry?

o Dostoyevsky’s “The Dream of a Ridiculous Man”

Suddenly I noticed in one of these patches a star, and began watching it intently.  That was because that star had given me an idea: I decided to kill myself that night.  I had firmly determined to do so two months before, and poor as I was, I bought a splendid
revolver that very day, and loaded it.  But two months had passed and it was still lying in my drawer; I was so utterly indifferent that I wanted to seize a moment when I would not be so indifferent - why, I don't know.  And so for two months every night that I came home I thought I would shoot myself.  I kept waiting for the right moment.  And so now this star gave me a thought.  I made up my mind that it should certainly be that night.

The main idea is that its ok to ask questions about life, and that there can be a meaningful discourse about it.  Not that there are solutions. But that other people have thought about it and the person isn’t alone.  So the flip side of preventing suicide is promoting life, and providing rational, understandable reasons for living.  Obviously there is a plurality of ways to live, but validating and accepting the questions in culture and society. 

Affirmation of Life/Rejection of Suicide Thoughts
• Mental illness by its nature must be linked – its hard to imagine anxiety without depression, schizophrenia without anxiety, suicide without depression – the DSM provides a descriptive nosology, but when attempting to find explanatory models for these phenomena, its more likely that there is a common difficulty or problem manifesting in different manners depending on the person’s experiences, circumstances and genetic make up
• Difficulty = problems in accepting, integrating with the human condition, the human condition including everything that is possible (death, disease, sickness, suffering, stress, loss)
• Dealing with the human condition is the province of spirituality and religion
• The core of religion/spirituality seems to be
o A surrender of the self and a renouncing of sensory pleasures
o An idea to live and die by (eg. serving others)
o Letting go of the ego (eg. “I need to succeed. I need to be better than other people”)
• Wittgenstein read Tolstoy’s “Gospel in Brief” and loved it, and apparently thereafter gave away all his money and lead a very simple and frugal existence.  Tolstoy was apparently in a suicidal state 2 years after the publication of Anna Karenina, and seeked the world over for solace, and after going through philosophers, Islam and Buddhism finally found Christianity.  He gave away his money and tried his best to live a Christian life
• Kierkegaard “The thing is to find a truth which is true for me, the idea for which I am willing to live and die for”
• This surrender of the self and bliss from the obliteration of questioning and doubt leads to a mild sustained euphoria, low levels of anxiety, increased satisfaction with life – it looks like mental health to me. 
• Nietzsche “He who has a why to live for can bear with almost any how”
• A singular, unitary purpose seems to be a really good promoter of mental health “I have to live for my kids, and make sure that they grow up to be good people”, “ I have to live for God”, “I have to help other people”, “I’m a doctor and I do good work for other people”, “I’m an author and I have a book to write” etc all seem kind of essential – the ennui/lack of purpose/angst common to emo kids “Life’s meaningless”, “We’re all going to die, so whats the point” attitude is the antithesis of this position and obviously its not “healthy”.  Whether its “bad” or “wrong” is a different matter.

If we’re meaning seeking creatures (always wondering about the meaning of life), it makes sense for psychiatrists to help people find meaning in their circumstances.  Evidently there is abundant scope for meaning in any one set of circumstances, because by its nature it is subjective (if the person believes it, it works) and transcendent (meaning is independent of the action – two people do X (go to a party, study medicine, work a 9 to 5 job, play cricket) and report vastly different experiences, usually contingent on the meaning they placed on that activity