Why the book was written.

The situation in the U.S.: there are more than 80 deaths from suicide every day, while an estimated 300,000-600,000 people a year survive suicide attempts. 116,000 are hospitalized; seventeen percent, some 19,000, of these people are permanently disabled each year. These numbers refer to acts formally classified as suicides, but there are also many lifestyle choices that may be called "slow suicide". 6 pp.

Views concerning suicide have varied over time and culture, ranging from violent opposition to active encouragement. Chapter two is an historical sketch of ideas about suicide, from early Egyptian to the present. Emphasis is on Western (Greek, Roman, Christian, European) positions. 7 pp.

Three ways to examine suicide are sociology, psychiatry, and biology. The sociological perspective looks at society's influence on its members; how do various social conditions (and their changes) affect suicide rates. The psychiatric approach emphasizes and examines the individual, and the conflicts within a particular mind leading to self-destructive behavior. The biological view sees physical disorders, often a biochemical imbalance, as the "cause" of suicide and other psycho-pathological problems, like schizophrenia. 8 pp.

Chapter four cites general reasons described in the suicide literature; these range from "altruistic" suicide to "an attempt to manipulate others". There is also a brief discussion of the conceptual difficulties that arise from such a wide variety of intents being lumped together as "suicide". 9 pp.

Adolescents attempt suicide roughly ten times as frequently as do adults, but their fatality rate (per attempt) is about one tenth as high. This chapter briefly describes some differences between adult and youth suicides, and describes some international data to put U.S. statistics into perspective. 6 pp.

"When an old person attempts suicide he almost fully intends to die." Chapter six describes the high suicide rate among the elderly, and the reasons cited in the medical literature for these numbers. 6 pp.

"Are suicidal people crazy?" While schizophrenia and depression carry a 10-15% lifetime risk of suicide, most people with these diagnoses do not kill themselves. Suicide is also associated with physical illness and with alcoholism.

"How would I know if someone close to me was considering suicide?" The more familiar method consists of sensitivity to various verbal and behavioral clues; but the fact is, while many people consider, mention, or threaten suicide, far fewer make a suicide attempt. Sociological and biological risk factors are an alternative prediction model. However, using any or all tools, the ability to identify which individuals will commit suicide remains negligible. 18 pp.

Chapter 8 opens with a brief examination of the circumstances under which suicide may be the right thing to do. It continues with a look at suicide intervention. Temporary hospitalization is the most frequent form of intervention, but it is not clear that long-term hospitalization is helpful in preventing suicide. 7 pp.

Much of medical practice has shifted from treatment of acute infectious disease to treatment of chronic or degenerative illness, such as cancer and stroke. Illness-driven suicide is one of the consequences of this change. Many physicians feel that euthanasia and assisted suicide are sometimes appropriate, and in some circumstances would want it for themselves. 14 pp.

The driving force behind assisted suicide is, in large part, the failure of the medical system and its practitioners to deal caringly and compassionately with the dying. 4 pp.

Pain is often treated inadequately and patients' advance directives are frequently ignored . Attempts to improve the situation have been largely unsuccessful. Hospice and comfort care are alternatives to dying in the hospital and/or to suicide in response to terminal illness. Hospices generally treat patients with skill and sensitivity, but they are not universally effective, and not everyone wants a lingering death, even with the best of care. 9 pp.

These documents, while well-intended, are unreliable. This is partly because end-of-life medical decisions are sometimes too complicated to be made on the basis of prior legal documents; more often it is because physicians and hospitals ignore or are unaware of the patient's advance directives. 17 pp.

"...without knowledge of proper dosages and methods, suicide attempts are often bungled, leaving the victim worse off than before." There are two main practical problems with assisted suicide: (1) in most places it's illegal; (2) in many cases the job is botched. These are related. Because assisted suicide is illegal, most practitioners are amateurs with limited knowledge and no supervision. 8 pp.

Euthanasia has been openly practiced in the Netherlands since 1973. The Dutch experience has been cited both by proponents and opponents of euthanasia and assisted suicide; each position is summarized. 6 pp.

Euthanasia and assisted suicide are not panaceas---people will still kill themselves on account of present misery; but not over fears of future helplessness. Improved medical care---and caring---for the dying will decrease the impetus for suicide, assisted or not. But in the absence of such care, or when it fails, each of us who so decides should have the option of a chosen death. 11 pp.

Fatalities range from 8 or 9 deaths out of every 10 attempts with guns, to fewer than one of ten with cuts or with drugs. Hanging, carbon monoxide, and drowning are also particularly lethal methods, while most other gases or poisons are substantially less so. Injury data is both more complex and less available. 10 pp.

"Asphyxia" is any process that cuts off the oxygen supply to the brain. This includes such seemingly unrelated methods as a plastic bag over the head, hanging, and carbon monoxide poisoning. Death occurs within roughly 5-10 minutes after complete asphyxia. Some of these methods are suitable for suicide; none are appropriate for a suicidal gesture. 28 pp.

Cutting and stabbing are not common means of suicide in most of the world; however, around 10 percent of suicidal gestures/attempts are from wrist cutting. Unlike some all-or-nothing methods cutting and stabbing can be made about as lethal as you choose to make it, if you know what you're doing. 22 pp.

Drowning is an effective and quick means of suicide, usually taking between four and ten minutes. Whether or not it is minimally traumatic, as some have claimed, is in dispute. It is responsible for only 1.3% of suicides in the U.S., land of the handgun, but is much more common in many other parts of the world. It is a distinctly poor choice for a suicidal gesture. 14 pp.

The focus of this chapter is information on the toxicity and lethal dose of some commonly used drugs and household chemicals, and is meant to help (1) those who want to survive a suicidal gesture pick a relatively safe drug and dose; (2) those who intend to die pick a drug with a more-or-less acceptable combination of lethality, speed, and unpleasantness. 41 pp.

Electrocution is another effective, but rarely used, method of committing suicide. It is not a good choice for a suicidal gesture. The potentially lethal effects of electricity on the body include heart stoppage, respiratory failure, and burns. 20 pp.

Shooting yourself is a generally successful---76%-92% mortality rates are reported---but frequently messy method of suicide. Suicidal gun wounds to the head tend to be quickly fatal, but there is a 2-6% survival rate, and these people often have brain damage and/or disfiguring injuries. Gunshot is a method that can be, and all-too-often is, used impulsively, and doesn't require much planning, or time to reflect on other possibilities. 37 pp.

All forms of hanging and strangulation are effective methods of suicide. Many can be carried out by people with limited physical abilities and don't require complete suspension. Death occurs within about 5-10 minutes after complete cutoff of oxygen or blockage of blood flow to the brain (anoxia). These are highly lethal methods and cannot be done safely as a suicidal gesture. 35 pp.

Hypothermia (low temperature) is an effective, but infrequently used method of suicide. It is generally a poor choice for a suicidal gesture, unless one is sure of timely intervention. 19 pp.

Jumps from higher than 150 feet (10-12 stories) over land and 250 feet over water are almost always fatal; however most suicide attempts are from considerably lower. The consequences of lower jumps are unpredictable, and permanent injuries, including paralysis, are common. Jumping is thus a particularly bad choice for a suicidal gesture. 24 pp.