capability for lethal behavior. Moreover, they do appear to use a
kind of calculation related to burdensomeness (i.e., their death is
worth more to their community than their life). Their sense of be-
longingness, however, seemed quite high—another reason, from the
perspective of the current model, to view their deaths as other than
suicides, and many Muslim clerics concur that self-martyrdom and
suicide are distinct.10 Even here, however, the current view has some-
thing to contribute. It is possible that death and life merge for suicide
terrorists, such that they view death as a way to belong, and to belong
more fully than by anything they could do in life. In his 2004 book
entitled My Life Is a Weapon, C. Reuter identifies belonging in the
What Do We Mean by Suicide? ● 143
memories of family and society at large as perhaps the prime motive
for suicide terrorists. As noted earlier, in at least one example—sui-
cide attackers in the Iran-Iraq War—self-sacrifice was celebrated as a
marriage of the attacker to death.
Japanese kamikaze pilots can be viewed similarly. Excerpts from
the pilots’ “how-to” manual have been published.11 One excerpt read,
“Just before the collision it is essential that you do not shut your eyes
for a moment so as not to miss the target. Many have crashed into
the targets with wide-open eyes. They will tell you what fun they
had.” An excerpt entitled, “You are now 30 meters from the target”
read, “You will sense that your speed has suddenly and abruptly in-
creased. You feel that the speed has increased by a few thousand-fold.
It is like a long shot in a movie suddenly turning into a close-up, and
the scene expands in your face.” A subsequent passage entitled, “The
moment of the crash” read, “You are two or three meters from the
target. You can see clearly the muzzles of the enemy’s guns. You feel
that you are suddenly floating in the air. At that moment, you see
your mother’s face.” These step-by-step instructions seem designed
to increase the pilots’ courage and preparations for death, reminis-
cent of the concept of resolved plans and preparations emphasized in
Chapter 2.
Like suicide bombers, kamikaze pilots seem to calculate that their
death is worth more to their community than their life. A relevant
excerpt in this regard from the “how-to” manual read, “Sink the en-
emy and thus pave the road for our people’s victory.” Another read,
“Transcend life and death. When you eliminate all thoughts about
life and death, you will be able to totally disregard your earthly life.
This will also enable you to concentrate your attention on eradicat-
ing the enemy with unwavering determination.”
And also like the suicide bombers, high belongingness seemed to
characterize the deaths of kamikaze pilots. A relevant excerpt from
their manual read, “Remember when diving into the enemy to shout
144 ● WHY PEOPLE DIE BY SUICIDE
at the top of your lungs: ‘Hissatsu!’ (‘Sink without fail!’) At that mo-
ment, all the cherry blossoms at Yasukuni shrine in Tokyo will smile
brightly at you.” According to my model, one interpretation of this is
that the pilots’ need to belong has been met by death. Another inter-
pretation, of course, is that their elevated sense of belongingness is a
reason to define their deaths as other than suicides.
Menninger viewed deaths like these as nonsuicidal. In his 1938
book Man Against Himself, he wrote, “The heroic sacrifice of scientists who willingly incur the fatal risks incident to research, patriots
who lay down their lives for freedom, saints of the church and other
persons who give their lives for society, or for those they love, are
usually not considered suicidal.”12 My claim is though no model of
suicidality easily handles all of the definitional challenges presented
by examples like kamikaze pilots, my framework, relative to others,
provides more understanding of these complex phenomena.
Consider mass suicides in cults as another example. In both the
Jonestown and Heaven’s Gate incidents, people caused their own
deaths, seemingly intentionally. In Jonestown, where 914 people
died, the majority of people died from drinking a grape-flavored
drink laced with cyanide and sedatives at the behest of leader Jim
Jones; it should also be noted, however, that many people were mur-
dered in the Jonestown tragedy, either by gunshot or the injection
of poisons. In the Heaven’s Gate event, which caused the deaths
of thirty-nine people (two additional cult members died by suicide
in the months following), people died by ingesting high doses of
phenobarbital mixed with vodka, at the behest of leader Marshall
Applewhite. The Heaven’s Gate members believed that after death
they would be transported to a spaceship that was following the
comet Hale-Bopp, and that they would live on at higher evolutionary
levels.
It is plausible to argue that these were not suicides but rather mur-
ders perpetrated by the cult leaders. Also, the same point regarding
What Do We Mean by Suicide? ● 145
gender distribution in the World Trade Center deaths can be made
regarding Jonestown and Heaven’s Gate (more women than men
died in the Heaven’s Gate incident, for example). But if these deaths
are to be characterized as suicides, how does the present framework
explain them?
First, relevant to the acquired capability to enact lethal self-injury,
there were numerous discussions about and explicit rehearsals for
suicide in both the Jonestown and Heaven’s Gate incidents, similar to
the mental practice for suicide and aborted suicide attempts men-
tioned in Chapter 2. This was a harrowing aspect of Jonestown, in
which Jones tested loyalty by telling members that a drink contained
poison (when it did not) and asking them to drink it. In fact, habitu-
ation has been invoked as a factor at Jonestown: “Thus, with re-
peated incidents such as this, Jones was able to desensitize his follow-
ers regarding mass suicide.”13
Also, people in both groups endured considerable pain and provo-
cation. In Jonestown, in addition to the harrowing loyalty tests, peo-
ple worked seventy-four hours per week in agricultural fields or con-
struction in the searing heat of the South American jungle, and this
was in the context of a sparse diet and lengthy and regular religious
meetings.14 Eight of the eighteen men who died in the Heaven’s Gate
incident had undergone voluntary castrations.15
But what about belongingness? Shouldn’t the close ties among cult
members offset suicide risk, according to the current model? It is an
underappreciated fact that belongingness is low in many cults, par-
ticularly abusive ones.16 To be sure, people in such cults work, live,
and worship side by side (as people do in prisons, for example), but
their connection to each other is not such that multiple meaningful
and reciprocal relationships are cultivated; rather, their main inter-
per
sonal tie is to the cult leader, whose reciprocity is sporadic, one-
sided, and often manipulative or abusive.
It is also common for people to forego deep and lifelong relation-
146 ● WHY PEOPLE DIE BY SUICIDE
ships when they join cults (for example, some of the Heaven’s Gate
members abandoned their children when they joined the cult).17 Re-
garding feeling ineffective, people are routinely and severely sub-
jugated in cults. If mass suicides in cults are suicides rather than
murders, my model may explain more about them than can other
theories of suicide.
Although very different in character from suicides in cults, physi-
cian-assisted suicide also presents definitional challenges. Recall the
quotation that “if there were some little switch in the arm which one
could press in order to die immediately and without pain, then ev-
eryone would sooner or later commit suicide.” I think this view ne-
glects how scary death is to most people, but the remark does convey
the fact that, without such a “little switch,” suicide is difficult. Physi-
cian-assisted suicide is perhaps as close to a “switch” as is possible.
According to my model, suicide involves the accrual of fearlessness
about and the means for suicide (primarily involving habituation
and opponent processes) as well as the desire for death (constituents
of which are perceived burdensomeness and failed belongingness).
The means for physician-assisted suicide are in a sense prearranged.
Also, through a lengthy assessment and consultation process, death
by physician-assisted suicide may become less and less fearsome.
Therefore, competence and fearlessness may be implicated in choos-
ing physician-assisted suicide.
There is evidence too that burdensomeness is involved. Re-
searchers found that among amyotrophic lateral sclerosis (ALS) pa-
tients, those who were interested in assisted suicide had greater dis-
tress at being a burden than ALS patients not interested in assisted
suicide.18 Though the study does not precisely measure perceived
burdensomeness or failed belongingness, researchers have also re-
ported that, among hospice patients who refused food and fluids to
hasten death, pointlessness and meaninglessness in life were main
motivations. Patients in this group usually died within two weeks
What Do We Mean by Suicide? ● 147
and nurses indicated that on average these were “good” deaths (rela-
tively free of extreme pain and other discomfort).19
The author Caroline Knapp died this way. Knapp wrote honest
and well-crafted memoirs, including the books Drinking: A Love Story
in 1996 and Appetites: What Women Want in 2003. In each of these
two books, two things about her become clear: first, she went
through numerous provocative experiences related to her serious al-
coholism and equally serious anorexia nervosa; second, she was a
very strong person, as evidenced by her overcoming both alcoholism
and anorexia. She was diagnosed with late-stage, terminal lung can-
cer in 2002 and decided to end her life by refusing food and fluids.
She did this, her twin sister stated, as a way to take control.20 Given
what Knapp had been through, and given her strength, it does not
seem surprising that she would have the wherewithal to take control
like this.
Another phenomenon that presents definitional challenges is what
might be termed “quasi-suicide.” Consider for example a newspaper
reporter who has covered many wars, and in each, has had a number
of close calls, some due to recklessness. The reporter is killed by
enemy fire in a war zone that he was explicitly forbidden to visit by
military authorities. The model developed here applies at least with
respect to the acquired ability to enact lethal behaviors—the re-
porter’s repeated provocative experiences would have habituated him
to injury or death. The relevance of the other two aspects of the
model is less clear, however. It is possible that the reporter in the ex-
ample would harbor feelings of perceived burdensomeness and failed
belongingness, but it does not seem necessary; there is something
incomplete in the reporter’s resolve toward suicide.
In this connection, the concept of a “passive” suicide attempt should
be noted. A passive attempt occurs when one takes no or minimal ac-
tion but in so doing incurs risk. Refusing treatment for a life-threat-
ening condition would be one example. Stepping off the sidewalk
148 ● WHY PEOPLE DIE BY SUICIDE
into a busy street without looking would count as a passive attempt
also; here, minimal activity leads to someone else potentially being
the agent of death—a passive suicide attempt.
In Chapter 2, I emphasized the distinction between the categories
of suicidality—resolved plans and preparations versus suicidal de-
sire. Interestingly, passive suicide attempts are grouped under the
suicidal desire category. This suggests that passive suicide attempts
are distinct from more active, resolved attempts.
Consider the example of those who refuse HIV testing, despite be-
ing at risk, and who thereby deny themselves potentially life-saving
or -lengthening treatments. A situation like this was documented by
Peter Cassels in the June 13, 2002 issue of Bay Windows, a gay and lesbian newspaper in New England. The mother of a man who had
refused HIV testing and later died from complications arising from
AIDS explained that her son was very affected by homophobia and
never truly came out of the closet. She said, “On a subconscious level,
his refusal to be tested for HIV when he could have been treated, the
way homophobia affected him, maybe his death was a quasi-suicide.”
The man seemed to struggle with thoughts that his homosexuality
was a burden to his family and himself, and his sense of connection
seemed affected too. It is possible that he had the desire for death but
had not developed a strong capacity for lethal, active self-injury, and
instead used the passive means of HIV test refusal. The understudied
phenomenon of “quasi-suicide” thus seems at the margin of what my
framework would consider as truly suicidal, and needs more research
attention.
The phenomenon of suicide-by-cop, however, seems explicable
within my framework in that it shares many properties with other
suicide methods. Suicide-by-cop occurs when a suicidal person ag-
gressively provokes a law enforcement officer, who kills the person in
self-defense. Though this has elements of a passive suicide attempt,
What Do We Mean by Suicide? ● 149
in that the person is not the final agent of death, it also has active ele-
ments, in that the person has to engage and then actively and aggres-
sively provoke a police officer. In a study of people involved in a
standoff with police who acted provocatively toward them, those
who died as a result were compared to those who survived.21 Those
who died had signatures of the acquired ability to enact lethal self-
injury—for example, more previous suicide a
ttempts—and also of-
ten voiced a desire to die. They thus seemed similar to those who die
by suicide through other means. As to why someone would choose
suicide-by-cop over other methods, we have very little systematic
knowledge on method choice in general, and choice of suicide-by-
cop in particular. One could invoke explanations like anger at law
enforcement or at authority in general, but this seems a little unsatis-
fying.
Murder-suicide does not really present definitional challenges—
the person has clearly died by suicide—but raises another question:
Why murder someone first? Here again, relatively few systematic data
are available, in part because the phenomenon is relatively rare.22 Ap-
proximately 1.5 percent of all suicides occur in the context of mur-
der-suicide.23 A very interesting study determined whether the initia-
tors of murder-suicides had profiles more like those who die by
suicide or more like those who commit homicide. Seventy-five per-
cent of the initiators of murder-suicide were depressed and 95 per-
cent were men. In both these ways, they resemble those who die by
suicide. By contrast, perpetrators of homicide were not depressed
and one-half were women. The study concluded that the murder-
suicide and homicide groups are distinct populations.24
But still, why murder someone before one’s own death by sui-
cide? One answer involves elderly, depressed men who are caretakers
for impaired spouses. In a study comparing men who had died by
suicide to those who first killed their spouse and then died by sui-
150 ● WHY PEOPLE DIE BY SUICIDE
cide, researchers found that half of the murder-suicide group were
caretakers of an impaired spouse, as compared to 17 percent of the
suicide group.25 Depression was very common in both groups. A
substantial number of murder-suicides involve older men who are
depressed and confronted with the care of an impaired spouse. Some
number of these murder-suicides likely involve suicide pacts, in which
the spouse consents to joint suicide. Though the context and dynam-
ics are different, this is reminiscent of the phenomenon mentioned
earlier, in which people in Japan contacted one another over the
Internet to plan their suicides.
A Comment on Method
Why People Die By Suicide Page 19